Magic Johnson is Alive 20 Years after Announcing He Had HIV

Yesterday’s Washington Post Sports has a clip from CNN, 20 years ago, when basketball star Magic Johnson announced on TV that he had HIV, the virus that causes AIDS. The date was Nov 7, 1991.

“Where were you when Magic made his announcement? What were your thoughts on Johnson and HIV/AIDS that day and how have they changed?” asks Matt Brooks in his column.

I can’t quite recall where I was. Probably I was at the hospital working, possibly even taking care of a patient with HIV. But I do remember thinking how much courage it must have taken for him to come out with it.

He understood, likely, that he would die soon, and his doctors probably thought the same. There were only two antiviral drugs approved for HIV back then. There was so much stigma, and fear.

Today you can see and listen to him in an interview on ESPN.

It’s great to see Magic Johnson back in the news, even if it’s (just) in a sports sections, and to be reminded that he’s alive, doing OK. The condition we thought was a death sentence has become a chronic illness, with so many drugs available for treatment it’s hard to keep track.

Related Posts:

Reading About Thinking (on D. Kahneman’s Ideas on Perceptions of Knowledge)

An article appeared in yesterday’s NYT Magazine on the hazards of over-confidence. The Israeli-born psychologist (and epistemologist, I’d dare say), Nobel laureate and author Daniel Kahneman considers how people make decisions based on bits of information that don’t provide an adequate representation of the subject at hand. He recounts how poorly, and firmly, army officers evaluate new recruits’ leadership potential and how brash, rash or naive traders maintain investors’ trust while weighing stocks to buy or sell.

The point, as I understand it, is that individuals, including influential and powerful people, routinely make recommendations without having adequate knowledge to support their decisions. And they do so comfortably.

Men are afflicted by overconfidence more than women, he suggests, although I’m not sure he’s right on this point. In the article, he uses reckless investors who rack up stock losses as an example: Guys are more likely to lose lots of money than are women who, in general, are more cautious in their investments and, perhaps, less confident about their predictions.

I’ll have to read Kahneman’s forthcoming book, Thinking Fast and Slow, to learn more about his views on differences between men and women’s cognitive biases.

Nearing the end of the magazine piece, Kahneman alludes to medical decisions. He suggests that some doctors, perhaps through life-and-death sorts of feedback on the outcomes, may be distinguished by their capacity to gauge their own judgment skills.

He writes:

We often interact with professionals who exercise their judgment with evident confidence, sometimes priding themselves on the power of their intuition…

And asks:

How do we distinguish the justified confidence of experts from the sincere overconfidence of professionals who do not know they are out of their depth? We can believe an expert who admits uncertainty but cannot take expressions of high confidence at face value…people come up with coherent stories and confident predictions even when they know little or nothing. Overconfidence arises because people are often blind to their own blindness.

And broaches the topic of doctors’ expertise:

True intuitive expertise is learned from prolonged experience with good feedback on mistakes. You are probably an expert in guessing your spouse’s mood from one word on the telephone…true legends of instant diagnoses are common among physicians….Anesthesiologists have a better chance to develop intuitions than radiologists do….

I read this article on the train last evening and found it fascinating, so much so I hope I can find time to read the full book. Even though Kahneman is just a single human, and necessarily biased like the rest of us, he’s got some interesting and well-articulated ideas. I’m curious, in particular, if he’ll further dissect the critical thinking pathways among different doctor types.

In my experience, we’re a variable bunch. But who knows?

ADVERTISEMENTS:

Related Posts:

A Medical School Problem Based Learning (PBL) Parody of ‘The Office’

Last week a video came my way via ZDoggMD, a popular blog by doctors who are not me.

The Office Med School Edition

The clip is a parody of The Office about Problem Based Learning (PBL).

In a typical PBL, the students meet regularly in small groups. On Monday they begin with clinical aspects of a case. The process involves finding information and researching relevant topics to “solve” the diagnosis and /or a treatment dilemma. Over the course of each week the students move forward, working through a hypothetical patient’s history, physical exam and lab studies to the nitty-gritty of molecules, genes and cells implicated in a disease process.

It’s a lot of fun, usually.

The video was uploaded in February, 2007. It’s attributed to a group of med students at the University of Pittsburgh, class of 2009.

—-

Related Posts:

New York City Mayor Bloomberg Promotes Healthy Lifestyle Choices

In the city where I live, it’s hard to buy a muffin at a Starbucks without stepping back from the counter and reconsidering. Swallowing 460 calories for a minimal-nutrient breakfast seems foolish.

So I eat fewer muffins than I used to. The posted nutritional tidbits, however imprecise, on the contents of pieces of quiche, slices of pizza and cups of thick soup, stick with me when I travel, and at home.

That’s me, just n=1.

Yesterday the mayor gave a speech at the U.N. He’s quoted in today’s WSJ health blog:

In a speech to the U.N. General Assembly earlier this week, Mayor Michael Bloomberg rattled off New York’s achievements: a tough anti-tobacco campaign that made cigarettes, at about $11.20 a pack, the most expensive in the nation and led to a reduction in adult smoking rates to 14%  in 2010 from 22% in 2002 (the national rate is 19.3%). A ban on artificial trans fats. Calorie labeling in restaurants. Ad campaigns linking soda consumption to obesity, and a national salt-reduction initiative.

No wonder, he noted, that life expectancy for New Yorkers has risen faster and is higher than for Americans overall, having increased 1.5 years to 79.4 years from 2001 to 2008.

These are just correlative findings. But they support, circumstantially and in my mind, for one, that public policy can impact human behavior and health.

Related Posts:

Should You Tell Your Employer When a Loved One Is Ill?

An article caught my attention in the September AARP Bulletin:

The Caregiver’s Dilemma considers the 61.6 million people in the U.S. who care for older relatives or friends. People with jobs are, understandably, unsure if they should let their boss or supervisor know they’re caring for someone who’s sick. This indirect cost of illness and aging in America is said to tally $33.6 billion each year.

The pressure on workers is tough, writes Sally Abrahms:

Many employees are in that elder care-giving boat, yet workers with work-family conflicts are often reluctant to raise the issue with superiors. They fear they’ll be viewed as not committed enough, or receive bad year-end reviews. They may also think that discussing their personal life is unprofessional or sense resentment from colleagues and the boss, who may have to pick up the slack during their absences…

The article reminded me of the dilemma faced by cancer patients, and by the parents or children of anyone who’s got a serious diagnosis and needs help. How much to tell the boss?

It’s a tough economy.

Related Posts:

Reducing Cancer Care Costs by Comparative and Cost-Effectiveness Research (CER)

Well, it’s the day after Labor Day, time to resume our discussion of Bending the Cost Curve in Cancer Care.

We’ve reached the end of the list, on ideas to reduce oncology costs put forth by Drs. Smith and Hillner in the May 25 issue of the NEJM. Really this 10th and final point intended for oncologists is two-in-one: “The need for cost-effectiveness analysis and for some limits of care must be accepted,” they chart. So doctors should embrace studies of comparative effectiveness and cost effectiveness.

Hard to argue with reason – they’re correct, of course. They write:

… The national imperative is to empower a transparent, acceptable, equitable, politically independent agency for guidance in making tough choices in the public interest so that doctors do not have to make them at the bedside.60 Ultimately, we will have to make decisions based on some criteria, and comparative-effectiveness61 and cost-effectiveness62 analyses are good ways to align resource use with the greatest health benefit.

This sounds great, and is probably right, but I don’t think it’s realistic.

A more detailed consideration on the issue of cost-effectiveness, IMO, came out a few weeks later, also in NEJM: Comparative Effectiveness Research and Patients with Multiple Chronic Conditions. This piece, by Drs. Mary Tinetti and Stephanie Studenski, considers the problematic application of CER in the real world.

The problem with CER, these authors emphasize, is that most medical patients have more than one condition and many are elderly; clinical trials tend to include, exclusively, patients who don’t have more than one major illness are relatively young. This limits the physicians’ abilities to apply data to their patients.

What’s more, reported results tend to focus on central results, but most patients fall elsewhere on measured curves:

The heterogeneity of treatment effects will further complicate CER. Although studies typically report average effects, most participants experience more or less benefit and harm than average. Such heterogeneity results from variability in patients’ initial level of risk for a given outcome, in their responsiveness to treatment, and in their vulnerability to adverse effects — issues with particular relevance to patients receiving treatment for multiple coexisting conditions.

The authors, who recognize the need for better research to support treatment decisions, write that “CER will probably accelerate the movement toward outcome-driven decision making, reimbursement, and quality assessment. As this shift occurs, we must move toward a focus on cross-disease, “universal” outcomes in research and clinical care.” Their thesis gets more abstract (which I admire), but meets a wall or two: the lack of consensus on a set of universal health outcomes, different parameters measured by the likes of the VA administration, CMS, the FDA, NIH and other huge agencies.

They make a practical suggestion, about the need for head-to-head comparisons in CER:

… interventions such as exercise that affect multiple conditions simultaneously should be a high priority…Studies should include assessment of the burden of treatments for patients and families. Another CER priority should be the examination of treatments for common pairs of diseases in which treatment of one may exacerbate the other. For example, when hypertension and osteoporosis coexist, what treatment best minimizes the risk of adverse cardiovascular outcomes without increasing the risk of falls and fractures?

All of this sounds reasonable to this patient-doctor, but it’ll take a lot of time and money to accomplish effective CER that encompasses the needs and conditions of sufficient numbers of patients in disease and age combinations to power any meaningful studies. You have to wonder at some point, as I have been lately, is all this clinical research worth the effort?

That said, I respect this paper‘s conclusions on CER:

Researchers have largely shied away from the complexity of multiple chronic conditions — avoidance that results in expensive, potentially harmful care of unclear benefit. We cannot improve health care’s quality, effectiveness, and efficiency without addressing its greatest consumers. Development and testing of innovative approaches to care for patients with multiple chronic conditions could prove the most lasting legacy…

My bottom line: CER, and consideration of treatment costs, should underlie reduction of cancer care costs in the near and long-term future. As to how we accomplish sufficiently careful research, and avoid inappropriate cutting of helpful treatments – especially those that prove beneficial for some younger and otherwise healthy cancer patients – is one of the two main challenges ahead.

(The other big challenge, mainly a moral one, is the subject of rationing, to which Smith and Hillner allude but don’t detail, and which subject I won’t address in this post.)

Meanwhile: thorough, apolitical, nuanced and transparent reporting of trial results would help doctors, patients and the general public understand what information is available.

Finally, in the next month or so I will look back over the full, provocative and generally excellent list by Drs. Smith and Hillner, and see what holds hope for the future of cancer medicine. What’s clear is that the path ahead mandates clear thinking through some very tough clinical decisions.

Related Posts:

Mars Chocolate Company Advertises With Broccoli


MARS chocolate ad

The other day, over lunch, I was reading the Sept 2011 issue of the Atlantic and came upon this image on p. 37. According to the not-so-fine print, this full-page broccoli fix is sponsored by MARS chocolate, North America, website listed:

www.marshealthyliving.com

So we can find out about nutrition from the company that manufactures M&M’s, Snickers, Twix, MilkyWay and 3Musketeers.

Part of a trend –

The New Yorker recently ran a profile of PepsiCo CEO Indra Nooyi that almost persuaded me the super-sized soda-based conglomerate does the right thing in the healthy living department.

Kinda like Shell, Exxon and BP doing good work for the environment.

Got it?

Related Posts:

What is a Cybrarian?

ML learned a new word on Twitter last week:

cybrarian: “a person whose job is to find, collect, and manage information that is available on the World Wide Web”

My source is the on-line, ever-handy Merriam-Webster dictionary.

(H/T to Dave deBronkart, who sent the term flying across cyberspace.)

—–

Related Posts:

NIH to Drop Requirement for Websites Disclosing Researchers’ Ties to Industry

sunshine image

Today’s word comes from Nature News that the NIH is dropping a proposed requirement for universities to disclose researchers’ financial ties to industry on websites. This is a loss for patients, who may not be aware of their doctors’ relationships with pharmaceutical companies and others who fund clinical trials, fellowships, conference junkets and other perks for physicians.

In 2010, NIH Director Francis Collins wrote: “As the nation’s biomedical research agency, the National Institutes of Health (NIH) must ensure that the research it funds on the behalf of US taxpayers is scientifically rigorous and free of bias.”

This sounds right to me, as it did to the folks at the health and safety arm of Public Citizen, according to the Nature report:

…a cornerstone of that transparency drive — a series of publicly accessible websites detailing such financial conflicts — has now been dropped. “They have pulled the rug out from under this,” says Sidney Wolfe, director of the Health Research Group at Public Citizen, a consumer-protection organization based in Washington DC. “It greatly diminishes the amount of vigilance that the public can exercise over financially conflicted research being funded by the NIH.”

As explained in the article, the proposal came about after evidence came to light that prominent NIH grant recipients had failed to inform their employers (universities and medical schools) about lucrative payments from companies that may have influenced their research. The problem now comes, in part, from lack of funding: the White House Office of Management and Budget (OMB) has no way to enforce the requirement.

That’s no surprise. But it turns out that academic groups lobbied against the requirement. According to the Nature News piece, the Association of American Universities and the Association of American Medical Colleges submitted a joint statement objecting that a website detailing physicians’ potential conflicts of interest (COI) would be onerous:

“There are serious and reasonable concerns among our members that the Web posting will be of little practical value to the public and, without context for the information, could lead to confusion rather than clarity regarding financial conflicts of interest and how they are managed.”

As a patient and as a physician who’s cared for patients in clinical trials and served on an institutional review board (IRB), I can’t be more clear in my thinking that the public should know about academic (and all) physicians’ ties with industry. Every institution with NIH funding should make this kind of information readily available and clear to patients. Otherwise, the faculty don’t deserve the NIH support they’re receiving for the research, nor do they deserve the public’s trust in their work.

Patients should be able to find this kind of information readily, before they enroll in clinical trials or decide to undergo any elective procedures, and even before they choose the physician who would guide them in health care decisions.

—-

Related Posts:

New Fairway Delivers Fresh Produce to My Neighborhood

On the local, national and nutritional fronts:

How refreshing, in this heat, that Fairway opened a new store on East 86th Street yesterday. Coincidently, Michelle Obama’s push to eliminate “food deserts” – places where it’s hard to find affordable fresh produce and other healthy foods – was highlighted this week when several big retailers signed on to the initiative.

PHOTO CREDIT: DNAinfo/Amy Zimmer (Manhattan Local News)

There was a carnival-like atmosphere on the sidewalk outside the new store, which occupies a large, multilevel space where there used to be a Circuit City (bankrupt, closed) and a Barnes & Noble (moved). Inside, I made a rough tally of unpackaged (6 varieties), nectarines (4), plums (3), string beans (4, including a yellow variant I’ve never seen before), potatoes (11 non-sweet, +  yams and “yellow yams”), onions (7), mushrooms (5), not counting the pre-packaged kinds), peppers (11), tomatoes (9) and beets (3).

You get the picture: if you’re looking for a fresh ingredient and it’s available anywhere New York, chances are you can find it here. Downstairs, there’s fresh fish, meat, coffees, baked goods, and tons of regular and organic grocery items. I counted 22 types of pure honey, not including differently-sized items of the same brand and flavor, and then stopped. Upstairs, there’s a limited selection of prepared foods, a competitively-priced smoked fish counter, a wide cheese selection, dried fruits, nuts and more.

I spent a while meandering through, and heard only positive comments. The shoppers seemed happy; the employees registered glee. A woman next to me on a briskly-moving line summed up the consensus: “This is the best thing that’s happened to the neighborhood in years.”

We should all be so lucky –

Related Posts:

The Trouble With Placebos

The latest NEJM features a big story about a small trial, with only 39 patients in the end, on the potential for placebos to relieve patients’ experience of symptoms. This follows other recent reports on the subjective effectiveness of pseudo-pharmacology.

My point for today is that placebos are problematic in health care with few exceptions. First, in clinical trials, patients sometimes agree to take what might be a placebo so that researchers can measure effects of a drug, by comparison. A second instance is, possibly, when doctors treat children. Even then, I’m not sure it’s wise to “train” kids to take a pill and expect to feel better.

The relationship of an adult patient with a physician involves, or should involve, trust and mutual respect. A person cannot possibly give informed consent for a treatment he or she doesn’t know about. So if the doctor’s giving a placebo to the patient, and making the decision for the patient because it might help, that diminishes the patient’s autonomy, or self-determination. In simpler terms, it’s condescending.

You might consider the hypothesis that there’s nothing wrong with something if it makes you, or someone else, feel better. But that’s kind of like saying the ends justify the means.

A placebo is, by definition, manipulative. I wouldn’t want any doctor to treat me that way.

Related Posts:

On Admitting Nice, Ethically-Minded People to Med School

This week the Times ran a leading story on a new med school admission process, with multiple, mini-interviews, like speed dating. The idea is to assess applicants’ social, communication and ethical thinking (?) skills:

…It is called the multiple mini interview, or M.M.I., and its use is spreading. At least eight medical schools in the United States — including those at Stanford, the University of California, Los Angeles, and the University of Cincinnati — and 13 in Canada are using it.

At Virginia Tech Carilion, 26 candidates showed up on a Saturday in March and stood with their backs to the doors of 26 small rooms. When a bell sounded, the applicants spun around and read a sheet of paper taped to the door that described an ethical conundrum. Two minutes later, the bell sounded again and the applicants charged into the small rooms and found an interviewer waiting. A chorus of cheerful greetings rang out, and the doors shut. The candidates had eight minutes to discuss that room’s situation. Then they moved to the next room, the next surprise conundrum…

This sounds great, at first glance. We all want friendly doctors who get along. It might even be fun, kind of like a game. (Sorry for the cynicism, injected in here, but it’s needed.) I’d even bet that the interviewers and successful interviewees would emerge feeling good about the process and themselves.

But don’t you think most premed students, who get through college, and numerous letters of recommendation, take the MCATS and achieve scores high enough to get an interview, are smart enough to get through this social test without failing? It’s what these young men and women are thinking, internally, that matters. According to the same article, the country’s 134 medical schools have long relied almost entirely on grades and the MCAT to sort through over 42,000 applicants for nearly 19,000 slots.

My math: that means nearly 19 out of 42 (almost half!) of med school applicants get in, here in the U.S.

If we want future doctors who are smart enough to guide patients through tough, data-loaded, evidence-based and ethically-complex decisions, we should make the academic requirements for entry more rigorous, especially in the areas of science, math and analytical thinking.

Related Posts:

Reducing Costs by Holding Back on Chemotherapy for Cancer Patients Who are Frail

This is the fourth in a series of posts on Bending the Cost Curve in Cancer Care, by Drs. Thomas J. Smith and Bruce E. Hillner, in a recent NEJM health policy piece. The authors’ third suggestion: to limit chemotherapy to patients with good performance status, with an exception for highly responsive disease, is surely one of the most controversial.

What they’re suggesting is a simple rule: “Patients must be well enough to walk unaided into the clinic to receive chemotherapy.” There are necessary exceptions, they point out, such as cancer patients disabled by another medical condition but who otherwise can carry out daily activities with relative normalcy. (I’ll offer an example: say a 50-year woman with multiple sclerosis who is wheel-chair bound but otherwise essentially well; she would be a candidate for treatment in this scenario.) But in general the authors would hold off on chemotherapy for cancer patients with a limited performance status  – a measure that oncologists use to assess how well, or disabled, a person is in their capacity to work, perform ordinary daily activities and care for him or herself.

I’m not sure I agree with the “walking” threshold, or ECOG performance status 3 or below, as the authors describe: “meaning that they are capable of only limited self-care and are confined to a bed or chair more than 50% of waking hours.” These criteria are subjective and problematic. But I do think the authors are onto a central, unavoidable issue in reducing health care costs. That is by limiting care, i.e. by rationing.

For elderly patients with cancer, especially for those who have significant other illnesses, it may not be appropriate for doctors to give chemotherapy and other, non-palliative cancer treatments. The authors don’t (dare) advise a particular age cut-off for therapy; they suggest using performance status criteria. They conclude this section of the paper on cutting cancer care costs with this statement:  “Implementation of such a simple threshold could dramatically decrease the use of chemotherapy at the end of life.”

The authors are right, that we (oncologists and other doctors) shouldn’t be in the business of routinely giving aggressive treatments to patients who are very old and frail, who are more likely to suffer harms of treatment than potential benefits. Not just because we can’t continue driving up U.S. health care costs indiscriminately, but because when very frail, elderly patients are given chemotherapy they’re less likely to recover after treatment. By not saying “no” to patients who are too fragile for a requested intervention, or by simply treating patients who are so feeble or demented, or both, that they’re unable to say “no” for themselves – such as sometimes happens in nursing homes and other chronic care facilities, doctors may cause more harm than good.

Some readers of this blog may be wondering how I can reconcile this position with what I’ve said about access to Avastin for women with advanced BC. In my opinion, patients’ age and, broadly, their functionality – if they can think and communicate seems at least as relevant as whether they can walk – should be factored into the risk/potential benefits analysis of almost any medical treatment.

So if we’re going to consider restricting cancer drugs and interventions based on cost, indirectly or overtly, we should account for patients’ ages, the potential length and quality of life to be gained: If there’s a 50 year old patient who might benefit from a costly cancer treatment, it’s likely that person will benefit more from that drug than would a 70 year old patient, or a 90 year old patient. It’s also more likely, but not a sure thing, that a younger, otherwise healthier patient will tolerate a given treatment with fewer side effects.

Hard to know where and how to draw the lines.

Related Posts:

FDA Approves New Assay for Her2 in Breast Cancer

This week the FDA approved a new assay for Her2 expression in breast cancer biopsies. The technology, Inform Dual ISH, is manufactured by Ventana Medical Systems, a Roche subsidiary.

From Ventana Medical: the HER2 and Chromosome 17 probes are detected using two color chromogenic in situ hybridization (ISH)

Inform Dual ISH works like this: technicians, typically working under the supervision of a pathologist, expose a tiny bit of a breast biopsy specimen, fixed on a microscope slide, to probes for Her2. This gene, normally found on human chromosome 17, is amplified in some breast cancer cells. The assay exploits an enzyme, linked to the genetic probe, which creates a color (in this case, red) upon exposure to a chemical. The system allows a pathologist, using a microscope, to “see” and measure the gene’s presence on chromosomes in cells of an ordinary biopsy sample.

What’s interesting about this in situ hybridization (ISH) kit is that it doesn’t require a fluorescent microscope for imaging. The Ventana probe generates a simpler, ordinary color signal that can be detected by a light microscope. Most commercial assays for Her2 use a method called immunohistochemistry (IHC); that technique relies on antibodies that bind Her2, a cell surface receptor that’s implicated in cancer cell signaling and growth. This and other ISH assays measure genes directly on the chromosomes; by contrast, IHC usually tests for protein.

Her2 is the molecular target for Herceptin, and there’s been considered discussion about how and where it might be accurately assessed. So the “readout” from this diagnostic test might inform a woman and her doctor in deciding whether or not she should receive treatment with Herceptin.

How pathologists evaluate breast biopsy specimens matters a lot, especially when you’re on the receiving end of a diagnosis and you’re choosing among treatments. In 2007, ASCO and the College of American Pathologists published guidelines on Her2 testing in the Journal of Clinical Oncology. These groups recently updated the recommendations. How this new assay will be received by these societies, I’m not sure.

A key question, in this author’s mind, is where the Her2 measurements take place, and whether women should rely on local labs’ assays – by whatever method – to determine the Her2-ness of their breast tumors.

Related Posts:

A Recipe for Fresh, Low-Fat Blueberry Muffins

This morning I noticed we had too many blueberries in the fridge. So while my husband went out for a run, I opened the windows wide (to cool the apartment), turned on the oven and made some fresh breakfast food.

fresh muffins, Sunday morning

It had been two decades or so since I’d baked anything like these. My recollection, mainly from my suburban childhood, was that muffins involved a fair amount of work; we used to pull out a mix-master with beaters, a flour-sifter, and all sorts of stuff that then had to be cleaned. That was far too much work for me this morning.

So I simplified and halved an old recipe I’d hand-written sometime back in my Moosewood years. And I adjusted it so there’d be less sugar, and swapped whole milk for skim.

Preparation time: 8 – 15 minutes, depending on your proficiency in the kitchen; Baking time: 30 minutes

Ingredients (for 8 small muffins):

1/4 cup softened butter (vegetable oil is OK, too; some people say that improves the texture and taste of the baked goods, but I’m not convinced and try to minimize chemicals in my cooking.)

2/3 cup sugar

1 large beaten egg

1/4 cup skim milk

1/4 teaspoon salt

1 teaspoon baking powder

1 cup flour (I used organic, which I happened to have, and didn’t bother sifting it)

optional: cinnamon, ~ 1/4 teaspoon

ripe blueberries, about 2 cups, washed

—-

Preparation:

1. Preheat the oven to 375 degrees (F)

2. Use a fork to smash the butter at the base of a deep, medium-sized bowl;

3. Add the beaten egg and mush everything together;

4. Add in the sugar, stir with a fork or large spoon;

5. Add the milk, swirl everything together with the spoon;

6. Add the salt and baking powder, mix thoroughly at this point to evenly distribute the salt and powder;

7. Add the flour, and mix again.

(This step completes a basic muffin batter.)

8. Now, add the fruit.* For blueberries: With extra-clean hands, grab a fistful of washed blueberries and squeeze them into the batter for flavoring. Then add in the remaining whole berries and mix those around, gently.

9. Insert paper cupcake holders into the holes of an oven-proof muffin tray. Drop about 1/3 cup of batter into each cup, not overfilling.

10. Bake for 30 minutes at 375 degrees in the center of the oven.

11. Remove from the oven. (If you’re compulsive, as I am: insert and withdraw a toothpick with a quick in-out stroke; if the muffins are cooked, raw batter won’t stick. If batter does stick to the toothpick, put the muffins back in the oven for 5 minutes or longer, until they’re done.)

—–

If you follow these instructions, you can make fresh muffins with minimal equipment and little to clean up. You can freeze and store the muffins, no problem, once they’ve cooled.

*There are countless fruit variations and other add-ins you might use. This morning I prepared half of the batter using a ripe, diced banana and a fistful of cut-up walnuts.

Considerations:

Not everything I cook is nutritious. And while I don’t advise eating muffins regularly, as these are essentially confections, I figure if you’re going to serve these to your family, it’s better that they be prepared with fresh ingredients and a minimum of chemicals, sugar, salt and fats. These have some relative advantages over similar breakfast treats:

These lack preservatives;

They’re roughly half the size of typical store-bought muffins (countering the super-sized effect);

They’re made with skim milk instead of whole milk;

They have approximately 2/3 the usual amount of sugar.

Besides, they came out great!

Of course, dear readers, I’d like to know what are the true nutritional benefits in blueberries, and what happens to their putative anti-oxidant properties once they’ve been baked for 1/2 an hour. But I don’t think anyone knows, for sure.

—–

Related Posts:

  • No Related Posts

Cooking With Leeks

A note on cooking with leeks, inspired by a NYT Well post with a list of related Recipes for Health:

I use leeks all the time, as my neighbors are probably too aware. I use leeks sautéed in olive oil as filler, mixed with an egg and flour for a tart, or to season simple pasta, or to flavor and decorate roasted potatoes.

How I prepare leeks is this:

First I cut off the base and ragged tips of 3-4 stems, slice the mainly dark-green stems lengthwise, and then cut the stalks into 1 – 3 inch sections, depending on what they’ll be used for. Because there’s often dirt from the ground deep in the lower, paler sections of the leeks, I manually expose and separate each rounded layer, and then wash everything  under briskly-running water, thoroughly rinsing at least three times.

You don’t have to dry the cut, washed leeks. What I do is heat a heavy, wide pan on the stove, add a thin layer of olive oil, and then throw on the damp (or dry) leek pieces. With the flame set low, I toss on about a half teaspoon of salt for a volume of 3-4 large stalks. Sometimes I add fresh ginger, cut into tiny pieces, into the mix.

And then I work on other things in the kitchen – often while listening to NPR or talking to my mom on the phone – while the leeks wilt. If I’m running late, I’ll put a lid on the pan, which makes the leeks soften faster, but that’s not ideal. Every few minutes I stir them around a bit with a wooden spoon or spatula, until they’re soft and, typically, shiny with varied shades of green.

You can store cooked leeks in the refrigerator for a few days, if they’re in a sealed container. So you might, as I have, use a small amount with pasta on a Monday, and then use the remainder for a goat cheese and leek tart later in the week. There are many variations, and I’ve only started using this vegetable in the past four years or so.

This summer I intend to try making a potato-leek soup.

According to Martha Rose Shulman, writing for the Times, leeks are milder than onions but contain sulfur compounds present in onions and green garlic that some people find hard to digest. Leeks are a good source of nutrients like lutein and zeaxanthin, carotenoids – thought to be important in vision, calcium, iron, magnesium, phosphorus, potassium and vitamin K. Leeks are fiber-rich, I might add.

I should learn more about each of these elements; how they’re best cooked and absorbed. Unfortunately I’m still searching for the nutrition textbook they never assigned in med school.

Related Posts:

First Look at the Burns Collection of Early Medical Photographs

CBS News has posted a gripping set of images, mostly of cancer patients, dating to the 1880s. The photos from the Burns Archive are graphic, as much as they’re telling, instructive and rare.

 

This photograph, taken in New York City in 1886, is one of the earliest ever taken of breast surgery. Surgeons had begun to adopt infection-control measures in the operating room, but at this point they hadn’t yet adopted the use of surgical masks and hats and their surgical gowns were simply put on over their street clothes. The anesthesiologist whose hands are visible holding the patient’s arm on the left side of the frame is wearing street clothes. Anesthesiologists were the last doctors to don surgical clothing in the operating room.

Credit: Dr. Stanley B. Burns, via CBS News

According to its website, the Burns Archive houses the nation’s largest and most comprehensive collection of early medical photography (1840-1920). It turns out the collection is based on East 38th Street. It’s nearby, and I should explore it for real.

Meanwhile, I recommend that my non-squeamish readers take a look at the CBS-published images. If nothing else, these digitized relics display how far improved are surgical methods – and cancer treatments – since the late 19th Century.

Related Posts:

Defining a Cluster of Differentiation, or CD

One of the goals of this blog is to introduce readers to some of the language of medicine. As much as jargon is sometimes unnecessary, sometimes the specificity and detail in medical terms aids precision.

So what is a cluster of differentiation, or CD?

In medical practice, the two-letter acronym specifies a molecule, or antigen, usually on a cell’s surface. In 1982, an international group of immunologists got together for the First International Workshop on Human Leukocyte Differentiation Antigens. The initial focus was on leukocyte (white blood cell) molecules. The goal was to agree on definitions of receptors and other complex proteins to which monoclonal antibodies bind, so that scientists could communicate more effectively.

A few examples of CDs about which you might be curious:

CD1 – the first-named CD; this complex glycoprotein is expressed in immature T cells, some B cells and other, specialized immune cells in the skin; there are several variants (CD1a, -b, -c…) encoded by genes on human chromosome 1.

CD4 – a molecule on a mature “helper” T cell surface; T lymphocytes with CD4 diminish in people with untreated HIV disease.

CD20 – a molecule at the surface of immature B lymphocytes that binds Rituxan, an antibody used to treat some forms of lymphoma, leukemia and immune disorders.

 

In this schematic, an antibody recognizes a specific molecule, or cluster of differentiation, at a cell surface.

The CDs were named (i.e. numbered) not necessarily by the order of discovery, but by the order of their being deemed as bona fide CDs by HLA Workshop participants. There’s a pretty good, albeit technical, definition in FEBS Letters, from 2009:

Cluster of differentiation (CD) antigens are defined when a surface molecule found on some members of a standard panel of human cells reacts with at least one novel antibody, and there is good accompanying molecular data.

Perhaps the best way to think about CDs is that they’re unique structures, usually at a cell’s surface, to which specific antibodies bind. By knowing the CDs, and by examining which antibodies bind to cells in a patient’s tumor specimen, pathologists can distinguish among cancer types. Another use is in the clinic, when oncologists give an antibody, like Campath – which binds CD52, the responsiveness might depend on whether the malignant cells bear the CD target.

Still, I haven’t come across an official (such as NIH), open-source and complete database for all the CDs. Most can be found at the Human Cell Differentiation Molecules website, and information gleaned through PubMed using the MeSH browser or a straight literature search.

Wikipedia is disappointing on this topic; the list thins out as the CD numbers go higher, and the external references are few. To my astonishment, I found a related page on Facebook. Neither makes the grade.

Where should patients get information about these kinds of things? Or doctors, for that matter?

Related Posts:

TV Meets Real Life Oncology, and Anticipating the MCATs

Yesterday I wrote on some tough decisions facing a TV show‘s protagonist. She’s got metastatic melanoma and might participate in a clinical trial when the show resumes.

Now imagine you’re an oncologist, or a real patient with this killing disease – you really need to be on top of new developments, to understand the pros and cons, because someone’s life depends on it.

If you’re the doctor in the relationship, you need keep abreast of current information for all the other tumors types of patients in your care: what are the new findings, if any, what are the limitations of the data. You need to know how the advances apply to an individual person who, most likely, has another condition or two, like high blood pressure or, say, osteoporosis.

Oncologists ought to be familiar with new drugs, and how those compare to old ones, and the side effects, and the distinctions between tumors with and without BRAF mutations. They should know what BRAF stands for.

Melanoma is one form of skin cancer. We understand now there are breast cancer subtypes – with distinct behavior and responsiveness to treatments, with and without inherited and acquired genetic mutations (BRCA-1 and -2 were identified well over 10 years ago; there’s much more known now), dozens of lymphoma forms and innumerable leukemia subtypes. Lung cancer, prostate cancer, brain cancer… Each is a group of diseases.

But the science physicians apply in their work doesn’t just apply in oncology. Even in traditionally “softer” fields of medicine, like pediatrics, doctors need to know how congenital diseases are diagnosed with newer, cheaper methods for testing mutations; in gynecology, doctors need to know about inherited clotting dispositions; in psychiatry, doctors give medicines with complex metabolic effects that involve, or should involve, some grounding in modern neuroscience.

This is why we need to keep the MCAT hard. (I’ll write more on this current issue in medical education, soon.)

Have a great weekend!

ES

Related Posts:

Get Off My Case

In my inbox this morning, via ASCO‘s “Cancer in the News” feed:

The UK’s Telegraph (5/6, Beckford) reported that as “many as 20,000 British women could avoid developing” breast cancer “each year, if they took more exercise, drank less and ate better.” Latest figures “suggest that 47,600 women developed breast cancer in 2008,” and the World Cancer Research Fund estimates that estimates that “42 per cent of these cases…would be preventable if women developed healthier lifestyles.” The WCRF’s “10 Recommendations for Cancer Prevention include being ‘as lean as possible without becoming underweight’; keeping fit; limiting consumption of fatty, salty and sugary food and drink; eating fruit, vegetables and pulses; eating less red meat and processed meat; drinking less and choosing a balanced diet rather than vitamin supplements.”

This follows numerous reports that women may develop breast cancer or suffer recurrences because they eat too much, drink too much, work too much or fret too much. (But don’t relax and put down your vacuums, girls – there’s striking evidence that household chores can reduce your risk!)

Of course it’s wise from a general medical perspective – think in terms of heart disease, osteoarthritis, type 2 diabetes and other ailments prevalent in our too-developed world – to be slender instead of fat, exercise regularly and eat a balanced diet.

I’m tired of the press trumpeting poorly-done trials that feed into a stereotypic conception of how women should behave. Yes, diet and stress could play a role in any hormone-driven disease, but so do a lot of things. As for alcohol, maybe consumption is a surrogate for wealth and living in a place like the U.S. where people drink freely, where breast cancer rates are unseemly.

We should be sure of the facts before pronouncing these fatal flaws in our ways of existence and being. Plenty of women feel badly about their tumors and disfigurement without this added layer of insult.

And what did you eat for dinner last night, big brother?

Related Posts:

newsletter software
Get Adobe Flash player