Mushroom Lasagna

The leaves disappear from the trees;
The time of the singing of the birds is done;
And the sizzling of sauteed mushrooms can be heard across the land.

There’s a sadness that comes to me in late autumn, as the days shorten and nature’s color palette moves from brilliant yellow, orange and red into the muted browns. But then I think of the mushroom, and my spirits begin to lift. Add in pasta, Parmesan cheese and a bechamel sauce, and let’s just say I’m ready to stop the season’s clock right here and now and live in November forever.

No, I did not make this week’s NY Times recipe for Gooey Wild-Mushroom lasagna – Although it looks delicious, there’s too much cheese in that dish for both my taste and my waistline.  I wanted a simpler recipe that would let the mushroom’s flavors dominate and fit a bit better into a healthy lifestyle. The recipe I ended up using began with Ina Garten (How much do I love her?…), got tweaked a bit at the Smitten Kitchen (Check out those pics…) and then of course, I had to tweak it some more myself to make it less calories and add a few more flavors.  What resulted was honestly one of the best things I have ever made or eaten. We served it for Sunday dinner with broccoli on the side, then the next night as a side with broiled steak (OMG…) , and again tonite as a smaller side along with roast cauliflower and a steak salad. Each time I ate a little less, and enjoyed it a little more. (Meaning it reheats well.)

I’d like to experiment a bit more with this recipe – adding in some shallots, using a bit less flour, perhaps upping the proportion of broth to milk in the bechamel, or replacing it altogether with this olive oil bechamel from Martha Rose Shulman. Turns out Martha Rose has already made a mushroom lasagna with olive oil bechamel. (Great minds think alike.) It looks incredible.  I think I’ll make that one next time. I’ll let you know how it turns out.

Mushroom Lasagna

For the pasta
3/4 pound dried lasagna noodles
1 tbsp olive oil
1 tsp salt

For the bechamel
3 3/4 cups skim milk
1/4 cup mushroom broth (from the cooking mushrooms or made with dried mushrooms – instructions below)
1 stick butter
1/2 cup all-purpose flour
1 tsp kosher salt
1 teaspoon freshly ground black pepper
1/2 teaspoon ground nutmeg

For the mushrooms
2 tbsp olive oil
2tbsp butter
1 1/2 pounds cremini mushrooms
1/2 tsp salt
Fresh pepper
1 clove minced garlic
3 small stems of fresh thyme leaves

For the lasagna
1 cup freshly grated parmesan cheese
Paprika (for the top)

1. Preheat your oven to 375°F. Lightly grease a 9×13 inch lasagna pan with olive oil or butter. (I use a le Crueset pan and highly recommend it.) Bring a large pot of water to boil with salt and a oil. Add the lasagna noodles and cook for 10 minutes. Drain and set aside.

2. Slice mushrooms 1/4-inch thick. Heat 2 tablespoons olive oil and 2 tablespoons butter over medium in the bottom of the large skillet or saute pan. Cook the mushrooms with a 1/2 tsp of salt, pepper to taste and the thyme for about 5 minutes, or until they are tender and release some of their juices. (You may need to do this in two batches if you don’t have a really large saute pan). Now here’s what I did that I think is kinda’ clever – you know how the mushrooms give off so darned much liquid, and then by the time you’ve cooked it off you’ve got a small dry mushroom? Well, I got tired waiting for it to cook off and wanted my mushrooms plump, so I drained off about a 1/4 cup of that rich brown broth and added it to my bechamel.  If you don’t want to do that, you can soak some dried mushrooms in boiling water and make a little mushroom broth instead and add that to the bechamel. In the last few minutes, add the garlic so it does not burn.

3. Heat the milk in the microwave or on the stove and set aside. Melt 1 stick butter in a large saucepan. Add the flour, then cook over a moderate heat constantly stirring until it turns a rich nutty brown (about 4 minutes – don’t leave it and keep stirring). Pour in the hot milk, a little at a time at first and then the rest quickly, whisking to combine. Add the broth, still stirring. Stir in salt, pepper and nutmeg and continue cooking over medium-low heat, whisking frequently, until it is thick (about 5 minutes). Set aside.

4. Spread some of the sauce in the bottom of a lasagna pan (8×12 or  9 x 13 baking dish). Arrange a layer of noodles on top, then more sauce (about 1/4 of what remains), 1/3 of the mushrooms and 1/4 cup grated parmesan. Repeat two more times then top with a final layer of noodles, your remaning sauce and last 1/4 cup of parmesan. Sprinkle with a bit of paprika. Bake for 45 minutes, or until top is browned and the sauce is bubbly. Let sit at room temperature for 15 minutes before serving.

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More mushroom recipes from TBTAM

What to Eat on NYC Marathon Day – Tri-color Pasta with Creamy Mushroom Sauce

Keeping with my recent theme of Autumnal-colored meals, I chose a tricolor pasta to use with this luscious creamy mushroom sauce from one of my fave cookbooks, Regional Italian Cuisine. The dish hails from Tuscany, where more genuine folk would serve the sauce with a mixture of homemade egg and spinach tagliatelle, and call it Paglia e Fieno (“Straw and Hay”). It was a great way to use up the last of the basil from my garden before the cold weather gets it.

It was also a great dinner to wind up a brisk autumn day during which I walked the city for over 3 hours – which is what happens when you decide to meet a friend for a walk in Central Park followed by brunch on the day of the NYC Marathon, and find yourself detoured for blocks by the race at practically every turn.  I didn’t mind the extra-long walk a bit – the weather was glorious, the city shining and beautiful, and the people ebullient – this is one of New York City’s finest moments.

On my way to the park, I caught the wheelchair front-runners as they came off the Queensboro Bridge into Manhattan.

And happened to be along the Park Drive as the female front runner hit mile 24.

The reservoir, as always, was glorious. And for a Sunday morning, gloriously empty.

We ate brunch on the Upper West Side at French Roast, sitting outside in the sun – how we scored a table without a wait is a small miracle in itself.  On the sidewalk, a bookseller was plying his wares – in this case, a tabletop filled with books on philosophy and psychoanalysis. If I didn’t know better, I would have thought Woody Allen was having a stoop sale.

As I headed down Broadway after brunch, marathoners in their orange capes clogged the sidewalks. A half hour later, back near home on First Avenue, runners were still coming off the bridge into Manhattan in droves.  Amazing, really. The sheer number of runners, cheered on by their friends, family and fellow New Yorkers, filling the streets of New York’s boroughs, and Manhattan from the east to the west side.

Detours and police barricades notwithstanding, Marathon Day is hands down my favorite day in this amazing city I am privileged to call home. Congrats to all the runners in today’s race, from the front-runners to the last stragglers. I hope your day was as wonderful as mine.

Tri-Color Pasta with Creamy Mushroom Sauce

This is not exactly a dieter’s dish, although a limited portion served with a large salad could be a meal well within a calorie-counter’s daily budget. To be more genuine use 1/2 lb spinach fettucine and 1/2 pound regular fettucine instead of the tricolor pasta.  To be truly genuine, make your own egg and spinach tagliatelle, as outlined in the original recipe.

1 lb tricolor pasta
3 1/2 ounces mild raw prosciutto
11 ounces fresh mushrooms (I used crimini)
Juice of 1/2 lemon (plus another tbsp or so for the sauce at the end)
1/2 bunch fresh basil leaves, torn
1/2 bunch fresh parsley, minced
1 cup heavy cream
1/2 cup plus 1 tbsp beef stock
1 garlic clove, crushed
1 1/2 tbsp butter
Salt and freshly ground pepper to taste
Parmesan cheese for serving

  • Start your pasta water heating.
  • Cut the ham into thin strips and set aside. Clean the mushrooms, slice thin and drizzle with the lemon juice.
  • In a saucepan, melt 1/2 tbsp butter and add the crushed garlic. Simmer over low-med heat until the garlic is soft. Pour in the cream and beef stock and allow to cook down until smooth and dense.
  • Meanwhile, in a small frying pan, melt 1 tbsp butter. Add the mushrooms and saute until limp. Add the parsley and ham and saute a bit more until the liquid of the mushrooms has evaporated and the ham begins to crisp a bit at the edges.
  • By now, your pasta water should be ready. Start your pasta cooking. When it is done, drain it well and place in a warmed bowl.
  • Season the cream sauce with pepper, salt if needed, and a little more lemon juice, and pour over the hot noodles. Toss with the mushroom-ham mixture and the basil leaves. Serve with grated parmesan cheese.

Autumn Red Quinoa Salad with Edamame, Roasted Sweet Potato & Cauliflower

Here’s a nice healthy lunch for autumnal days. I love the colors – the bright green edamame, the orange sweet potato, red pepper, and yellow cauliflower against the red grain reminds me of an autumn hillside. Packs easily to take to work and keeps for several days in the fridge. Serve it with a dollop of my new fave food, sheep’s milk yogurt.

Autumn Red Quinoa Salad

I used what I had on hand for this salad – ergo the roast peppers Mr TBAM had just made and the basil and parsely from the garden. The olive oil from the veggies and the peppers was enough for me, but you might want to add a bit more olive oil. We didn’t have any red onion or scallions – if we had I would have used either one.  

For the Quinoa
1 cup red quinoa (I used Quinoa Harvest  Inca Red Quinoa)
2 cups water
1/4 tsp salt

Roasted veggies
3 tbsp olive oil
1 large sweet potato, peeled and cut into 2 inch dice
1 small head cauliflower, trimmed and slices lengthwise into 1/2  ince slices
Kosher salt and pepper to taste

Other salad additions
16 blanched, frozen edamame pods (I used Whole Foods 365 organic edamame)
6 strips roasted red peppers in garlic & olive oil, cut into 1 inch pieces. (We had homemade on hand, you can use jarred)
1 stick celery, cut into small dice
2 heaping tbsps capers (optional – probably not needed if you have scallions or red onion)
1/3 cup chopped fresh parsley (+ a few sprigs for garnish)
6 basil leaves, chopped
Juice of 1 large lemon

  1. Preheat oven to 425 degrees fahrenheit
  2. In a medium saucepan, mix 1 cup red quinoa and 2 cups water with 1/4 tsp salt. Bring to a boil, then cover and simmer on very low heat for 15 minutes without stirring. Remove lid, fluff and cool.
  3. While quinoa is cooking, toss diced potato and cauliflower slices in olive oil, spread out on cookie sheets and sprinkle with kosher salt and generous pepper. Roast 15-30 mins till done, turning halfway through. Let cool.
  4. Steam and slightly cool the edamame. Pop open and collect the seeds in a small bowl. Salt lightly.
  5. In a large bowl, layer the quinoa with the roast veggies, celery, peppers, capers, edamame (all but a few seeds for garnish), basil and parsley. Squeeze juice of a large lemon atop it all and toss lightly. Garnish with a few saved edamame seeds and a bit of parsley. Serve.

The Mississippi Personhood Amendment – An Open Letter to Dr Freda Bush

On November 8, Mississippians will be voting on ballot amendment 26 , the so called “Personhood Amendment” that if passed, would declare a fertilized egg a person.

The question at hand is, would the Personhood Amendment be used to outlaw contraception?

Dr Freda Bush, an Ob-Gyn and spokesperson for the Personhood amendment in Mississippi, is misleading voters that it will not. In a press conference in support of the amendment in September, she stated this –

The personhood amendment will not ban the use of hormonal contraceptives.

The video of this press conference is being used to reassure voters about the intent of amendment 26. And yet the information Dr Bush presents about contraception and the amendment stands in complete contrast to that which the personhood movement itself has presented. Here is the standard “talking point” on contraception from personhood sites at states across the country seeking to pass similar amendments –

Won’t a Personhood Law Outlaw Contraceptives?

No, recognizing personhood has no effect on contraceptives because true “contra-ception” only prevents conception (fertilization). However, personhood would prohibit any chemical abortion that kills the youngest boys and girls before or after they implant in their mother’s womb. When the abortion industry says that personhood would outlaw contraceptives, it’s lying. These people have spent decades telling women that such chemicals did not kill a living embryo. Women should know whether or not a chemical would kill their children. A personhood law will end the lies.

It has been a long standing tenet of the anti-abortion movement that birth control pills are considered to be “chemical abortifacents”. They will most surely attempt to use this amendment, if passed, to outlaw hormonal contraception.

Still not convinced? Check out the Colorado Personhood website, where they adress what they call the “scare tactics” of those who oppose the amendment. Here, they try to convince voters that the amendment would not ban contraceptives, and yet in the end only barrier methods come out unscathed.

Contraception comes from the words “contra” and “conception”. Properly understood it means something that prevents conception. In 1965 the American College of Obstetricians and Gynecologists issued a medical bulletin which “officially” changed the definition of conception from the union of a sperm and an egg to implantation of the young human being in the wall of the uterus. The reason they did this was to make chemical abortifacients seem more palatable to the American people who would now be tricked into believing that the human being did not begin until implantation. While the AMA and pro-abortion bioethicists have tried to obfuscate the meaning of conception, embryology is very clear about the beginning of life: the beginning of life (under normal sexual reproduction) takes place when the sperm touches the ovum. Barrier methods of contraception that prevent the union of the sperm and the egg will not be outlawed, since neither a sperm nor an egg by itself is a human being.

Dr Bush, you and I both know that to our patients, the word “Contraception” means more than just condoms. You yourself have stated that you prescribe birth control pills in your practice. Can you honestly tell me that the “talking points” of this campaign do not encompass the intention of making such prescribing activities illegal?

You have admitted publicly since your press conference that

“I’m not the authority on what would and would not be banned”.

I think that is correct. And yet you have portrayed yourself as that authority. As a result, your press conference is being used to spread misinformation that directly contradicts what appears clearly to be the true intent of the law, which is to outlaw both abortion and any birth control method other than diaphragms and condoms.

Dr Bush, you must by now realize the full intentions of those who are using you. They are taking full advantage not only of your pro-life politics, but of your gender and your race to sway voters to vote against their own self-interest, for a bill that would limit their access to the contraceptives they have relied upon, and that you have prescribed, for years.

Fortunately, it’s not too late. You still have time to hold another press conference. To tell the public, and your patients, the truth about Amendment 26. Don’t tell them that their birth control is safe if you are not sure it is. Tell them the truth.

Your patients have trusted you for years. They deserve no less.

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Required reading – The Next Front in the Abortion Wars – Birth Control.

Photo credit – Phil Bryant, AP Photo. Licensed for editorial use.

The Meaningful Use Song (with Apologies to Gilbert & Sullivan)

As billing compliance leader in my department, I’ve been charged with getting my colleagues on board with Electronic Medical Record Meaningful Use. (What does meaningful use have to do with billing? It’s complicated, but the codes up until now have been reported along with billing codes, so it sort of fell into my lap. Lucky me…)

Generally, meaningful use refers to using the EMR in a way that harnesses its immense power to store and retrieve data in a way that makes sense and potentially improves clincal outcomes- by checking for drug interactions in real time, for example, or to track blood sugars, blood pressure or other data, or to allow for electronic prescriptions and shared data between clinicians using common language.

Specifically, when we say “meaningful use” these days, we are referrring to the list of meaningful use standards developed by CMS – a very specific list of 25 objectives, along with defined quality measures (like percent of women getting mammograms) that will be used to report and track health outcomes in practices using EMRs.

CMS is offering financial incentives to medical practices to use their EMR in a meaningful manner this year. We will be reporting data starting in October 1 to CMS, and must meet 20 of the 25 meaningful use objectives and report outcomes on chosen quality measures to qualify for the incentive payment. In addition, we are reporting separately to the government on the use of electronic prescribing, and face possible penalties for docs who are still stuck on paper. In time, our outcomes on the quality measures will be reported to the public on the CMS website.

Does Meaningful Use Improve Clinical Outcomes?

That’s the 20 billion dollar (the amount 2009 Hi-Tech Act allocated to the meaningful use incentive program) question. We really don’t know as yet whether or not EMR use itself favorably impacts patient care.  Some studies say EMR use does not improve health outcomes, but more recent studies of diabetes care and in low resource areas have suggested that EMR use may be beneficial.

We also have no idea if docs who attain meaningful use are better docs than those who don’t. Despite this, the CMS website will have clear implications as to the outcomes of doctor’s practices in terms of standard quality measures. It’s a bit worrisome to me, especially since so many of the outcomes are driven by patient compliance (a word I know a lot of my readers don’t like, but there it is…) Not to mention the thorny issue of using mammogram screening in women over 40 as an outcome measure when we just decided that it is no longer recommended to routinely perform it in everyone. (Don’t get me started on that issue again…)

Overall, I think meaningful use is a step in the right direction

I do see meaningful use as an attempt to rein in the wild, wild west of EMR development to try to create some standardized functionality and communication. It’s also a way to begin to corral the freestyle and autonomous EMR use that has evolved among early EMR users, who did what they needed to do to get their work done during the evolution of the EMR around them, but who now need to step back and reassess how well (or not) they are using this powerful tool that has been foisted upon them.

But my god, this whole process has been painful.

And so damned complicated, I needed a song to keep it straight. Ergo that parody up there, which actually covers all 25 meaningful use requirements as defined by CMS. (or at least as I see them…)

Of course, I could have just learned the Meaningful Yoose Rap. But please… me singing rap?

Emergency Contraception is NOT an Abortifacent

When patients ask me how emergency contraception prevents pregnancy, I tell them that it’s primary mechanism is to delay ovulation (release of an unfertilized egg from the ovary).  There is no evidence that the EC aborts or prevents implantation of an already fertilized egg.

The efficacy of EC depends on where you are in your menstrual cycle when you have unprotected sex –

  • If you are destined to ovulate in the next 1-5 days, EC will delay the release of the egg from the ovary until the sperm have lost their viability in the reproductive tract. This is how it works.
  • If you’ve already ovulated and the egg is still in your reproductive tract, you’re possibly already pregnant by the time you take EC. If so, it’s not going to work.
  • If you’re not due to ovulate for >5 days or are 5 days or more past ovulation, then you’re unlikely to have gotten pregnant anyway, and the EC hasn’t done much. (But take it anyway, please, since not every ovulation is predictable)

Now a nicely done study reinforces yet again that delay of ovulation is indeed the mechanism by which this important contraceptive works to prevent pregnancy.

Researchers enrolled 450 women presenting for emergency contraception at a clinic in Chile,where they assessed where in their cycle these women were at the time of unprotected intercourse by using hormone assays and ultrasounds throughout the rest of that menstrual cycle to see if they ovulated, menstruated or became pregnant.  (Previous studies relied on menstrual history alone to pinpoint ovulation, a much less reliable methodology.) The EC used in this study was levonorgestrel.

Altogether, 103 women who took EC did so just prior to ovulating – Although 16 pregnancies would be expected in this group based on normative data, none of theses women became pregnant. In contrast, 45 women took EC on the day of ovulation – 8.7 pregnancies would be expected to occur in this group , and in fact, 8 pregnancies did occur.

The efficacy when used before ovulation was 100%. On the contrary, when used after ovulation has occurred, the number of observed and expected pregnancies is not statistically different, indicating that no reproductive process subsequent to ovulation is interfered with by LNG-EC. This finding is incompatible with the inhibition of implantation by LNG-EC and is consistent with the mechanism of action of EC reported in a recent review.

Other research has shown that EC does not alter the proteins in the endometrium necessary for the implantation of  the fertilized egg.

Although overall, EC has not had a major impact on unplanned pregnancy rates in the United States, it remains an important method of contraception for women. It’s important to counteract misinformation about its mechanism of action for women considering it’s use.

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More info on EC from The Emergency Contraception Website

Prenatal Tay Sachs Screening – Not a Perfect Test

This week’s NY Times has a most powerful and beautiful essay written by Emily Rapp, entitled “Notes From a Dragon Mom”, in which she describes what it is like to parent a child who is destined to die. Rapp’s 18 month old son Ronan has Tay Sachs disease, a progressive and incurable neurologic disorder that will result in his death within a few short years of life.

How do you parent without a net, without a future, knowing that you will lose your child, bit by torturous bit?

Depressing? Sure. But not without wisdom, not without a profound understanding of the human experience or without hard-won lessons, forged through grief and helplessness and deeply committed love about how to be not just a mother or a father but how to be human.

Rapp’s essay is a foray into the true connection between parent and child, and, in a way, a celebration of how that relationship is all the more special because it is devoid of the pressures of perfect parenting for the perfect future.

Ronan has given us a terrible freedom from expectations, a magical world where there are no goals, no prizes to win, no outcomes to monitor, discuss, compare. But the day-to-day is often peaceful, even blissful.

As a mother, I want to thank Rapp for her wisdom as she shows us all how to be better parents, and wish her continued strength and joy as Ronan’s mom.

As a doctor, I’d like to address the section of the essay where Rapp talks about Tay Sachs gene mutation screening.  It’s a short paragraph with just enough information to answer the question the reader probably has, which is – “How did this happen, when we have prenatal testing for Tay Sachs?”. Unfortunately, it is also just enough information to confuse and even frighten women who have had or are considering having prenatal screening for Tay Sachs.

The prenatal test I took for Tay-Sachs was negative; our genetic counselor didn’t think I needed the test, since I’m not Jewish and Tay-Sachs is thought to be a greater risk among Ashkenazi Jews. Being somewhat obsessive about such matters, I had it done anyway, twice.  Both times the results were negative.

Oy. Let’s see what I can do here…

A TAY SACHS SCREENING PRIMER

What is Tay Sachs?

Tay Sachs is a genetic disorder caused a recessive mutation in the gene for hexosaminidase-A, an enzyme that catalyzes the breakdown of fatty acids in the brain. In the presence of defective Hex-A, fatty acids accumulate in the brain, causing permanent damage and progressive neurologic decline and eventually, death.

Babies born with Tay Sachs carry two copies of the defective gene, one from each parent. Parents who are carriers of recessive genes can be detected though prenatal genetic screening. This screening has been concentrated to date in high risk groups, which in the US are primarily Ashkenazi Jews, who have a carrier incidence of 1 in 30.

Who Should be Screened for Tay Sachs?

At this point in time, prenatal Tay Sachs screening is recommended to be offered to individuals from groups with increased mutation carrier incidence  – Ashkenazi Jews, French Canadians, Louisiana Cajuns and Pennsylvania Dutch. Rapp is of Irish descent,  a group with a mutation carrier incidence somewhere between 1/50 and around 1/200.

Of course, a major reason why couples screen for Tay Sachs, and for other genetic disorders, is because they want the option to terminate an affected pregnancy. An indeed, with the advent of prenatal diagnosis, the incidence of Tay Sachs among children born in the Ashkenazi Jewish population has plummeted.

In addition to using screening prenatally, some Jewish communities screen much earlier, and actually maintain online databases of Tay Sachs carrier information, so that couples can log on and screen out one another before embarking on a courtship, in an attempt to reduce marriages between two carriers. In Montreal, voluntary high-school based Tay Sachs screening programs have led to a 90% decline in the incidence of Tay Sachs in high risk communities.

Tay Sachs – Not Just a Jewish Disease 

Rapp has also written an essay on Salon entitled ” Tay Sachs is not a Jewish disease“, in which she argues that the panel of Tay Sachs genes tested should be expanded beyond the most common mutations found in the Ashkenazi Jewish populations.

…we need to consider more carefully who should get tested for what, and why. As it turns out, there are about a hundred mutations of the Tay-Sachs gene. Unfortunately the common, standard prenatal screening only detects the nine most commonly detected mutations – commonly detected among those of Ashkenazi Jewish descent , like my husband.

…Until gaps like this are rectified, until the testing catches up with the facts, and until insurance companies are willing to redefine the “standard” array of tests, more families will suffer this kind of horrific loss and the great potential of prenatal screening will never be achieved.

In Rapp’s case, she and her husband indeed would have qualified for screening, and I am assuming from the fact that she was tested twice that they knew in advance that her husband was a mutation carrier.

Tay Sachs Carrier Screening

There are two ways to determine if a parent is a carrier for a Tay Sachs gene mutation – DNA testing (carrier screening) and Hexosamindase -A activity levels.

DNA Carrier Testing

Among Ashkenazi Jews, DNA carrier testing will detect up to 99% of carriers. In the case of a couple where only one is Ashkenazi, initially carrier screening the Jewish member of the couple is thus a good way to go, since the DNA screening tests perform so much better in that population.  Then, if that individual screens positive, the next step is to screen the non-Jewish member of the couple. And that’s where the DNA test falls short –  in non-Ashkenazi individuals, it detects at most 60% of affected individuals. In Rapp’s case, the gene she carried was a rare one indeed, having” last surfaced in 1997, among people of Moroccan descent”.  Thus, it is not surprising that Rapp, despite being a mutation carrier, would have had a negative carrier test result using the available DNA testing.

There are to date over 100 known mtutations in the Hex-A gene that can lead to Tay Sachs disease, and we just do not as yet, nor are we likely soon, to have commercially available screening test for every mutation known to date. In the case of a non-Jewish individual married to a Jewish carrier, non-DNA screening for Hexosaminidase-A activity provides a better alternative to DNA testing.

Hexosaminidase-A Activity Testing

Individuals who carry Hex-A gene mutations, while phenotypically normal, have lower than normal levels of Hex-A serum activity on a simple blood test. This test actually formed the basis of the first screening for Tay Sachs, before we had DNA testing, which is thought to me more specific.

In some ways, though, DNA testing is too specific – it’s like searching for 1 of 100 needles in a haystack. And when you only know how to find 9 of those 100 needles, maybe you’re better off using a magnet – Hex-A Activity testing. It may not tell you which gene you have, but at least it tells you whose haystack has the needles. At that point, you would proceed to testing the baby.

Some might even use Hex-A testing as first line testing in an Ashkenazi individual, or combine it with DNA testing to get as close to 100% certainty as possible even in that population. And, as populations diversify through intermarrriage, Hex-A activity levels are being suggested as a better screen that DNA testing.

Of course, even hex-A activity testing isn’t perfect . But it’s pretty darned good.

Testing the Baby

Remember, that even if both members of the couple are carriers, there is only a 25% chance that the child will be affected. So if both members of the couple are Tay Sachs carriers, or if one is a carrier and the other uncertain, then testing the baby is done using CVS or amniocentesis to test for Hex-A activity, DNA or both. CVS and Amnio are both invasive tests with a small but real risk for miscarriage. Preimplantation genetic testing is also available for couples undergoing IVF who wish to screen for Tay Sachs.

But even these test are not perfect. Which, in the end, was the whole point of my writing this post. So let me say it again –

NO PRENATAL DIAGNOSTIC TEST IS PERFECT

We can talk about how to make Tay Sachs screening more effective. We can expand the number of genes we test for, and the number of individuals who are offered screening, in order to come closer to realizing, as Rapp puts it “the great potential of prenatal screening.”

But we cannot, and must not, set up the expectation among women and families that the technology exists and is available that will guarantee them a perfect child. We cannot set up the expectation that technology exists to detect every child with Tay Sachs, or any other genetic disorder, prenatally.

Or, as the National Tay-Sachs and Allied Disease Organization so eloquently puts it –

We are all carriers of recessive genetic diseases but standard healthcare practice does not screen everyone for all diseases because the technology does yet exist to accurately and cost effectively screen everyone.

Which, in the end, brings me back to Rapp’s most excellent essay, which teaches us to love our children for who they our for as long as we have them – whether that is three months, three years, or a lifetime.

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For more information on Tay Sachs Screening

I Hate Fluorescent Overhead Kitchen Lighting

Adam Roberts, the Amateur Gourmet, abhors the cold flourescent lighting in his otherwise totally awesome retro LA apartment kitchen. He solved the problem by getting some mist table lamps from CB2 and placing them around his kitchen. Nice fix, Adam!

I had a similar issue here in my NYC rental apartment, which I have solved when my brother in law, who built our dining room wall unit, left behind a task light. I simply clamped the task light to my spice cabinet, bouncing the light off my white ceiling. Viola! Warmth and light. Even with the overhead flourescent light on as well, the room has a warm feeling. Maybe not as cool looking as Adam’s but I love the feel. See the difference –

Fluorescent light on – Food looks unappetizing and I feel depressed.

Task light/fluorescent combo – Aaaah….Happy food, happy cook.

Steel Cut Oats with Cinnamon, Dates and Sheep’s Milk Yogurt

It’s healthy, it’s delicious, and with the littlest bit of planning, it can be made conveniently enough for the busiest lifestyle. I know, because I live that lifestyle. And until now, breakfast was a coffee and a muffin from the truck on the way to work. No longer.

Once or twice a week, here’s what I do – while we’re cleaning up the dinner dishes, I start the oatmeal cooking. When it’s done, I take the pot off the stove and put it in the fridge. In the morning I will take out a quarter of the original batch, put it in a glass jar and heat it in the microwave. (I’m avoiding plastic when I can.) I then take the jar and put in in a bag with a small container of yogurt, a bowl and a spoon. On the way to work, I stop for coffee at the truck, and by the time I reach my desk, the oatmeal is still warm (I only love 5 blocks from work). I spoon the oatmeal into the bowl with the yogurt, and sink into my morning heaven. If I’ve gotten to bed early, I’ve also gotten up early, and beaten my first patient to the office by at least a half hour, so I can take my time and really enjoy it. If not, I just start in on office hours, nursing my oatmeal between patients throughout the morning. Either way, I’m happy.

My long term goal it to get up really early and exercise, and to eat before I get to work, but for now, this is working for me. And its a heck of a lot healthier than a muffin.

Sheep’s milk Yogurt?… Really?

OMG once you’ve tasted it, you’ll never go back to the cow. It’s got a tangy freshness that is just so special.

From a health perspective, sheep milk has a higher calcium and  nutritional content than cows milk, and while it also has more fat, 25% of that fat is medium chain triglycerides, which may benefit weight loss. Plus I find it that much more satisfying than low fat yogurt, so I only need a few ounces to feel satisfied. With Old Chatham brand, the one I’m using now, you can skim the cream off the top for a lighter fat version.

Sheep’s milk is also rich in omega-3 fatty acids and linoleic acid, and may have favorable effects on cholesterol and heart disease risk. In one study, switching from cow to sheep’s milk lowered total cholesterol among folks who ate a dairy-rich diet.  In another, sheep’s milk cheese consumption led to favorable changes in inflammatory and atherogenic markers.

The best tasting brand I’ve eaten so far is from Bellwether Farms in California (maybe because it was my first…), but the yogurt from Three Corner Field Farm is a very close second. Old Chatham makes a sheep yogurt that is more akin to the greek yogurt, and has wonderful flavors like maple and ginger.

Oatmeal with dates, Cinnamon & Sheep’s Milk Yogurt

This batch will make 4 servings. Bob’s Red Mill oats, which I am using now, calls for 3 cups of water to 1 cup of oats and a 20 minute cook time, but I’m happier with 3 1/2 cups water and a longer cooking time. You should experiment with the brand you use to find the amount of liquid and the cook that works best for you. I also like Whole Foods 365 and Trader Joes Brands. Dates have the wonderful quality of melting into the oatmeal as it cooks, dispersing their sweetness throughout, obviating the need for maple syrup or brown sugar, and, along with the cinnamon, giving it a wonderfully nutty brown color.

  • 1 cup Steel Cut Oats
  • 3 1/2 cups water
  • 1/4 tsp kosher salt
  • 1 cinnamon stick
  • 12 dates (Medjool if you can find them) pitted and cut into small pieces
  • 2- 6 oz containers of sheep’s milk yogurt (you’ll eat 3 oz each day)

Combine water, salt, oatmeal, cinnamon stick and chopped dates in a medium saucepan. Bring to a boil over medium heat. Lower heat as far as possible, cover and cook 30 minutes, stirring several times to keep it from sticking, and removing the lid for the last 10 minutes if it seems too liquidy.  Remove from heat, remove cinnamon stick, cool and store in fridge. To serve, remove 1/4 of the oatmeal, reheat for 1-2 mins in microwave. Serve with a side of sheep’s milk yogurt. Enjoy!

Nutritional info (calculated at Caloriecount.com)

More Make-Ahead Steel-Cut Oats Recipes from Around the Web

  • Pinch My Salt uses McCann’s, makes 8 servings at a time and refrigerates each serving separately in small containers
  • Mark Bittman cuts morning cooking time to 7-10 mins by making Overnight Steel Cut Oats (and tops w/ almonds and dried cranberries)
  • The Novice Chef tries her hand at overnight oats
  • Two Peas and  a Pod top their oatmeal with brown sugar and then torch it, creme brulee style. Definitely a weekend recipe.
  • Ohsheglows makes hers ahead, and has 5 different recipes on her blog, some using almond milk
  • Side of Sneakers makes her overnight in a crock pot and also uses almond milk
  • Apartment therapy uses little jars like mine.

Do you have a favorite steel cut oats recipe?

Tips for steel cut make-ahead success? A favorite brand of sheeps milk yogurt? Feel free to post it in the comments section below.


The Wired Doc – An Icon Narrative

Matt Moore’s iconographic representation of the digital habits of the wired physician, drawn for Wired Magazine’s App Guide.

… I was hired by Wired to illustrate 20 visual narratives for this special issue focusing on smart phone and tablet apps, and the people who use them… Hopefully my abstracted icon narratives get your imagination wandering in the right direction.

I like it.

Mammograms – Reality Check

A well-written and balanced article on mammography from USA Today may help move the conversation about this screening test away from hype and a bit closer to reality. The title – “Mammogram is ‘terribly imperfect’, though recommended.”

For women in their 40s, mammograms reduce the risk of dying from breast cancer by about 15%… But mammograms miss some cancers and raise false alarms about others, causing women to go through unnecessary follow-up tests… “We’re saying, ‘Mammography is a terribly imperfect test, but we’re recommending women get it,'” Brawley says. “The task force was saying, ‘Mammography is a terribly imperfect test, and women have to make a decision about whether to get it in their 40s.'”

I encourage all women to read and share this article.

What I love about the article is how clearly written, non-inflammatory and concise it is, proving that the mainstream media can get it right when it comes to health information. The article also includes a fabulous summary graph that is simple to interpret and very clearly conveys just what it is mammograms can and cannot do when it comes to preventing deaths from breast cancer.
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More reading on mammograms from TBTAM and elsewhere

Linguine with Littleneck Clams, Roasted Tomatoes and Caramelized Garlic

Kudos and a huge thanks to Melissa Clark at the NY times for this wonderful recipe, now in the running to replace Mr TBTAM’s signature recipe as our family classic clam sauce. (I now realize I have never posted Mt TBTAM’s clam sauce recipe, but promise to do so – I actually have a video of him making it.)

This meal was one of several that came from a Saturday morning bike trip to the Union Square Farmer’s Market (I’ll post that too), where we found gorgeous cherry tomatoes and fresh garlic. The herbs came from our own container garden. Gradually, we’re shifting away from stocking the fridge at the supermarket to getting fresh things at the farmers market when we can, and tailoring our week’s dinners around that. It makes for a more empty fridge throughout the week as we work our way through what’s there while it’s still fresh. I like it.

Linguine with Littleneck Clams, Roasted Tomatoes and Garlic

The recipe I’m posting here is Melissa’s recipe with a few modifications  – Mr TBTAM doctored it up at his mother Irene’s suggestion, she having made it herself the week before. Their changes were to add a can of clams (to get more clam-flavored broth), increase the garlic from 14 to 20 cloves  (it’s roasted, so don’t worry, it’s not too much) and adding fresh basil and parsley instead of mint. 

You may want to make the original recipe instead of our version. Either way, be sure to read and the accompanying article explaining the traditional Italian method of saucing pasta and why it’s done that way. I think there may be a way to shorten the recipe a bit and keep to tradition, what with all the taking of things out of and back into the pasta pot. Suggestions in this vein are welcome.

We served the dish with a side of sauteed kale, a salad and warm loaf of crusty bread for dipping in the wonderful sauce. 

20 garlic cloves
2 pints cherry tomatoes
1/4 cup chopped basil
6 tablespoons olive oil, plus more for drizzling
1/4 teaspoon kosher salt
1 teaspoon fresh ground black pepper
Salt to taste
1 pound dry linguine
1 teaspoon crushed red pepper flakes or 1-2 small dried red peppers
1/2 cup dry white wine
4 dozen littleneck clams, scrubbed
1 can minced clams
1/4 cup chopped parsley (plus more for garnish)

Heat the oven to 450 degrees. Smash and peel 12 garlic cloves; peel and finely chop the remaining 8. Toss the smashed garlic with the tomatoes, basil, 2 tablespoons oil, salt,and 1/4 teaspoon black pepper. Spread out in a layer in one or two baking pans (make sure they aren’t too crowded, so they don’t steam) and roast the tomatoes, tossing occasionally, until they split open, 15 to 20 minutes.

Cook the pasta in a large pot of salted water until it is 2 minutes from being done to taste. Drain.

Return the pasta pot to medium-high heat. Warm 4 tablespoons oil in the pot. Add the chopped garlic and red pepper flakes; cook for 30 seconds. Add the wine and let simmer 2 minutes. Stir in the roasted tomatoes and garlic. Add the clams. Cover the pot and cook until the clams open, 5 to 10 minutes. Use tongs to transfer open clams to a bowl; discard any that do not open.

Add the pasta and 3/4 teaspoon black pepper to the sauce in the pot. Cook, tossing, until pasta is just cooked through. Return the clams to the pot and toss with the pasta and parsley. Divide mixture among serving bowls. Garnish with a little more parsley if you want and drizzle with more oil.

Remembering Steve Jobs – A Round-up of Reads and Memories

Just spent an hour or so at my IMac in my own personal memorial to Steve Jobs, reading everything I could get my mouse on about him. Thought I’d share a bit of what I found, the best of which is his commencement speech at Stanford in 2005, something I’ve watched several times before but can’t listen to enough. When I get up the guts to really follow his advice, I’ll let you know.

A truly great man. A truly great loss.

Does Sharing Contest Invitations on Facebook Increase Your Chances of Winning? Do the Math.

“Jean Georges Dinner”, reads the message title in my in-box. That’s enough to get my attention, spam or no. I open the email. It’s a contest at Bloomspot for a seasonal wine tasting and pairing for two at Jean Georges.

That’s a no-brainer. I click the link embedded in the email, fill in my email, zip code and city, and click Enter. Jean Georges here I come! Wait, what’s this?…

Increase your chances. INVITE FRIENDS.
Get a bonus sweepstakes entry for each friend who enters.

Hmmm… “Increase your chances” Chances of what? I notice they did not say “increase your chances OF WINNING”.

Now I’m not dumb. I know that increasing the contestant pool is not a good thing when it comes to improving one’s odds of winning a contest.

But they are giving me additional contest entries. Doesn’t each additional entry effectively double the odds in my favor? Hmmm…This may not be as simple as it looks.

Time to do some math.

(I know, I know…I have much better things I should be doing with my time. But I just saw Moneyball, and am re-enamored with statistics. And you know me, ADD-girl,  I just head where my brain takes me… )

It’s interesting when you do the numbers. Those extra contest entries you get for sharing on Facebook initially do increase your absolute odds of winning. But those odds only stay increased if the pool of contestants doesn’t grow or move more than a level or two beyond the initial share. Because once it does, the whole thing actually starts to work against you and everyone else, and your absolute odds of winning become really, really low. At which point, having more shares actually increases your relative odds of winning over having less shares.

Let me show you…

  • Suppose I am the 100th entrant into the contest. My chances of winning are 1/100 or 0.01.  I send you a Facebook invite, and you enter. Now my chances are 2/102 or 0.0196. Hey, it worked! I increased my chances!
  • So I send an invite to a second friend, who also enters. Now my chances are 3/104 or 0.028. Whoo-hoo! Sharing is power! But wait –
  • What if my first and second friend each invite two friends? This dilutes my odds, but actually not by much.  My chances are now 3/112 or .0267.  I’m still ahead.
  • But what if 10 friends accept the invitation, and each friend has another 10 friends who accept it, and each of those has 10 friends who accept it?  Then my odds become 11/2320 or .004 – lower than they were when I first entered the contest!
  • On the other hand, my friends and I are not the only ones in this contest. Suppose, when all is said and done, the contest has 50,000 entries, including me and my pool of friends and our 2219 entries (excluding the initial 99 entries before I joined).
    • My odds with sharing would be 11 in 50,000 or .00022.
    • My odds without sharing would be 1 in 47,781 or .00002. So sharing increased my odds by tenfold – but just  look how low all of our odds have become!
  • What if I and the first 100 entrants decided not to share with anyone else on Facebook? We’d all have much better odds than we’d ever have by sharing. But talk about trying to get the cat back into the bag…

Bottom Line

Sharing contest invitations on Facebook is fun, but the more everyone shares, the lower the odds of winning for everyone. (So stop sharing everyone, will you?…) Once a contest gets big, sharing can increase your minuscule odds of winning to slightly less minuscule, so you might as well go for the big share and enjoy the ride. Understand you are sharing your email address, effectively building up a mailing list for the contest sponsor, which was probably the whole point of the contest in the first place.

If you really want to win something, stick to your church raffle. The odds are much better.

And if you want to keep your odds up in a contest, definitely do not blog about it, since now you’ve told everyone, and you didn’t even get a single extra sweepstakes entry.

Biking the Harlem Valley Rail Trail

Where the Metro North Railroad line ends in Wassaic, New York

is where the Harlem Valley Rail Trail begins.

From there, its 10.7 miles of paved riding past farms

fields,

and wetlands,

through forests,

and along stretches of Rte 20 and then narrow country lanes

to Millerton, NY.

There you can stop for a tea tasting or a bite at the Harvey & Sons Tea Factory Shop,

visit Gilmor Glass Works,

or shop for books, antiques or bicycle gear,

before heading back the way you came, to the train station at Wassaic and then home.

Of course, if you wanted to bring along a picnic lunch, you could have picked up provisions at Cousins Market just down the road from the train station in Wassaic,

where they make great sandwiches using homemade roasted peppers.

Which is what we did.

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The entire Harlem Valley Rail Trail, when it is finished, will run 46 miles from Wassiac to Chatham, NY. Much of the trail north of Millerton is still under development, though the stretch from Under Mountain Road to Copake Falls Station is complete. One can put together a longer ride than ours (We did a total of about 22 miles round trip) if you are willing to head off the trail onto nearby (hilly) roads.