Monthly Archives: December 2013

Penne with Vodka Sauce

A guest post by OBS Housekeeper, pasta cook extraordinaire and sister of TBTAM.

penne vodka 5The kids are all together for the first time in months and we have just 5 days until Christmas so it’s time to decorate the tree. In need of something simple and delicious for dinner I hit the freezer for some Vodka Sauce that I had made a few weeks ago.

penne vodka 1

Pair it with penne,

Penne vodka 2

a Caesar saladpenne vodka 3 and crusty Italian bread and dinner is served.

It must have been tasty because there were no leftovers! And the tree couldn’t be more beautiful! Happy holidays!

PENNE with VODKA SAUCE
Vodka sauce traditionally does not include garlic, but OBS housekeeper says “What’s a pasta sauce without garlic?”

Ingredients
1 stick Butter
1 Onion, finely diced
3 cloves garlic, finely chopped
1 Cup Vodka
2 – 28 ounce cans Crushed Tomatoes
1 pint heavy cream

Directions
1. In a skillet over medium heat, saute onion in butter until slightly brown and soft, add the garlic in the last munite or so.
2. Pour in vodka and let cook for 10 minutes.
3. Mix in crushed tomatoes and cook for 30 minutes.
4. Pour in heavy cream and cook for another 30 minutes.
5. Toss sauce with penne.
6. Add plenty of freshly grated parmesan cheese.
7. Enjoy!

The Forty Part Motet & Thoughts on Choral Singing

40 Motets Cloisters NYC

Thanks to my friend Rachel, I visited the Cloisters on the final day of Jane Cardiff’s stunning installation “The Forty Part Motet“. I’m sure I had a very different experience than what Cardiff imagined when she set up 40 speakers around an empty room, each one playing the voice of one of the singers of the Salisbury Chorus performing Thomas Tallis’s Spem in Allum.


Cardiff meant for listeners to move freely about the space, sampling the piece from the vantage point of the different singers in the choir, then stepping into the center to feel them all hit you at once.

“While listening to a concert you are normally seated in front of the choir, in traditional audience position. With this piece I want the audience to be able to experience a piece of music from the viewpoint of the singers. Every performer hears a unique mix of the piece of music. Enabling the audience to move throughout the space allows them to be intimately connected with the voices. It also reveals the piece of music as a changing construct. As well I am interested in how sound may physically construct a space in a sculptural way and how a viewer may choose a path through this physical yet virtual space.

I placed the speakers around the room in an oval so that the listener would be able to really feel the sculptural construction of the piece by Tallis. You can hear the sound move from one choir to another, jumping back and forth, echoing each other and then experience the overwhelming feeling as the sound waves hit you when all of the singers are singing.”

But on this last day of the exhibit, the crowds were too large to allow for free movement without disturbing others. Thus, I stood in one place for the entire piece, and then to listened to it 7 more times from 7 different vantage points in that glorious space. Only once did I make it to the center of the room, but found my favorite spot was in the back in front of a baritone, where I could feel the music starting far away then moving towards me, till finally I was in the music.

But no matter where I stood, I experienced an incredible feeling of community with the others around me, as we all were transfixed by the hauntingly beautiful voices and themes of Tallis’s music. Even small children were stunned into glorious silence, their wriggling stopped, their heads upon their parent’s shoulder as they stared dreamily upward.  As I looked around the room, the swell of the music combined with that feeling of shared emotion literally drove me to tears. I have rarely felt so connected to a roomful of strangers as I did in the midst of that music.

As a choral singer, I should be able to say that I experience this feeling of collective joy frequently, but the truth is that I don’t. When I’m singing, I’m usually too focused on getting the notes and the entrances right, counting along with my finger on the score, reading the notes I’ve written along the staff that remind me to slow down, or speed up, or watch my pitch, or the little eyeglasses that tell me to look at the conductor for an ending or change in tempo. It is rare that I experience the swell of emotion that comes from the experience of being in the midst of a collective voice.

But then it happened – on the very same evening as my visit to the Closters – when, as chance would have it, I was performing the Durufle Requiem with my chorus in our annual winter concert.

I had been standing at the back of my section for the rehearsals, a piece of cotton in one ear so that I could hear my own voice in the crazy acoustics of the space, afraid that I would be off pitch, knowing that it only takes one slightly off note from anywhere to throw me off, trusting only the organ to keep me from going sharp or flat.  But just before the performance, my fellow Soprani begged me to squeeze in between them so they could hear me – since I had only recently sung the same piece with the Cornell Music & Medicine Chorus, I knew it relatively well and had the entrances right, and they were counting on me for that.  So in the performance, I did as they asked. And whether it was because they got the entrances from me, or I got the pitch from them, or we all finally had had enough rehearsal to know the piece well, it was the best performance we’ve ever given.

And there were moments – not enough, but a few – where I felt confident enough in my singing to let myself listen for it, and there it was – that swell of emotion that comes from shared vocalization. That point in the Kyrie when we echo one another , then join in together. The soaring highs of the Libera mi. And those moments in the In Paradisum when we sopranos totally nailed our group solo.

Those moments of joy in choral singing really only come when you are confident enough in the music to let go and feel. And I got there because, between the two choruses and two performances, I had finally had enough rehearsal to get to that place.

I’m going to remember this next season, and dedicate myself to really learning the music early on. Woodshedding, we call it. The rehearsing you do on your own with the score and a piano or rehearsal CD to really learn the music. It’s  a lot of hard work, hours really, outside of the hours already spend in group rehearsal.

But the payoff ? It’s glorious.

Nuvaring – Weighing the Risks & Benefits

NuvaRing_compressedNOTE – THIS POST HAS BEEN UPDATED TO INCLUDE TWO NEW RESEARCH STUDIES THAT DO NOT FIND AN INCREASED CLOT RISK AMONG NEW RING USERS

You’re probably here because you read the recent article in Vanity Fair that highlights the stories of young women who suffered blood clots while using Nuvaring, and asks why this method is still on the market.

You may be wondering whether or not you should stop using the ring, and worried about what risks you’d be taking if you kept on using it.

I’m not going to get into the Vanity Fair article itself, except to say that highlighting individual stories, while making compelling reading, does little to really educate women about their own risks. Making Pharma into the bad guy is also compelling, and given how they behave in general, pretty easy to do.  But compelling reading does not necessarily make for good medical advice. Which is what women really need.

So let’s see if I can help out a bit with that.

As I see it, this issue at hand, is this – are the risk of blood clots, which are inherent in any estrogen-containing birth control method, higher in Nuvaring than in other birth control methods you might choose to use? If so, is that difference big enough for you to consider using something other than the Ring?  Or are the benefits you may get from using the Ring (convenience, compliance, and for some women, steadier hormone levels) enough to outweigh the increased risks?

 LET’S START WITH THE BASICS

You need to know a few things before we start.

1. If you have sex, unless you use birth control, you will most likely get pregnant.  The odds are about 80% in a year. So unless you plan on being pregnant, you’ll need to use something for birth control. That something is most effective if it is either hormonal or an IUD.

2. On average, your annual chance of getting a blood clot is about 3 in 10,000 if  you don’t use birth control.  This background risk varies with age, increasing from a low of 0.7 per  10,000 at age 17 to about 6 per 10,0000 at age 45. Other factors can increase your risk even further – genetics, obesity, and varicose veins can double the background risk at any given age.

3. Having a baby is always riskier that using birth control.  The risk of blood clots in pregnancy is the highest risk any woman can take, ranging from 4-28 times the background risk.

4. All estrogen containing birth control methods increase the risk of blood clots. Quantifying that risk is difficult, but it ranges from 3-6 times the background risk, depending on which study you quote and which method you are comparing. The risk is related to both the dose of estrogen (the higher the dose, the higher the risk) and the type of progestin used.

5. First and second generation pills have the lowest clot risk – These pills contain levonorgestrel, norethindrone and norgestimate, and their clot risk is about 3 times higher than the background risk. Newer pills using gestodene, desogestrel and drosperinone  have risks about twice that of levonorgestrel pills, as do the Nuvaring and Patch.  That risk is about 6 times the background risk.

6.  Overall, your chance from dying from estrogen-containing birth control methods is about 1 in a million.  

7. Birth control has benefits as well as risks. Birth control pills, the Ring and the Patch lower the risk of ovarian and uterine cancer. Birth control pills also lowers the risk of colon cancer and do not increase the lifetime risk of breast cancer. Birth control pills, the Nuvaring and the Patch are effective treatments for heavy menstrual periods, endometriosis, PMDD, acne, menstrual cramps and fibrocystic breast disease.

8. If you don’t want to be pregnant, and don’t want the risk of estrogen containing birth control, there are other methods you can use. These include condoms, progesterone only pills, spermacides diaphragm, and IUD. These methods each carries their own set of benefits and risks, but do not cause blood clots.

NOW, WHAT ABOUT NUVARING? 

A large Danish study suggested that the risk for a blood clot among users of the Nuvaring is about twice that of older levonorgestrel-containing pills, and is about the same as that from using the Patch, Yaz or pills containing desogestrel.  Initial data from the FDA in 2011 suggested the same thing.

However, when only new hormonal contraceptive users are studied, that increased risks is not seen. Two newer studies – one funded by the FDA, the other by the ring manufacturer, have shown equivalent risks between the ring and older pills. This data makes mores sense clinically than the Danish study because prior research has shown equivalent estrogen levels in the ring compared to pills.  It is important in studies of clot risk to compare new users to new users, since clot risks are generally highest in the first 6-12 months of hormonal contraceptive use.

At this point (As of update 2/16/14), the FDA has not changed the RING labeling other than to include the data from these last two trials. The manufacturer, however has settled lawsuits pending against it. (See this post for more)

BOTTOM LINE

Only you (hopefully with your doctor) can decide if the benefits you are getting from using Nuvaring warrant the risk of clots inherent in all estrogen containing contraceptives. For now, that risk seems that it may not to be larger than that in older pills, at least in two of three studies published to date.

For those who cannot remember to take a pill, or who have gotten pregnant due to missed pills in the past, the convenience of the Nuvaring may far outweigh their concerns about the potential for added risk. I have patients who have been through most of the major pills brands, and only found satisfaction on the Nuvaring. For such women, the relative difference in risk seems small in comparison to the benefit they are getting.

But if you’re considering starting hormonal birth control for the first time, and especially if your are over age 35, most experts would say to start with a low dose levonorgestrel, norethindrone or norgestimate containing pill first. If these pills work for you, why take an additional risk by starting with the Ring (or the patch, or Yaz or a desogestrel pill), even if  that risk is a small one?

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Additional Reading

Additional Reading on Clots & Contraception from TBTAM