Pink Glove Dance

I've been too busy to blog yet about the new mammo and cervical cancer recommendations, but promise that I will very soon. In the meantime, enjoy this video made by employees of the Providence St Vincent Health System in Portland, Oregon to raise breast cancer awareness.(Thanks to Carrie for forwarding it to me)

Swedish Meatballs

Swedish Meatballs are one of Mr TBTAM's specialties, made from a recipe given to him by my mother-in-law Irene, who modified it from The Casserole Cookbook. We usually serve the meatballs with buttered noodles, but they are also traditionally paired with boiled potatoes.

Perfect for those cold winter nights, which I hear they have a lot of in Sweden.

Meatballs Stockholm (Swedish Meatballs)

3 slices toasted rye bread
½ cup milk
1 lb. ground beef
1 egg, slightly beaten
½ small onion, grated
½ small onion, sliced
½ tsp. salt (or more, to taste)
¼ tsp. pepper
¼ tsp. grated nutmeg, ½ tsp. paprika, 1 tsp. dry mustard
4 tbsps shortening
2 cups beef bouillon
2 tbsps. flour
2 tbsps chopped parsley

Trim crusts from toast, break into small pieces and soak in milk for 10 minutes. Mash with a fork until smooth. Mix with meat, grated onion, egg and seasonings. Form into small balls about 2 inches in diameter. Heat shortening in saute pan. Add meatballs and sliced onion to pan and saute until meatballs are nicely browned on all sides. Pour off excess fat from pan and add bouillon. Cover and simmer for 15 minutes. Remove balls from gravy and keep warm. Mix flour with a little water and carefully add to gravy. Add parsley. Replace balls in gravy and heat just to boiling. Serves 4.

Veal and pork may be used in place of some of the beef. The meatballs are especially good if made early in the day and then reheated just before serving.
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Swedish Meatballs from around the web

There are lots of ways to make Swedish meatballs. Variations include using white instead of rye bread, substituting potatoes for bread, adding pork, and even using soy sauce in the gravy. Here are just a few recipes I found -

- Cooks Illustrated's recipe at What's on My Plate

- Ikea's recipe, from their cookbook. Like their furniture, not quite as well-made as one would have hoped. Assembly required.

- Kevin Week's recipe uses dill and mixes ground pork with the beef. I may try this one next time...

- Jamie tweaks Alton's recipe by using a tablespoon instead of a scale to portion out the meatball, making the recipe accessible to non-obsessive compulsive cooks.

- Twinkle at Yum Sugar does a streamlined version without gravy, served with lingonberry jam. She gets points for actually being in Sweden while making them...

- Cheap Talk spends way too much time wondering why Swedish meatballs are smaller than their American counterparts. (Very funny...)

Supplemental Folic Acid in Late Pregnancy Associated with Childhood Asthma

In yet another study assessing the impact of folic acid supplementation in pregnancy, Australian researchers have found an association between use of folic acid supplements in late pregnancy and the risk for asthma in childhood. The risk was not found with use of folate when it was confined to the prenatal period and the first trimester of pregnancy, a time when its use decreases the incidence of neural tube defects such as spina bifida. Intake of folate from dietary sources was also not associated with childhood asthma.

The study is quite muddied with confounding variables, imperfect data sources and no data on supplement use in childhood. Still it raises important concerns, and if its findings are replicated in other studies, it would suggest that folic acid supplementation should be limited to the prenatal and first trimesters. It's also important not to exceed current dosing recommendations for this important vitamin.

It also underscores what I've been telling my patients for years - it's always preferable to get your vitamins from dietary sources rather than supplements.

Photoshop Healthcare Reform

Congress clearly hasn't gotten the picture on what America really needs for healthcare reform. Which means you'll have to create it for them.

To that end, Dr Wes and his wife are holding the first and only US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

See Dr Wes' blog for rules, get out your cameras and your laptops and make it happen!

Dr Oz Gets it Right

As much as I rant against Dr Oz and as much as the Huffington Post is beginning to annoy me with it's celebrity gossip and daily almost nude photos, they both just redeemed themselves this week with Oz's wonderful column entitled. "Real Health Reform - What's Next?"

We need to create a culture of health and wellness that fosters a nationwide understanding that personal behaviors are a major factor in health and well-being. And at the same time, we need to make the necessary societal changes so that all individuals are supported in making the correct choices. We need to make it easier to do the right thing.

Oz recommends changes as sweeping as reforming the food supply, changing how we feed our children in school, improving air and water quality and finding ways to reduce stress and incorporate physical activity into our daily lives. Its an agenda much larger than anything facing the Senate right now, but includes many things that most American people can start to do today that don't require an act of Congress.

Ambitious, yes. Impossible, no.

Do the right thing.

I like it.

How to Delete a Calendar from Your iPhone

****Geek alert****

Ignore this post unless you came searching for this solution. 

After switching from Blackberry to Iphone, I forgot to remove Pocket Mac from my Macbook. As a result, when I synced my calendar to my iPhone using Mobile Me, a second calendar was created on my I Phone. Even when I removed Pocket Mac from my Macbook, he calendar remained. I searched everywhere for instructions on deleting it, without success. Then I figured it out. So simple.

Open up iCal on your macbook. You will see a list of your calendars on the top left. Cntrl click the one you want to delete, then scroll down to the "delete" option and Viola - Gone! Now re-sync your iPhone with iTunes. The offending calendar is gone.

This should work with any extraneous calender you've accidentally created on your I Phone. Mine just happened to be my Pocket Mac calendar.

Drugs for Cancer Prevention - NY Times Misses the Point

In yet another article addressing the war on cancer, The New York Times today tackles cancer prevention, focusing on alternative and mainstream Pharma products marketed to reduce the risk for cancer.

While author Gina Kolata seems to have done her homework when it comes to the failure of alternative medicine to prevent cancer, she has missed the story completely when it comes to telling why the medical profession and patients may have failed to embrace Big Pharma's push to use their drugs to prevent breast and prostate cancer. Of course, that's not surprising since almost exclusively, the experts she interviewed were those who conducted the clinical trials of these drugs.

Since I'm not a urologist, I'm not going to comment on the use of finasteride to prevent prostate cancer, except to point out that the one expert quoted in favor of its use has served as a consultant to Merck and AstraZeneca, both of whom make the drug, while the other works for Astra Zeneca.

So let's talk about tamoxifen and raloxifene, two drugs that are approved for the prevention of breast cancer.

Tamoxifen and Raloxifene

The maker of Evista (raloxifene) is targeting both docs and women, urging them to calculate their lifetime risk for breast cancer and consider taking the drug if that risk for breast cancer is increased. Since raloxifene is also approved for treatment of osteoporosis, the drug makers are selling it as a two for one.

Both tamoxifen and raloxifene cut the risk for breast cancer in half among high risk women who use the drug for 5 years. Tamoxifen also prevents DCIS and LCIS in addition to invasive cancer, while raloxifene does not reduce these risks.

But, Tamoxifen can cause uterine cancers. The risk is low, about 1 in 500, but includes uterine sarcomas, a particularly aggressive tumor, and may persist even after the drug is discontinued. There is no screening for uterine cancer in tamoxifen users - ultrasound is useless, since the endometrium very frequently appears abnormal even if there is no cancer. We docs are left telling women just to tell us if they bleed.

Now, for women who are taking tamoxifen for treatment of breast cancer, the risk for uterine cancer is almost always outweighed by the benefits in terms of cancer treatment. But for woman who have never had (and may never get) a breast cancer, the uterine cancer risk is a deal breaker, especially when she asks what I can do to screen her and I tell her "nothing". I can quantify it for her - look, your risk for breast cancer will be reduced from 20% to 10%, I might say - and your risk for uterine cancer increased by less than one percent.

Okay, I'm interested, she might say. So tell me - Are there any other risks?

Yes, I'll say.

Both raloxifene and tamoxifen carry an increased risk of thromboembolism. According to the package insert for Evista (raloxifene), DVT occurred in 1 out of every 100 women using the drug for an average of 2.6 yrs, over twice the rate for placebo users. Fatal stroke risk was about 1.5 times higher in Evista compared to placebo users, though that risk was concentrated in postmenopausal women at increased risk. Unfortunately, nowhere in the marketing materials for Evista is there a risk calculator that helps me or my patients assess their personal risk for these complications from the drug.

So, I'll fudge it. Now my risk calculation for this patient looks something like this - Breast cancer, lowered from 20% to 10%. Uterine cancer, increased by 0.2%, but no screening. Blood clot risk = 1%. Fatal stroke risk = 0.3% over 5 yrs if you have risk factors, miniscule if you don't.

Okay, she'll ask me. How is it going to make me feel?

Probably fine, I say, but there are some side effects that might bother you, the most common of which is hot flashes in about 10% of users. Some women experience joint pains and leg cramps as well. These symptoms can occasionally be severe, although only about 1% of users stopped the drug because of hot flashes in the clinical trials. And most women will notice an increase in vaginal mucus that, as a gynecologist, I don't have concerns about. Not uncommonly, my patient will have had a friend who has experienced a bothersome side effects from taking Tamoxifen. That's usually the kiss of death for any drug - a girlfriend with a side effect...

And oh yeah, there's also the increased risk for cataracts with Tamoxifen, but not raloxifene.

Now, if a woman has osteoporosis, I can add that to the plus side of the balance scale for raloxifene use. Now I've got to do her risk for fracture based on her bone density and talk to her about the other options she may have to treat her osteoporosis as well.

Is anyone really wondering why we docs and our patients haven't jumped onto Big Pharma's cancer prevention bandwagon? We're asking patients to balance competing statistical risks for conditions she may never get, in return for a benefit she may never need.

I do prescribe raloxifene it for treatment of osteoporosis, and if there is a strong family history of breast cancer, I may even try to steer my osteoporotic patients who are not at increased risk for clots towards using it. However, it is the rare patient who chooses this drug over a bisphosphonate such as Fosamax and Actonel when I inform her of the risks and benefits of both these classes of drugs. Even patients with strong family histories of breast cancer just don't want the potential side effects of a drug in return for a reduced risks for a cancer they may never get.

Hello - Birth Control Pills?

Kolata completely misses out on the fact that millions of women are already taking a pill that reduces their risk for cancer - the birth control pill. It cuts ovarian cancer by up to 80% and endometrial cancer by almost half.

Like Tamoxifen and Raloxifene, the pill carries an increased risk of blood clots, a trade off many women are willing to make in return for prevention of pregnancy, which itself carries an even higher risk of clotting. Not to mention the benefits the pill can confer for women with menstrual disorders such as dysmenorrhea, menorrhagia, endometriosis and its efficacy in treating acne and even PMS. For most healthy young women, the balance of benefits and risks of pill use is favorable, even before considering the cancer prevention aspects of the pill.

For the record, I inform each and very patient who starts estrogen containing birth control that there is an increased risks of clots. I quantify it for them, tell them that it is a real risk and give them strategies they can use to minimize these risks. Surprisingly, that discussion has rarely deterred a patient from starting on hormonal birth control. It may be that pill patients are younger and feel more invincible than the older women being targeted by the makers of Evista. But I think most of them are actually weighing their risks of pregnancy against the risks of blood clots, comparing this to their perceived downsides of barrier methods and/or the IUD, and coming out on the side of using the pill.

Prevention is the holy grail for Big Pharma

Let's face it - an indication for prevention of a disease grows the potential market of a drug by millions. But if you're going to market a drug to healthy individuals, it better be free of risk or have some other benefit that patients can see right away.

Otherwise, it just ain't gonna' sell.

Which probably explains why Kolata tells the story of the cancer prevention challenge as though it were a failed pharmaceutical marketing campaign. Missing from her article, unfortunately, is the question that asks whether pharmaceuticals are really the right strategy to prevent cancer. Or that asks if we really mean to ask 100% of men over 50 to take a drug to prevent prostate cancer, when, in the same breath, we are telling them we should stop screening for it? Or whether 100% of women over 60 take a drug that increases their risk for thromboembolism and uterine cancer so that 20% of them won't get breast cancers that some are suggesting may regress or be so indolent that they will die of something else before it kills them?

Of course, we could just sell them another drug to lower their clotting risks..

Feeding the Chemo Tummy

The good thing about being both a doctor and a cook is that when you don't have any more medicine to offer, there's always the food.

Case in point - my sister's chemo-induced nausea. Despite maximum doses of Zofran, she still finds herself quite queasy, usually between meals. We decided to try some mint lemonade and bingo! - the stuff really works for her. She'll nurse a tall glass all afternoon to help keep her tummy in control.

Then, her good friend Lorraine, an onco nurse, told us she heard anectodal reports from her colleagues that macaroons were also helpful for chemo and radiation induced GI distress, both upper and lower. Well, that was all I needed to head to the kitchen to whip up a batch of cousin Jessie's macaroons. Indeed, Sis found them useful when she has that empty stomach queaziness. (They didn't work if she had already eaten something that makes her nauseus.)

Unfortunately, Sis is now on a low residue diet and macaroons are off the list. Coconut is a nut, after all, so don't overdo it, and avoid them completely if you are at risk for obstruction. And remember, both these foods are high in sugar, so take them in small doses. Fortunately, that's the way they seem to work best - a sip here, a nibble there...

Minted Lemonade

Make lemonade either homemade or from canned concentrate. (I would not use powdered) in a 2 qt pitcher withy a lid. Tear up a whole lotta' mint leaves (we use about a 1/4 cup torn leaves) and mix them in with the lemonade. Store in the fridge - it will keep for several days. Serve over lots of ice. Alternatively, freeze the mint with water in ice cube trays and use the mint ice cubes in your lemonade.

Jessie's Macaroons

I'm sure any macaroon recipe would work, but these macaroons are the best I've ever had. Cousin Jessie makes for Passover every year, so of course, they are flourless. Be sure to use unsweetened coconut - the sweetened stuff has additives like propylene glycol and sulfites.

2/3 cup egg white
¾ cup sugar
1/8 tsp salts2 ½ cup natural coconut
1 tbsp cornstarch
1 tsp vanilla
½ tsp almond extract
1 tbsp white corn syrup
Almonds

Combine all ingredients, stirring well, in a moderate size saucepan. Heat over mod heat till warm. Off heat let stand 10 mins. Line baking sheet with parchment paper. Drop by tsp or small scoop onto baking sheet and place half an almond on top. Bake in 325 oven 18-20 mins till golden. Let cool on the paper. Store in a tightly covered container.
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Sorry for Poor Quality photo - it was taken with my old phone.

Impaired Physicians - in the Bathroom?

So I'm sitting here taking my required annual hospital online training, and I read that one of the signs of an impaired physician is "frequent bathroom use".

Guess that puts all us perimenopausal and pregnant female docs who drink water and coffee and also happen to have bladders under suspicion.

Treating Vitamin D Deficiency

If, like me, you are doc who is increasingly screening for and finding vitamin D deficiency, you're probably wondering the best way to replenish body stores of this essential vitamin.

I have found that simply telling my vitamin D deficient patients to increase their daily intake of Vitamin D3 to 800-1200 IU does not result in adequate levels. I have had success using 50,000 IU Ergocalciferol (Vit D2) weekly for 12 weeks, transitioning to 1000-1200 IU Vit D3 daily after that for long term replacement.

Now a study has been published showing that a regimen of 50,000 IU ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week is effective for up to 6 yrs at restoring and maintaining adequate vitamin D levels in most vitamin D deficient patients. For those with normal levels to start, the every other week regimen alone is sufficient to maintain them. This regimen is fairly cheap, about $6 a month here in NYC. 

This study reinforces the results of another recent study showing that, for most patients, Vitamin D2 is as effective as D3 in restroing and maintaining normal levels of vitamin D.

That's good to know.