ACOG to Legislators – Get Out of Our Exam Rooms

In a strongly worded editorial in the NY Times, James T Breeden, MD, President of the American Congress of Obstetricans & Gynecologists (ACOG) has spoken out in support of Planned Parenthood and against recent legislative attempts to limit access to reproductive health care. After boldly pointing out the much-denied obvious – “The onslaught of laws focusing on denying reproductive health care rights is a concerted campaign against women,” Breeden then proceeds to succinctly and unequivocally address the four major fronts in that campaign –

Evidence-based medicine -“These laws are not grounded in science or evidence-based medicine.”

Planned Parenthood -“Efforts to de-fund Planned Parenthood, which provides cervical cancer and mammography screening, contraception and other preventive care to millions of women, are egregious and disproportionately hurt poor women.”

The Legal Practice of Abortion -“Mandating that women be legally forced to undergo transvaginal ultrasound or any other medical procedure against their will and against their physician’s judgment is an outrageous violation of patient autonomy and the confidential doctor-patient relationship.”

The physician-patient relationship and the legal practice of medicine -“Politicians were not elected to, nor should they, legislate the practice of medicine or dictate the parameters of the doctor-patient relationship. Our message to politicians is unequivocal: Get out of our exam rooms.”

Thank you, thank you Dr Breeden and ACOG, for speaking out on behalf of the obstetrician gynecologists who have dedicated their lives to the reproductive health care of women, and who are outraged on this attack on both our patient’s right to reproductive health care and on our right to legally practice medicine.

Roasted Carrot & Ginger Soup with Cheddar Dill Scones

I don’t know about your husband, but mine is out of control when it comes to food shopping.

It’s not his fault, really. He is a victim of his own evolutionary programming, which, in a bizarre maladaptation to modern society, is triggered whenever he enters Costco. At that point it begins to fire off uncontrollable urges that he cannot possibly resist, as co-activation of the male hunter-gatherer gene and the bargain hunting gene drives him to purchases extremely large boxes and bags of foods in quantities that we can’t possibly store in our NYC apartment or eat before they go bad.

Like the 5-pound bag of baby cut carrots be brought home last week. (What on earth was he thinking?… )

Short of setting up a take out salad bar in the dining room or throwing a cocktail party for 100 complete with the world’s largest crudite platter, I was going to have to figure out some way to use those little suckers.

But I love a challenge. And, thankfully, my family loves carrots.

Hopefully, you love carrots too, because that’s about all you’ll be getting on the blog this week. Today, it’ll be carrot soup. Wednesday, Carrot Cake. Then on Saturday, a Moroccan Carrot Salad.

Feel free to post your own favorite carrot recipes in the comments section. I’m starting to run out of ideas, but unfortunately, not carrots – there’s still about a pound left.

ROASTED CARROT & GINGER SOUP

I modified a recipe from the Silver Palate Goodtimes Cookbook, leaving out the wine and using olive oil instead of butter and roasting the carrots first. Serve with Cheddar Dill Scones (recipe below) and garden greens tossed with Lavender Honey Vinaigrette.

  • 4 tbsp olive oil (divided)
  • 1 1/2 pounds baby-cut carrots (or thickly sliced regular carrots)
  • 8 cups chicken stock
  • 1 large onion
  • 3 cloves garlic
  • 3 large pieces of crystallized ginger, finely chopped
  • 1 bay leaf
  • Salt and pepper to taste
  • Fresh dill to garnish

Toss the carrots with 2 tbsp olive oil, salt and pepper in a large bowl, then spread out on a baking sheet and roast at 400 degrees F for about 15-20 minutes till they start to soften and are browned.

In a soup pot saute the onions, ginger and garlic in 2 tbsp olive oil over medium high heat till onions are soft. Add stock, carrots and bay leaf. Heat to boiling, then reduce heat and simmer, uncovered, about 15 minutes.

Remove the bay leaf. Puree in the pot using an immersion blender. Season with salt, pepper and lemon juice if desired. Garnish with fresh dill and serve. Also delicious cold.

CHEDDAR DILL SCONES

Modified from Ina Garten. I cut back the butter from 3 sticks to two and used whole milk instead of cream – it just seemed like an insane amount of fat, especially since I was also adding cheese and eggs.  Ina adds the dill and cheddar at the end – I just added them right in with the wet and dry ingredients so I would not have to work the dough so much. I also added a tad of pepper for a slight kick.  

  • 4 cups flour
  • 2 tbsp baking powder
  • 2 tsp sea salt
  • 1/4 tsp ground black pepper (or a pinch cayenne pepper)
  • 2 sticks cold butter, diced
  • 4  cold large eggs, beaten lightly
  • 1 cup cold whole milk
  • 1/2 pound mild Cheddar, small dice
  • 1 cup minced fresh dill
  • 1 egg beaten with 1 tbsp water for egg wash

Preheat oven to 400 degrees F.

Combine flour, baking powder, and salt into a large bowl. In another bowl, beat milk, eggs and dill.With a pastry blender, cut the butter into the dough until it is the texture of coarse meal. With a wooden spoon, stir in the cheese.Make a well in the center, pour in the egg-milk-dill mixture, and working quickly with the spoon and eventually your hands, make a shaggy loose dough.

Turn out dough onto a well-floured surface and knead lightly for just a minute or less till workable. Pat or roll to 3/4 inch thickness and using a biscuit cutter, cut out your scones. Lay out on baking sheet lined with parchment or waxed paper.

Brush with egg wash and bake till golden, about 20-25 mins.  Serve warm.

TO SERVE THIS MEAL TO COMPANY

This is a very easy meal to serve to company as a lunch or light dinner.

The soup can be made up to a day ahead and reheated. You can also roll, cut out and flash freeze the scones ahead.  You can wash and dry your greens ahead and refrigerate, and make your dressing ahead.

Just before your guests arrive, take out the salad greens and dressing and put the greens in a salad bowl.  Preheat your oven.  Twenty minutes or so before you plan to serve dinner, pop the scones in the oven.  While the scones are baking, reheat the soup and hold it warm. Once the scones are done, call everyone to the table, dress the salad  and enjoy!

If this meal seems too light, add some grilled sausages or Irene’s baked chicken. 

Introvale Recall – The FDA (rightly) plays it safe

A birth control pill packaging error has led to a recall of Introvale, a 3 month birth control pill and generic for Seasonale. The apparent mix-up was that the placebo week was placed in the 9th instead of the 13th row of the pack.

Sandoz notified the public that it issued a voluntary recall of 10 lots of its generic oral contraceptive Introvale in the US, following a recent report of a packaging flaw. A consumer reported that the white placebo tablets were mistakenly in the ninth row (labeled “Week 9”) of the 13-row blister card, rather than in the correct position in the 13th and final row (labeled “Week 13”). Each three-month blister card contains 84 peach-colored active tablets and seven white placebo tablets in 13 rows, each representing one week. While the white placebo tablets can be clearly distinguished from the peach-colored active tablets, the risk of an unintended pregnancy for a patient taking the wrong tablet over several days cannot be excluded.

The lot numbers involved in the recall are as follows: LF00478C, LF00479C, LF00551C, LF00552C, LF00687C, LF00688C, LF00763C, LF00764C, LF00765C and LF01261C. These lots were distributed only in the US between January 2011 and May 2012.

RECOMMENDATION: If a patient finds a white placebo tablet in any position other than the 13th and final row (Week 13), they should immediately begin using a non-hormonal form of contraception and contact their healthcare professional.

The FDA is being appropriately cautious, and so should you. Follow their recommendation, especially if you have not been perfectly taking your pills. The pills are not what they should be, and they should be replaced.

But I have to admit, of all the pill packaging errors we’ve had to date, this one worries me the least. Here’s why – Traditional birth control pills have a placebo week once a month without impacting efficacy. So, unless the placebo week in the Introvate pack is one of the first 3 weeks of the pack, its placement elsewhere in the pack should do nothing more than give you an unexpected menstrual period. Certainly a placebo week that occurs after a full 8 weeks of active pills is not something that makes me concerned.

One exception would be a woman who had missed a pills or two just before that placebo week – not you’ve extended the pill free interval beyond 7 days and that’s a pregnancy risk. Which I suspect is one reason why the FDA is being extra cautious with their recommendations. I also suspect they’re making sure they’ve covered the possibility that there could be other issues with these lots.

What’s going on with birth control pill manufacturing these days?

I’ve never seen so many recalls – this is the third one in recent memory for me. All different manufacturers, all different pills. Anyone have any ideas?

The Sense of An Ending – a TBTAM Book Review

The Sense of An Ending, Julian Barnes Man-Booker prize-winning novel, is one of the most beautifully written and engrossing books I’ve ever read. It is also one of the shortest – a mere 160 pages. As Barnes has said “It is a concise novel. I couldn’t make it any shorter, and I don’t think I could make it any longer.”

It is a story, really. A very specific story about a very specific time and place in the life of a man, Tony Webster. Webster’s memories of that time, however erroneous they may be, reverberate beneath his life thereafter, until the day when he learns that he has been bequeathed a diary, a bequest that ultimately will upend his memories and his well-worn sense of who he is and has been. The startling and unexpected truth of what actually happened is revealed in the books last pages. Yet even that truth, while final and irrevocable, is incomplete, as is our memory and our knowledge of those we think we know.

This is a book you can read in one very long sitting, as if Webster were spending a long afternoon and evening with you, telling you a story about a pivotal event in his life. You’ll stop for dinner perhaps, then take up on the porch afterwards and sit till the wee hours until a sense of an ending is achieved.

At some point, you will learn that he has had a wife and a daughter, and even give you glimpses into these relationships. But what he tells you about them will be limited to what you need to know for this story, or as Webster puts it “They are in this story, but this story is not about them”.

In truth, this is the way we tell one another stories, isn’t it? We may glide off track occasionally, or dip into detail when necessary, but our listeners will pull us back on track “What happened next?” or ” Get back to the story”.  Barnes anticipates his reader’s need to move the story forward, while leaving us craving just a bit more detail than he gives us. But we are moving on towards an ending, so onward we go.

It’s a wonderful construct for ADHD readers such as myself who tend to become sucked into a book for long periods of intense time, but then have trouble picking it up again later. The satisfaction of completing the book, without skimming, in just two sittings was for me, enormous.

This was my first introduction to Barnes, and I’m adding his books to my long list of must-reads. I may make Love,etc my next. At 240 pages, it’s a bit heftier, but still manageable for my attention span. Although I may have to start with A Pedant in the Kitchen – at 136 pages, this collection of essays on cooking seems just about right for my plate.
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This is an unsolicited review. 

HRT – Still No Place for Prevention

In a much-needed and thoughtful analysis, the United States Preventive Service Task Force has summarized what we have learned about HRT since the Women’s Health Initiative was published in 2002. (See summary chart above.)

They have also issued draft recommendations on the use of HRT for prevention of disease.

The U.S. Preventive Services Task Force (USPSTF) recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women.

The USPSTF recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

I wholeheartedly agree. 

The USPSTF Recommendations do not address the use of HRT for treatment of menopausal symptoms

That’s an important message for women who may want to consider using HRT for a few years around menopause. In that setting, the heart disease risks are probably minimal for an otherwise healthy woman, while the breast cancer risks, while real,  are quite small.

I tell my patients their breast cancer risk is about 1% higher for 20 years of HRT use, so HRT use for a few years conveys far less than even that risk. On balance, using HRT to get through the peri-menopause is not a terribly risky decision, and for women with severe symptoms, it is not an unreasonable choice.

Despite this reassurance, most of my patients with mild to moderate symptoms are choosing to forgo HRT and deal with their symptoms in other ways – exercise, reducing or eliminating alcohol, trying to lower stress. Those with more severe symptoms are still using hrt, but they are aiming for lower dosing and transdermal regimens, or considering non-hormonal alternatives such as SSRI’s instead.

It’s called informed choice. And when given that choice, these days,  more women than not are choosing against using HRT.

And just in case you’re interested, here are my rules for prescribing HRT.

The USPSTF Recommendations do not address premature menopause

Most practitioners agree that women with early menopause benefit from HRT. The risks for osteoporosis in this group is quite high, and symptoms are often quite severe.

In my practice, almost all of these women choose to use HRT until they reach the usual age of menopause, at which they begin to think about it the same way the rest of my patients do and usually wean off over time.

The USPSTF Recommendations do not address vaginal estrogen use

The one symptoms of menopause that does not get better over time is vaginal dryness. Most women, unless they are very frequently sexually active, will need to use something to treat dryness.

One treatment option is low dose vaginal estrogen.  Most practitioners feel comfortable prescribing vaginal estrogen, even in women at risk for blood clots and even in most women with breast cancer.

My patients, however, tend to want to avoid estrogen in any form and so they usually will try non-hormonal treatments first.  I’d say that about half of these women eventually end up using vaginal estrogen.

Those who might disagree with the USPSTF

The window theory believers

The WHI naysayers will argue that no one has properly studied HRT the way in which it is most often used, and in which it is most likely to prevent heart disease – namely, starting at menopause and continuing indefinitely.

They hypothesize that there is a “window of opportunity” during which estrogen will protect against heart disease, and after which starting estrogen will worsen pre-existing heart disease.

Subgroups analysis of WHI findings suggest that they may be correct in this regard. In the WHI, women starting HRT shortly after menopause had a lower risk of cardiovascular disease than those starting 20 years or more later.

Unfortunately, even if HRT were cardio-protective, the risks of breast cancer (and stroke and blood clots) with combination HRT use cannot be ignored, and mitigate against prescribing hormones for reason of heart disease prevention.

The Gap Theory Believers

There are those who argue that the estrogen-only arm of the WHI actually showed less breast cancers, indicating a potential protective effect of estrogen on breast cancer. They theorize something called the “gap theory”, which states that estrogen, when started 10 years of more after menopause, actually acts to inhibit breast cell growth. They are supported in this by in vitro data.

Unfortunately, while the gap time theory may explain the findings of the WHI estrogen-only arm, it is irrelevant to clinical practice, since the way most women use HRT is to start it at menopause. (ie., there is no gap)

They are both right – and both wrong

If both the gap and window theories are correct (and I suspect they are), when considered together they actually support the findings of the WHI and the recommendations of the USPSTF.  Starting estrogen at menopause may prevent heart disease, but it increases breast cancer risk.  Waiting to start HRT may decrease breast cancer risks, but it increases the risks of clotting and stroke and dementia. Or, as my mother used to say, “You’re damned if you do and damned if you don’t.”

The benefits of HRT as they exist in practicality and theory come at a price. That price is high enough to recommend against  the use of hormone replacement for the prevention of chronic disease.

If you have any issues with the USPSTF Recommendations on HRT –

You can submit a comment to the Task Force between now and June 26, 2012.

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Chart above from USPSTF Draft Recommendations on HRT

First Bread of the Season

We’ve only got one day to open up the cottage, having stopped along the way to taking my eldest daughter back to college for her summer research session.

There’s so much to be done. We really should clean out the gutters and scrub down the porch and the outdoor furniture.

The stone patio (and I use the word patio loosely) is overgrown; but the weeds are too pretty to pull right now, and gratefully, I let it be.

The herb garden needs weeding and replanting – only the thyme has survived.

But we’re only here for a day, so we just do the bare minimum while the girls sleep in. Mow the lawn, sweep the porch and put out the furniture, wipe down the refrigerator and the open kitchen shelves, sweep the kitchen and dispose of the two dead animals we found outside in the garbage can. (Somehow, it seems there are always dead animals…)

Then, before the day gets too far along, I head back into the kitchen to do what I love most when I am here – bake bread. We’ll serve it at lunch with egg salad made with thyme from the the garden, and sliced tomato and avocado. They’ll be plenty left to pack sandwiches for the road, and I’ll give the second loaf to my daughter to christen her new apartment at school.

Later this afternoon we’ll all head down to the lake for a cold but glorious first swim of the season. We feel so remarkable afterwards that I decide from here on in, we will shall call it “taking the waters”. The girls will sunbathe on the floating dock and Mr TBTAM and I can catch up with the our neighbors and make plans for the rest of the summer. Tonight after dinner, we’ll have S’Mores on the back deck under a crescent moon, then play Boggle before an early bedtime. After all, we’ve got a long drive ahead of us tomorrow.

In a few weeks, we’ll be back again to properly settle in, but this christening has been exactly what the season needed.

Wheat Bread, No.1

This bread recipe comes from Mrs CH Leonard’s Cookbook, circa 1923, a little gem I picked up at last year’s antique fair. This is my first foray into the book, compiled by a woman who, according to the preface –

…may properly be styled as one of those olden times wives and mothers who personally superintends and much of the time actually selects and prepares the food for her family.

This, of course, stands in contrast to myself, who –

…may be properly styled as one of those modern times wives and mothers whose husband usually cooks weeknights and stocks the larder since he works near Fairway and sees a Saturday morning trip to Costco as sacred as completing a mignon, and who pretends she’s a good mother on weekends, when she cooks and posts recipes on her blog to create the impression that she is one of those olden times wives and mothers who… you get the point.

Mrs GH Leonard’s recipes read like recipes your grandmother might give you – rich with detail, but vague as to exact amounts and cooking times.  The book also contains medicinal recipes and household cleaning formulas scattered amidst the foodstuffs – the “Antidotes for Poisons” chapter, for example, comes just before “Chafing Dish Recipes.”

I’m reprinting Mrs Leonard’s recipe exactly as written –

Take 3 pints of flour to 1 pint of wetting. The ‘wetting” may be either milk or water  or half of each, but must be warmed. It milk is used, scald it and let it cool to a temperature of 75 degrees, or pour boiling water in the milk and let the milk and water cool to the same temperature.  The flour should not be so cold as to cool the wetting below 75 degrees. Dissolve one cake compressed yeast in one cup warm water; add this yeast to the wetting; salt to taste; add 1/2 tbsp lard and 1 of sugar and mix with flour in a large bowl or pan in a stiff batter; place the batter on a moulding  board and knead to a stiff dough; work in all the flour necessary at this kneading. Some breads require more flour than others. Grease a large bowl or pan, put in the dough, and set in a warm place to rise; also grease the top of the dough. When it has risen sufficiently, knead with as little flour as possible to keep from sticking, form into loaves and put into greased tins, pet it rise and bake. To test the oven, throw a little flour in the oven; if it browns quickly the oven is all right ; if the flour burns the oven is too hot. The fire must be hotter after the bread has been in 10 minutes. An ordinary sized loaf requires 45 minutes  for baking. When taken from the oven, brush the loaf over with milk and place where it will cool quickly or near an open window.

I used 1 envelope instant yeast rather than compressed yeast.  For “lard” I used olive oil, used 1.5 tbsp salt “to taste”, assumed “1 of sugar” meant 1 tbsp of sugar, and used about a cup of flour for the kneading. Following Mrs Leonard’s method for determining oven temp, I ended up with 400 degrees fahrenheit, which I raised to 425 degrees after 10 minutes of baking.

The bread was delicious – think homemade Wonder Bread, but a little more dense and without the squishiness, meaning that you can’t roll this bread up into a little ball and pop it in your mouth the way you can with Wonder Bread. Sorry. A very nice sandwich bread that should toast beautifully.

Osteoporosis Drugs – You Got to Know When to Fold ‘Em …

If you are one of the millions of Americans taking a bisphosphonate drug for treatment of bone loss, you’ve most likely worried about what you’ve gotten yourself into.

Earlier this month, the FDA took the highly unusual step of publishing the results of their investigation into reports of atypical fractures of the femur occurring in long term users of drugs like Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate) and Reclast (zoledronic acid).

Now we have yet another investigation confirming the association of these fractures with bisphosphonate use, and correlating the increasing risk with increasing duration of therapy.

When categorized by duration of treatment, compared with no treatment, the odds ratio for an atypical fracture vs. a classic fracture were 35.1 for less than two years of treatment, 46.9 for two to five years of treatment, 117.1 for five to nine years and 175.7 for more than nine years.

What’s Going On Here? 

How do drugs that are supposed to prevent fractures cause new ones? That’s a good question. And the answer is complicated, so let’s see if I can simplify it.

Think of your bones as a road system that is constantly being remodeled depending on where the traffic is. There’s a large well-funded road crew constantly digging up the old road and replacing it with new road. They work in small sections scattered throughout the system, so as not to disrupt the road’s integrity. The members of the crew that digs up the old road are called the osteoclasts –

 and the ones who fill in and re-pave it are called the osteoblasts.

Now suppose over time, for whatever reason – age, bad weather (underlying medical conditions), lack of road material (vitamin D deficiency, menopause) –  you’ve dug up or lost more roads than you’ve replaced (Osteoporosis).  So you start treatment with a bisphosphonate like Fosamax or Actonel or Boniva. These drugs work by cutting back on the digging crew, but keeping the paving and refilling going in the areas that have already been dug up, thus rapidly bringing miles and miles of untravelable road into good use. Not to mention it’s a nice strong road, becoming mineralized over time. (That’s your bone density increasing.)

The whole thing is working so well that you send almost the entire road crew on a prolonged vacation. (Suppression of bone turnover, which is how bisphosponates work) Now you’re left with a skeleton road crew (pun intended), which, for most folks is still enough to deal with the usual cracks and potholes that appear over time, and can keep the road (your bones) in good working condition. But in some of you (perhaps those who are genetically predisposed) the downsized crew just can’t keep up with the repair work. As time goes on, the structural integrity of your bones becomes weakened. And then one day, for no apparent reason, just during the course of usual activity,  a small crack that the crew hasn’t yet repaired becomes a large crack – and you’ve just fractured your femur.

You don’t have to be on a bisphosphonate for these kind of atypical fractures to occur. Some folks just get them. But taking a bisphosponate increased the chances in predisposed individuals, and that chance increases the longer you take the drug, especially if your bone mass is in the osteopenic or normal range.

Exactly What are the Risks?

The chance that you’ll get one of these atypical spiral fractures while taking bisphosphonates is extremely low –  one study estimates the incidence at about 32 per million users per year, compared with over 10 times that many fractures prevented in the same million users.  So overall, the benefits of these drugs still far outweigh the risks.

However, drilling down into the fracture data reveals that we can do better than just accepting a rare risk in return for a common benefit.

Those who develop atypical fractures appear to be  individuals whose bone mass in the femur is in the normal or osteopenic range, as opposed to those whose hips show osteoporosis. This happens to be the very same group that recent studies suggest may safely stop Fosamax after 5 years without losing the benefits of having been on the drug.

So, if continuing the drog for longer than 5 years adds little benefit but increases risks, even if those risks are rare, it becomes pretty darned obvious what we need to do.  Stop the drug.

Which reminds me of that song from Kenny Rogers – “You got to know when to hold ’em / Know when to fold ’em / Know when to walk away /Know when to run… ” Not that treating osteoporosis is a gamble, but the Gambler’s advice rings eerily true for this class of drugs.

 

When to Fold ‘Em

New data suggest that as long as your bone density is above the osteoporotic range, you can stop taking your bone meds after 5 years.  Continuing the drug past that time only brings added risk without any benefit.

When to Hold ‘Em

If you’re at increased risk for fracture and have been taking your meds for less than 5 years, you may still be getting benefit without significant risk. Remember that these drugs decrease the risk of conventional osteoporotic fractures at over 10 times the rate that they increase the risk of atypical fractures, so don’t throw the baby out with the bathwater.  But make sure you are getting adequate vitamin D, calcium and weight bearing exercise to maximize the benefits you’re getting while you’re still on these drugs. And discuss with your doctor whether its worth considering coming off the drug in the future if your bone mass improves into the osteopenic range.

If you’ve been on these drugs for 5 years or more, but your bone mass is still in the osteoporotic range, you also may still be getting benefit from continuing treatment. Ditto if you’re at high risk for vertebral fractures. You are not in the group at highest risk for atypical fractures, but are in the group at highest risk for the more common type of osteoporotic fractures. Talk to your doctor about the comparative risks of continuing vs stopping treatment. It may not be a straightforward decision, as we don’t have exactly clear guidance on when to stop in everyone.  But at least have the conversation.

Should You Even Be in the Bisphosphonate Game?

Not everyone taking bisphosphonates needed to start them in the first place. Aggressive marketing and disease mongering by Big Pharma initially led to overuse of these drugs for treatment of osteopenia, a condition we now know does not necessarily need to be treated.  With the help of the FRAX fracture risk calculator, we’re now able to determine which patients with osteopenia are at significant fracture risk and require treatment (very few, it turns out) and which ones can be adequately managed with lifestyle, calcium and vitamin D (most).  Talk to your doctor about using FRAX before deciding if treatment is warranted. 

Remember too that bisphosphonates are not the only drugs that treat osteoporosis. Other medications to consider include hormone replacement,  Evista (raloxifene) and injectable terapeptide. Each of these drugs has its own set of risks and benefits, and some work better than others depending on your type and location of bone loss, so a reflex switch from bisphosphonates may not necessarily be the best option. As always, its best to talk with your doctor about what is right for you.

Bottom Line

The optimal duration of bisphosphonates for most individuals appears to be between 3-5 years. Beyond that point, unless there is osteoporosis at the hip or a high spinal fracture risk, there appears to be added risk rather than additional benefit to prolonged use of these medications, and it may be time to consider stopping therapy.

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Resources

 

Behind the Counter in the UK

 

While waiting at Heathrow for our flight home from London, my mother in law Irene, recalling the turbulence on our ride over, decided to get herself something for motion sickness. Off we headed to the airport pharmacy, where we discovered that motion sickness drugs are sold behind the counter in the UK, along with cough and cold syrup, paracematol (Tylenol) and many other drugs that we Yanks can scoop up freely from the pharmacy shelves here in the USA.

Upon questioning Irene about her health and other medications she was taking, the cheerful and helpful pharmacy tech called over the pharmacist, who firmly but politely refused to sell her the drug due to concerns about the potential to worsen her glaucoma. Irene was a bit taken aback, since her eye doctor had told her she could use the meds. But, having no local doc to override the pharmacist, we accepted the pharmacist’s verdict. Thankfully, our plane ride home was smooth sailing.

Overall, I was quite impressed with the caring attitude of the pharmacy tech and the pharmacist, as well as the seriousness with which they took their jobs. The risks of over the counter drugs may seem minimal, but not everyone takes the time (or has the corrected vision) to read the package labeling and warnings. Having someone vet your purchase for you could be potentially life saving.

I asked the pharmacist how the morning after pill is handled in the UK – turns out women requesting the med see him in his office for a private consultation prior to getting the drug, which has no age restriction. Not a bad idea, I think. Maybe we need to expand our behind the counter system in the US.

Then I think about the right to life pharmacists.

And change my mind.

Asparagus with Mustard Vinaigrette

 

A quick post and pic for a quick and delicious asparagus recipe from yesterday’s New York Times. Perfect for using the chives that have had their annual rebirth in my terrace garden. We added some sliced avocado, otherwise made it as written. The gorgeous thin spring asparagus are from Fairway.  We had enough vinaigrette leftover to use tomorrow in something else – I’m thinking of trying it with chopped eggs as an enlightened egg salad.

 

April in London (Part 4) – Shakespeare ‘s Birthday Tour

By sheer coincidence, our visit to see my daughter during her semester studying Shakespeare at RADA occurred during the week of the Bard’s birthday, making her class production of All’s Well That Ends Well seem even more special than it already was for us. Even more coincidental was the fact that we had tickets to see King John in Stratford-Upon-Avon on the day that town was celebrating their most famous son, and chanced upon the Globe Theater’s birthday celebration the following day while heading to the Tate Modern! If we had joined a Shakespeare’s Birthday Tour group we could not have planned it better. In fact, I’m thinking we should do this again next year and call it the TBTAM-SBT. Who wants to join us?…

Stratford-Upon-Avon

The Bard’s birthplace is a reasonably priced, lovely two-hour train trip from London’s Marylebone Station on Chiltern Railways.  Train tickets can be purchased online and retrieved at the station’s kiosk with your credit card. (I bought ours a good three weeks before we left the US.)

At Marylebone, we also purchased a very reasonably priced and delicious breakfast of cappuccino and sandwiches for the trip from one of several purveyors that were open that hour on a Saturday morning.

The train cars have seats with tables, so we ate our breakfast in a leisurely fashion during the train ride while gazing at the lovely English countryside, which was brushed with swaths of bright yellow rapeseed fields,

and the occasional sheep or cattle pasture.

We divided the remainder of the time between napping and reading, and arrived rested and raring to go at Stratford-Upon-Avon. From the station, it’s a short walk along the road into town (just follow your fellow travelers up the low hill), along which we found a lovely little antique store (you see why I want to come back, right?…),

and a Polish grocery and pastry shop.

Then – O my rapturous heart! – we came to Rother Street Marketplace, where the Warwichkshire Farmer’s Market – held between 9am and 2 pm on the 1st and 3rd Saturday of every month, year round – was in full swing. (How ever did I plan this trip so perfectly???)

The veggies were gorgeous

the offerings unusual

and practically every booth was giving out samples.

We tasted the most delicious cheeses, pates, sausages and jams, purchasing gifts to take home and some pastries for later.

To see more photos of the Market, click on the thumbnail images across the bottom of the slide show below. (Click FS to view best in full screen mode, then esc to return to this post.)

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After the market, we headed further into town towards the Bard’s Birth house.

By this time, the town’s birthday celebration was in full swing, with a parade, a live band playing American classic rock songs ala’ Jimmy Buffet (???) and plenty of activities for Shakespeare lovers of all ages. The town center has a bit of a Disney atmosphere, and the price of admission to the Birth house was too steep for our taste. But we did stop for tea at the cafe overlooking the Birthplace gardens, and visited a small museum there for free.

Next we walked on to Shakespeare’s school

where we encountered the locals in full birthday parade regalia.

And then it was on to the Swan Theater

where we saw a most amazing production of King John in previews with the Royal Shakespeare Company.

Set in time around the 70’s at a hotel ballroom party (think Bar Mitzvah or family wedding reception), complete with karaoke singing and a perfect rendition of the final dance from Dirty Dancing (we Yanks in the audience went wild – I think the locals didn’t quite get it), this production was powerful, edgy and utterly fantastic.

Don’t let the party  atmosphere fool you – there’s a severed head, a child’s death and a full-out war between England and France taking place here. Alex Waldemann (with whom we had a lovely conversation outside after the show) was brilliant as King John. In a magnificent switch of gender roles, director Maria Aberg cast Pippa Nixon in the pivotal role of the Bastard, adding a whole new layer of heterosexual tension into her relationship with John. The Archbishop was also cast a female – Paola Donisatti – who plays the papal representative with an androgynous air, large sunglasses and a real mean streak. The rest of the cast, male and female, is equally stellar. This production should come to New York – I’m sure it would play to sold out houses at BAM.

Having missed the rain shower that occurred while we were in the theater, we emerged to sunshine and decided to walk along the Avon River,

past Wisteria clad cottages

and a small “on the run” production of Romeo and Juliet,

to Holy Trinity Church, a real working parish,

where, for two pounds, you can enter the chapel where Shakespeare and his wife Anne Hathaway are buried.

As we left Holy Trinity, we were serenaded by the screams of Juliet, who, having wandered in with her on the run production, awoke from her drugged sleep to find her dead Romeo in the corner of the main chapel.

Emily now insisted that we needed to have genuine fish and chips, and so we did, at Barnaby’s Fish Restaurant and Take Away just past the theater.  I smelled a tourist trap, but it was a charming little place, and we had managed to get ourselves inside the restaurant just as another storm broke yet again, so it was a welcome stop despite what turned out to be a rather mediocre meal.

We were rewarded with a rainbow as we exited the restaurant, a sure sign from the Bard himself that this was truly a day to remember. Soon enough, we were back on the train, where we were washed by the setting sun as we headed back to London. Our ride back was a bit longer than the way out, but no matter. We slept, and read, and dreamed of a city by the river where 448 years ago, a writer was born.

I could just as easily have spent the entire weekend at Stratford-Upon-Avon, and just may if I do the SBT again next spring. According to our cab driver at Stratford, who of course knew the play we had seen, there are plenty of places to stay, and the town is a popular weekend home location for Londoners.

The Globe Theater

The next morning, Shakespeare’s actual birthday, as we headed to the Tate Modern on SouthBank, we were approached by a young woman who offered us free admission to the Globe Theater museum and a marathon reading of Shakespeare’s Sonnets. This was the grand opening of the Globe to Globe Shakespeare Festival, in which Shakespeare’s plays will be performed at the Globe in 37 different languages by theater troops from all across the world. The sonnets were read in those same 37 languages, most of which were represented by at least one or more theater goers in the gallery.

We felt part of this amazing worldwide community of people who have been touched by the writings of one man.

It was magical. Next week, Emily will be back at the Globe, seeing Julius Caesar performed in Italian. I wish I could be with her.

So there you have it

The TBTAM Shakespeare’s Birthday Tour. I couldn’t have planned it this perfectly if I had tried. And while I am sore tempted to try it again next year, I wonder if that is tempting fate?  For, as Shakespeare has been quoted to have said (though I do not know from which play it comes) –

Good luck is often with the man who doesn’t include it in his plans.

April in London (Part 3) – Old Spitalfields Antique Market

It’s not Portobello Road, but it’ll have to do for this trip.

On other days Old Spitalfields Market is a mix of new, crafted and retro chic in the midst of a neighborhood known for its trendy shops – a destination for those in search of whats hip and what’s hot.

But on Thursdays, it’s just antiques.

And that’s hot enough for me.

Believe it or not, I bought nothing.

Having arrived at the end of the day after a late lunch across the street at St John’s Bread & Wine, some stalls were already beginning to close.

So I decided to just putter around among the remnants of lives once lived instead of spending my time looking to find that perfect thing.

A new experience for me,

and one that I highly recommend.

Oh yeah.

I forgot.

They also had cookies.

So I guess you could say I did buy something.
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Up Next – April in London (Part 4) – Shakespeare’s Birthday Tour

Old Spitalfields Market

April in London (Part 2) – Where We Ate

We did not eat here –  The Churchill War Rooms Kitchen

On my last visit to London, I was overruled by my kids whenever I tried to plan a meal at a special restaurant – they insisted we allow serendipity to rule when choosing where to eat. This time, with Irene on my side, and half the child contingent at home (sadly, but in this case…), I actually planned a few meals ahead of time, letting the restaurant location drive what else we did that day.  Thanks ever so much to pastry chef and blogger Shuna Fish Lydon, whose London fave restaurant list served as our personal Zagat guide to the city.  I’m hoping this post will serve as helpful to my readers as her post was for me.

St John’s Bread and Wine
94-96 Commercial Street, London E1 6LZ.


Our first dip into Shuna’s list yielded the best meal of our trip – Lunch at St John’s Bread and Wine on a rainy Thursday mid-afternoon.  St Johns specializes in what is called “nose to toes” eating, a traditional British way to use all of the animal, which is why the menu was rife with offal dishes, offal being the word used to describe organ meats such as kidney, tongue and liver, which despite what you may think, do not necessarily taste awful. (Sorry, I just had to do the obvious…)

We played it safe just in case and started with the salted beef broth with dumplings. Irene, who readers know is the best home cook in the world, declared it the best soup she’d ever eaten. (Anyone who has ever tasted Irene’s chicken soup will appreciate just how stellar this beef broth was…)

I think I agree. Next up was the best appetizer I’ve ever eaten – Fois Gras and Duck Liver Toast with a side of cornichons.

If you have any doubts as to how good this really was, just look at this bread.

Irene insisted that we guild the lily, and while I only did this for one bite, that bite was such stuff as dreams are made of…

Finally, a salad that I plan to replicate at home very very soon – cauliflower, leeks and chickpeas with capers and a light horseradish dressing.


The crowd at St Johns that late afternoon was mostly hip bald British chef-types and young male foodies with an occasional woman thrown in for color. The owner of the place was holding court at a table near us and there was lots of wine flowing. I felt a bit like I had crashed a private party, but we were treated quite well despite being the only non-locals in the place.

St Johns is worth making a special trip. Go on a Thursday and combine it with a visit to Spitalfields Antique Market just across the street, which is what we did.

Olivelli Ristorante Paradisio
35 Store St, London WCiE 7BS

This unassuming restaurant on Store Street in Bloomsbury was around the corner from our hotel, and we popped in for lunch on Friday after my daughter’s final performance at RADA (Did I mention she was wonderful?….).The service was excellent, and while the pasta and risotto were quite fine though not especially memorable, the mussels were probably the best I’ve ever eaten. On the smaller side, which I like, perfectly cooked and seasoned and teeming with garlic. If you’re looking for a good meal in Bloomsbury, this place is a sure bet.

Chez Marcelle
34 Blythe Road, London W14 0HA
+442076033241

My sister-in-law Nancy, who frequently visits London for work, recommended this lovely restaurant in Olympia for delicious, well-priced Lebanese food.  It was our first meal in London, and set the tone for what was a great trip food-wise. The #10 bus took us practically there from our hotel in Bloomsbury, making it not as out of the way as one might think.

Chez Marcelle is a one woman show starring Marcelle herself, who hosts, cooks, hosts and serves, along with only one assistant the night we ate there. We arrived on the early side, about 6:30 pm, and had Marcelle’s undivided attention until the place began to fill up, afer which we had to share her with the other diners. That meant we had to wait until she was finished preparing our neighbor’s meal before she could write out our check, but that was fine with us. This is not haute cuisine, but home cooked authentic Lebanese food, every dish freshly prepared by Marcelle and every dish delicious. Here are some examples from our meal –

  • Bazinjan Rahib  – Grilled aubergine peppers, onions, tomatoes and parsley dressed w/ lemon, olive oil & garlic. Like baba ganoush, but better, and added to my list of things to learn to make.

  •  Grllled Halloumih Cheese

  • Jawaneh – Grilled chicken wings with garlic and lemon juice

  • Kebbe Maklieh

If you love Lebanese food, Zagat has compiled their top 5 London Lebanese restaurants, but they don’t list Chez Marcelle. Someone needs to let them know about this special place.

Gourmet Burger Kitchen (GBK)


Okay, I admit this restaurant is part of a chain, but the burgers,”made from 100% West Country beef”, are fabulous, the price is right and there’s a branch on Maiden Lane, making it a perfect place to grab a quick bite pre or post theater.  The service on Maiden Lane was not as good as at the Putney branch, where we ate the last time we visited London.  But the atmosphere was lively, our fellow diners friendly and talkative, and the burgers tasted just as good, if not better than the ones we ate at the more sedate Putney branch. Great fries and milk shakes, too. With branches all around London, GBK is a one place to keep in mind when you need a reliably good meal fast. Or just crave a fabulous burger.

The Modern Pantry
47-48 St John’s Square, London EC1V
4JJ 020 7553 9210

The Modern Pantry was another recommendation from Shuna that I wish I could say I loved as much as she did, but…

Any menu that takes a paragraph to list the title of a single dish is probably making cooking more complex than it need be.  Other than a delicious scallop on a bed of parsnip puree, I found the food overly fussy, with competing flavors and no rhyme or reason as to why certain ingredients were paired.  I know this is called fusion cooking, but it seemed more like mishmash cooking to me – almost as if I had filled my plate with several different dishes from a buffet rather than ordered a single dish. For example –

  • Confit duck leg, sweetcorn, black beans, sugar snaps & coriander, plum & Bramley apple relish
  • Fig, apple & raspberry oat crumble, goats curd sorbet, runny cream

That said, the service was fabulous, the wine absolutely incredible (such legs!…), the atmosphere warm and inviting and the location on St John’s Square – perfect.  So if fusion cooking is your thing, you’ll love The Modern Pantry. The place was packed, so you won’t be alone. Tell them I sent you.

Tea at the Tate Modern Level 7
Bankside, London SE1 9TG

The Food at the Tate is well-priced, with views of St Paul’s Cathedral and the city that alone are worth the visit, and more than made up for the lack of decent art on display downstairs on the day we visited. (Don’t get me started on Damien Hirst..)

The scones with clotted cream were surprisingly and unnecessarily large – but they were moist and delicious and the tea was lovely, served in little tea-press pots. My cheese platter was a bit disappointing – nothing special about the cheeses they chose to feature. The tea sandwiches and baguette were fine. But the views – I could have sat there forever.

Store Street Espresso
40 Store Street, WC1E 7DB

Best place for coffee in Bloomsbury, according to my barista-trained daughter. My one cup of takeaway cappuccino was perfect, so I’d agree. Not to mention great atmosphere, free wi-fi, decent food and a book exchange.
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More London Restaurant Reviews 

Up next – Old Spitalfields Antique Market 

Nutella Settles Lawsuit for $3 Million – Will You File For Your Piece of the Settlement?

The Ferrero Group has agreed to pay $3 million to settle a lawsuit that claims they are falsely advertising Nutella as a healthy breakfast food. (See their ad above – What do you think?)

The suit was brought by a handful of US consumers, but you can get in on the settlement to the tune of $5 per jar of Nutella that you may have purchased, up to a total of $20, no receipt needed.

The Nationwide Class provides for a settlement fund of $2,500,000 and the California Class provides for a settlement fund of $550,000 for a total of $3,050,000. Class Members can receive up to $4 per jar of Nutella that they purchased during the time periods listed above. Class Members who purchased multiple jars of Nutella during the time periods can submit a claim for up to five jars for a maximum award of $20 per household. If the value of the claims of the Nationwide Class exceeds $2,500,000, or the value of the claims of the California Class exceeds $550,000, then payments will be reduced proportionally.

I think the lawsuit was appropriate

I love Nutella. Who doesn’t?  But marketing Nutella as breakfast food? That moves it from the candy aisle in your brain to the meal part, takes away the guilt component and makes it a part of your daily routine rather than a once in while indulgence. It’s brilliant marketing, actually.

But there’s no way that stuff is part of a daily wholesome breakfast. As a mom and a physician, that the ad truly pissed me off when I first saw it.  Nutella’s first ingredient listed on the label is sugar. And yet sugar is never mentioned in the ad – just hazelnuts, milk and cocoa. So yeah, I think that’s false advertising.

Some have suggested that the lawsuit is frivolous. A Nutella breakfast is no worse than a bowl of sweet cereal, something advertised to kids all the time, they say. Just read the label, others tell us, and anyway, how stupid can you be not to know that Nutella is basically spreadable candy in a jar?

To them, I’d argue that many American consumers, who may have trouble affording a trip to Disney World,  let alone to Europe, have until recently never heard of Nutella. For many of them, this ad was their introduction to the product. Imagine that if the first time you heard what a Hershey bar was, it was being advertised as part of a balanced wholesome breakfast. Would you think that was false advertising?

I do agree that all it takes is a glance at the label to know what you’re buying, and abdicating responsibility for your wallet and your health to advertisers is not smart. But highlighting to ad makers that smoke and mirrors won’t fly is the right thing to do. If this makes the Mad Men pause before writing their next line of copy, then I say $3 million is a small price to pay. Not to mention all the free advertising the settlement is netting Nutella. Hmmmm… I wonder if the whole thing isn’t just one giant marketing scheme?

This isn’t the first time Ferrero has been asked to stop pretending Nutella is healthy

They’ve been slapped on the wrists in Europe for the same thing. The UK actually banned Nutella’s breakfast ads there. But attempts by the EU to ban advertisting of unhealthy foods is meeting opposition, in large part because of fears that it would hurt Nutella’s business.

Please. That stuff is like crack cocaine. It will always have a market.

Do you know what pisses me off even more than that stupid Nutella ad?

I just found out that the Nutella sold in the US is not as good as the stuff they make and sell in Europe.

Now that’s something to sue about…