In the Laboratory, Resveratrol Blocks Estrogen’s Beneficial Effects on Vascular Smooth Muscle

Researchers have shown that Resveratrol, in low concentrations similar to those attained with red wine consumption, actually impairs estrogen’s beneficial effects on vascular smooth muscle growth in the laboratory.

Background

One of estrogen’s beneficial actions in the body is thought to be its inhibition of the smooth muscle cell growth that occurs at the sight of vascular injury – cell growth that leads to atherosclerotic plaque formation.

Resveratrol is the substance that has been hypothesized to mediate the protective effect of red wine against heart disease. Resveratrol is said to inhibit platelet clumping, another critical step in plaque formation, as well as to have antioxidative effects.

But resveratrol also has anti-estrogenic activity and  blocks estradiol metabolism.  How might this mitigate its putative protective effects?

What they did

The researchers  grew vascular smooth muscle cells in the lab, then added both resveratrol and estrogen at levels simlar to those attained in the human body. They found that resveratrol blocked estrogen’s growth-slowing effect on the vascular cells.

These considerations imply that moderate consumption of wine or resveratrol-containing health supplements (20–500 mg) by premenopausal women or postmenopausal women on estradiol could attenuate the inhibitory effects of estradiol on VSMC growth and abrogate the vasoprotective actions of estradiol.

Interestingly, when the resarchers upped the dose of resveratrol to supraphysiolgic levels that are unattainable in the human body, they were able to override the effect on estrogen and get inhibition of growth. They tell us that it is at these unattainable levels that much of the research showing resveratrol’s protective effects on heart disease has been conducted.

Bottom Line

The effects of resveratrol are complex, have been shown only in the lab, mostly in rats at levels unattainable in humans, and may not be as beneficial as you think.

Enjoy your wine if you want, but in moderation and without expectation other than a nice palate and a little buzz. A healthy diet, a healthy weight and exercise remain the mainstays of heart disease prevention.

Could this be why we get hot flashes from red wine?

Still, it makes me wonder….

If this effect of resveratrol is real, then maybe Mother Nature is trying to keep us away from the stuff that might mitigate what little our remaining estrogen might be doing for our hearts.

Just a thought…

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UPDATE – GSK has halted research on use of a resveratrol related compound for treatment of multiple myleoma after subjects in the trial developed kidney failure.

Prophylactic Oophorectomy in BRCA Carriers Reduces Mortality

Removal of the ovaries (oophorectomy) in women who carry harmful BRCA mutations prevents both ovarian and breast cancer, and reduces overall mortality.

In a landmark study published last week in JAMA, researchers followed 2343 women with BRCA1 and BRCA2 mutations for a mean of 3-6 years (range 0.5-27 yrs), and compared cancer and mortality outcomes between those who had risk-reducing surgery (172 had mastectomy and 993 had removal of the ovaries) and those who chose not to have surgery. Those who did not have surgery were offered aggressive surveillance for breast cancer (annual mammography and breast MRI) and ovarian cancer (ultrasound and Ca125 testing every 4-12 months).

In women who underwent risk-reducing salpingo-oophorectomy, 1.1% were subsequently diagnosed with ovarian cancer (ie, primary peritoneal cancer), 11.4% were subsequently diagnosed with breast cancer, and 3.1% subsequently died of any cause. In women who did not undergo risk-reducing salpingo-oophorectomy, 5.8% were subsequently diagnosed with ovarian cancer, 19.2% with breast cancer, and 9.8% subsequently died from any cause.

Ovarian cancer risks were higher in BRCA 1 (7-8%) than BRCA2 carriers (3%) who kept their ovaries. No BRCA2 carriers who had their ovaries removed got peritoneal cancer during the follow up. (This is consistent with prior literature on these mutations and ovarian cancer risks.) Nine women who had their ovaries removed had small occult ovarian cancers diagnosed in the removed ovaries.

Prophylactic oophorectomy was also protective against primary breast cancer, cutting the risk in half – from 22% to 11%. In women who had prior breast cancer, oophorectomy reduced the odds of a second breast cancer from 14% to 11%.

Prophylactic oophorectomy appears to be more effective in BRCA2 than BRCA1 carriers – there were no breast or ovarian cancer-related deaths in BRCA 2carriers who had their ovaries removed.  The surgery appeared to be of equal value in women over and over age 50.

While prophylactic mastectomy indeed reduced the risk of acquiring breast cancer (no women who had the surgery got breast cancer), it did not impact mortality.

Bottom Line

Women who carry harmful BRCA mutations have a markedly increased cancer risk ; 15-40% will develop ovarian cancer in their lifetime (compared to about 1% of the general population) and 6-% will develop breast cancer (compared to 12% of the general population of women).

While we can offer BRCA mutation carriers effective screening for breast cancer (mammogram, sonogram and MRI), we do not have an equally effective screening tool for ovarian cancer. Even the much touted ultrasound and Ca125 tests have not been shown to reduce mortality from ovarian cancer. In this study, in fact, women were offered sonograms and Ca125 testing, and although we do not know to what extent they actually availed themselves of the surveillance, it clearly did not offer them the same protection against ovarian cancer as oophorectomy.

The protective effect of oophorectomy in carriers of harmful BRCA mutations stands in marked contrast to oophorectomy in women at average risk of ovarian cancer, which has been shown to actually increase mortality when performed in women under age 65.

What are the risk factors for having a harmful BRCA mutation?

About 2% of women have risk facotrs for BRCA 1 and 2 mutations. According to the NCI, these are –

For women who are not of Ashkenazi Jewish descent :

  • two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
  • three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
  • a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
  • a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
  • a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
  • a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
  • breast cancer diagnosed in a male relative.

For women of Ashkenazi Jewish descent –

  • any first-degree relative diagnosed with breast or ovarian cancer; and
  • two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.

Women who have none of these family history patterns have a low probability of having a harmful BRCA1 or BRCA2 mutation.

How I Will Use these Study Results

I encourage women with suggestive family histories to see a genetic counselor to discuss BRCA testing. Despite making many such referrals,  I find most women don’t follow through.  “Why should I want to know?” they ask.  “What would I do differently if I had the BRCA gene other than worry?”

It’s an important question that deserves an answer. So I tell them –

We would offer prophylactic oophorectomy. That’s because we have no good screening that has been proven to reduce ovarian cancer mortality. But if we remove the ovaries, we can significantly reduce the odds of getting both ovarian and breast cancer.  With this new study, I can now tell these women that this cancer risk reduction also translates to a significant reduction in mortality. And give them some numbers to chew on as they think about what, if anything, they want to do.

The decision to proceed to oophorectomy is never undertaken lightly. Which is why BRCA testing is helpful – it may allow us to avoid surgery in women who test negative for harmful mutations. It is also why we offer oophorectomy at too young an age and certainly not until childbearing is completed in women who do carry harmful mutations. Sometime in the 40’s seems about the right age for oophorectomy in BRCA mutation carriers. The surgery can usually be done laparoscopically, with same day discharge in many cases.

The price we pay for oophorectomy, of course, is menopause. Menopause that we may not want to treat with estrogen because of your predisposition to breast cancer. However, there are non-hormonal ooptions for hot flashes that can be effective. And here it can get complicated, as some patients decide to have a hysterectomy as well as an oophorectomy, so that they can take unopposed estrogen, which (at least in the WHI) is not associated with an increased risk for breast cancer. (Not unreasonable thinking, in my opinion…) But these are just some of the things you’ll want to think about before considering prophylactic oophorectomy.

I don’t push prophylactic mastectomy, although it is certainly an option for BRCA carriers. This study makes this feel even more reasonable, because while mastectomy certainly prevented breast cancer, it did not significantly reduce mortality from breast cancer. I suspect that is because we’re pretty darned good at screening for breast cancer, and have very effective treatments. But some women will choose mastectomy regardless.

For women with suggestive family histories who choose either not ot know their BRCA status, or who opt for surveillance only, I encourage enrollment in a clinical trial of new screening methods for ovarian cancer. For those who don’t do this, I will do ca125 and sonograms, simply for the lack of anything else better to do.

One of these days, we’ll hopefully have an effective screening test for ovarian cancer. But until then, prophylactic oophorectomy remains an important option for women at increased risk for ovarian and breast cancer due to harmful BRCA mutations.

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NCI Fact Sheet on BRCA mutation testing

NCI Bulletin on this research study

Cervical Cancer Screening – The Jade Goody Effect

The Telegraph reports that the number of screening pap smears performed in the UK has declined, after an 8% blip upwards in 2009 when publicity surrounding the death of Jade Goody from cervical cancer may have led more women to have this important screening test.

NHS laboratories processed 415,497 tests in 2009-10, about 35,000 fewer than the previous year when 450,522. Miss Goody’s death in March last year prompted a 20 per cent increase in the number of Scottish women taking tests. More than 122,000 were processed between April and June last year, the statistics revealed.

The irony of course, is that British reality TV star Jade Goody did have pap smears, but chose to ignore her doctor’s recommendations for treatment when her pap smears came back abnormal.

Nonetheless, the decline in pap smears has led NHS of Scotland to initiate a campaign to reach the up to 25 % of young women who do not respond to invitations to have pap smears.

In England, women are invited to start pap smears start at age 25, while in the rest of the UK, they start at age 20. Britain’s guidelines are in line with the WHO’s, and it has been reported that Ireland may raise the start age for paps there to 25.   There are less than 60 cases of cervical cancer annually in the UK in women under age 25.  Is this enough to justify nationwide screening in women in the 21 to 25 age group?

Jade’s Mum thinks so. She has backed a local British campaign to lower the age when pap smears are initiated in Britain from age 25 to age 21 to bring it in line with the rest of the UK.

Decisions about when to initiate cervical cancer screening must weigh the risks of false positives and the risks of treatment, which can impact fertility, against the risk of missing the opportunity to prevent cervical cancer by treating precancerous changes in the cervix before cancer develops.

Here in the US, we recently upped the age for initiating cervical cancer screening  to age 21 in normal women, because cervical cancer is so exceedingly rare in women under that age unless there is some immune compromise. Abnormal pap smears in women under age 21 are almost certainly due to transient HPV infection that will never progress to cervical cancer, but which leads to thousands of unnecessary colposcopies and biopsies annually.

Caper Love – Chicken Salad with Capers and Lemon

I am in love with capers these days, having rediscovered them in my new favorite lunch, the Atlantic Smoked Salmon Tartine from Pan Quotidian.  This led me to purchase the world’s largest jar of capers from Costco.  Since then, I’ve been adding them to anything and everything, and finding that they enhance almost any dish.

What is a caper, anyway?

Capers are the immature buds of the caper bush, Capparis spinosa. The caper bush is a low growing, hardy plant that thrives in the semi-arid climate of the Mediterranean, where it can be found growing on the wailing wall in Jerusalem and on Roman fortresses in Italy. (My capers are actually imported from Spain.) Capers come in different sizes, the smallest, called non pareilles, being the most precious. Most capers are brined and preserved in vinegar, although the Italians sometimes preserve theirs in salt.

The Forgotten Caper

Although capers are an essential ingredient in certain dishes – Pasta Puttanesca, Tarter Sauce, Tapenade and Caponata come to mind – for most of us, they seem to be an afterthought. After all, capers are frequently used in small amounts – “1 tbsp capers”, or “a few capers” – which makes them appear unimportant. In fact, if it weren’t for fridge clean outs, many of us probably wouldn’t even know we have capers.   “How old are these anyway? Think they’re any good or should I throw them out?” (They’re in vinegar, so they’re fine, by the way.)  The teensy bottle reinforces this dismissive view of capers. “Don’t mind me”, it says. “In fact, just pretend I’m not here. I’ll sit here behind the mayo till you think you need me.”

Let’s hear it for capers!

Well, I say it’s high time we moved capers to the front of the fridge, give them the respect they deserve and start using them more often. They’re great in egg salad, perfect scatted on a lox and bagel sandwich, and lovely on chicken. Why not put a little bowl out on the table with a tiny spoon like another condiment?  If you’re like me, you’ll find you’re using so many capers you’ll need the big jar.  I’m actually almost ready to buy another bottle, and it’s only been a few months!

But be careful – just because you have a lot of capers does not mean you want to use more than a tablespoon or two in a recipe – they carry a big punch for such little guys. Like anchovies, capers add saltiness to a dish, so you may want to cut back a bit on the salt in your recipe to compensate.

Chicken Salad with Capers

This salad uses a 1:1 mix of mayo and non-fat Fage Greek Yogurt. If you like you salad wetter, just increase the amounts of each in equal proportions. You can substitute finely chopped cilantro for the celery. There is just a hint of lemon – you can add more if you like to taste.

3 cups bite-sized cut-up cooked chicken
3 tbsp non-fat mayo
3 tbsp non-fat yogurt
2-3 tbsp capers (start with 2 and increase per your taste)
1 large celery stick, finely chopped
1/2 tbsp lemon juice
Pepper to taste (you probably won’t need salt)

Mix the chicken with the rest of the ingredients in a large bowl. Serve with grilled pita wedges. And a little bowl of capers with a tiny spoon on the side. In case you want a few more.

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More Caper Love

This post is my contribution to Weekend Herb Blogging, hosted this week at TasteSpace , with four years of wonderful archives at Cook Almost Anything.

Onion-Herb Bread

This herb-filled bread is based on yet another recipe from Criag Claiborne’s NY Times Cookbook (c 1961). It is called Spiral Bread, and uses scalded milk, a throwback method that some think originated in the days before pasteurization as a way to sterilize milk before baking. In fact, there ‘s more to it than that – scalding works to enhance rising by inactivating enzymes in the milk that inhibit yeast activity.

Claiborne uses a double-flour addition mixing method that may enhance aeration by adding only half the flour and mixing very well with a mixer before adding the rest of the flour and kneading.

I did get a very nice rise on this bread. While the herb filling was delicious, the bread itself seemed bland – I think I’m becoming a whole wheat addict. Everyone else, however, loved this bread.

I modified Claiborne’s herb filling to accomodate what I had growing in my backyard herb garden and what I had in the fridge – therefore, scallions became onions, thyme and rosemary were added and the overall quantity of herbs allowed me to make just one filled loaf and one regular.

Onion-Herb Bread

This recipe wil make one herb-filled loaf and one regular loaf. To make two herb-filled loaves, just double the filling ingredients.

1 cup scalded milk
2 tbsp sugar
2 1/2 tsp salt
1/4 cup butter
1 cup lukewarm water
2 (1 1/4 oz) packages yeast
7 cups sifted flour
Olive oil
Onion-Herb filling (recipe below)

Scald 1 cup of milk in a small saucepan. Add sugar, salt and butter. Stir and cool to lukewarm.

Pour 1 cup lukewarm water in a large bowl of standing electric mixer. Add yeast and stir until dissolved. Add milk mixture. Add 4 cups flour, stir in and then beat well. Add remaining flour, remove from mixing stand and mix in by hand till dampened. Let stand 10 minutes.

Turn dough out onto a floured board and knead until smooth, about 10 minutes. Place in a greased bowl, grease surface, cover and let rise in a warm place (80-85 degrees Fahrenheit) until doubled in bulk, about 45 minutes to an hour.

Punch dough down, turn out onto a smooth surface, and let rest 10 minutes.

Grease two 9x5x3 inch loaf pans.

Split dough in half, and roll one half out into a rectangle about 9 inches wide and 1/4 inch thick. (Make sure it will fit into your loaf pan). Brush with lightly beaten egg and spread filling over it, leaving a one-inch border on all edges. Roll up like a jelly roll and pinch the edges to seal. Place seam side down into greased loaf pan.

Flatten the other half of the dough and fold over twice to make a loaf. Place seam side down in loaf pan. Brush tops of both loaves with oil and let rise, covered, for another hour.

Preheat oven to 400 degrees fahrenheit. Bake bread one hour, turn out and cool on rack.

Onion-Herb Filling

1 cup finely chopped parsley
1 cup finely chopped onion
3 cloves finely minced garlic
3 tbsp thyme, finely chopped
3 tbsp rosemary, finely chopped
3 tbsp finely chopped basil
2 tbsp butter
1 egg, lightly beaten
1/2 tsp kosher salt
Fresh ground black pepper
Pinch of cayenne pepper

Cook onions in butter over moderately high heat in a skillet until translucent. Add garlic and herbs and continue cooking, stirring, until herbs are thoroughly wilted but not brown. Add seasonings. Cool.

Reserve 1 tbsp of the beaten egg. Add the balance to vegetables. Use in bread, above.

Anadama Bread (adapted from the NY Times)

My last bread attempt was a whole wheat anadama bread recipe from Craig Claiborne’s 1961 NY Times cookbook, modified by using honey instead of molasses. It was delicious, but denser than I’d like due to a poor rise, and with too thick and hard a crust.

This time, I made a more traditional anadama bread using white flour and molasses, modifying a recipe from the NY Times for the food processor.  The result  – a soft, moist, slightly chewy, not quite spongy textured bread with a nice crust. The flavor was lovely, although I think I prefer the nutty sweetness of my whole wheat version.

Using white flour instead of whole wheat definitely gave a better rise, though the rise did not entirely hold up during the baking. The original recipe is made in a mixing bowl with a dough hook, and calls for mixing for 7 minutes till it pulls away from the sides – that may be the kneading-substitute. I made mine in the food processor, taking it out to a floured board much sooner than 7 minutes when it became clear that if I continued, I’d wear out the food processor motor, and kneaded for about 2-3 minutes. I suspect this may not have been enough kneading, and thus I did not get optimum gluten formation. It could also be the 2,000 foot altitude here in the Endless Mountain – high altitudes can cause too fast a rise with poor structure. However, given my poor rises here in the past, I suspect its the gluten and not the altitude, since we are just not that high up. (Although your ears do pop on the way up and down the mountain…)

Anadama Bread (adapted from the NY Times)

The original recipe adds nutmeg, which for some odd reason I did not have.

1/2 cup cornmeal
water as directed below
1/2 cup molasses
6 tbsp butter, softened
1 – 1/4-ounce package active dry yeast
4 1/2 cups all-purpose flour (plus more for kneading)
1 teaspoon kosher salt
Oil for greasing.

1. In a bowl, stir together the cornmeal and 1 cup water. In a saucepan over medium-high heat, bring another cup of water to a boil. Add cornmeal mixture and cook, stirring constantly, until mixture is very thick, about 10 minutes. Stir in the molasses and 2 tablespoons butter. Cool till tepid and transfer mixture to food processor.

2. Whisk the salt into the flour in a large bowl. In a small bowl, stir together the yeast and 1/2 cup water until yeast has dissolved, add to cornmeal and pulse for a second. Add flour 1/2 cup at a time, pulsing for several seconds after each addition. Process until dough starts to pull away from sides of bowl, or in my case, until the processor starts to sound like it’s going to wear out, then turn the dough out onto a floured board and knead it for a few minutes, adding more flour as needed to keep the dough from sticking. (I ended up adding about another 1/2 – 3/4 cup flour)

3. Place dough into a lightly oiled bowl and cover with oiled plastic wrap. Allow dough to rise for 1 1/2 hours, or until it has doubled in size.

4. Lightly grease 2 9-by-4-inch loaf pans. Press down dough and divide it into 2 equal pieces. Fold each piece loosely into a loaf and place each in a pan. Cover with plastic wrap and allow to rise for 30 minutes, or until loaves have doubled in size.

5. Preheat oven to 350 degrees. Bake loaves for 45 minutes to 1 hour, or until bread is a dark golden brown and sounds hollow when tapped.

6. Allow bread to cool in pans for 5 minutes, then turn out onto wire cooling rack.

Yield: 2 9-by-4-inch loaves.

News I Will Use

Vacation and an afternoon on the front porch with the laptop provides a chance to catch up on my journal reading. Here are a few tidbits from today’s front porch reads that I will likely use clinically –

Acyclovir and Valcyclovir use in the first trimester of pregnancy continues to appear safe.

These drugs are commonly used to treat Herpes. In a little over 1800 exposed pregnancies, the rate of birth defects (2.2%) in pregnancies where these two drugs were used in the first trimester was comparable to non-exposed pregnancies (2.4%). Until now, data has been limited to voluntary registry reports to the FDA of acyclovir exposure –  about 500 exposed pregnancies with reported birth defect rates of about 3% in exposed and non-exposed pregnancies. This study was a review of a large Danish national birth database, and used pharmacy records to assess exposure. Limitations? (1) Pharmacy records may not indicate actual drug exposure; (2) Not enough exposures to assess impact on individual birth defects, just overall rates; and (3) Famcyclovir, another drug commonly used, was used by only 26 women in this study, so conclusions about its comparable safety cannot be drawn.

Using Lubricant for Speculum Insertion

In a commentary in the August Green Journal, Oz Harmanli and Keisha Jones make the case that lubricant, when applied properly, does not interfere with Pap smear interpretation or testing for sexually transmitted diseases, and should be routinely used for pelvic exams.

I usually lubricate the speculum with water, and am generally known for doing gentle exams, but will likely increase my use of lubricant during routine exams after reading this commentary. I remain concerned about my ability to read a wet prep after using lubricant in women presenting with symptoms of vaginitis – the gels can make the slide difficult to read. In addition, the lubricant we use has antibacterial properties, so I still probably will try to avoid using it if I plan to send bacterial or yeast cultures.

Oral Contraceptives Suppress Ovulation Just as Well in Obese as Normal Weight Women

In this well-done study of  20 microgram pill users, ultrasounds and hormone levels were done to determine if and when ovulation might occur during oral contraceptive use. Obese women had no more ovulations than normal weight women. Not surprisingly, non-compliance with daily pill use was the biggest predictor of ovulation during pill use.  An unexpected finding was that obese women missed more pills, although they did not always report this to the investigators.

Uterine Artery Embolization vs Hysterectomy – 5 year health outcomes

Uterine Artery Embolization or UAE (also called Uterine Fibroid Embolization or UFE) is a emerging alternative to surgical treatment of uterine fibroids. In UFE, small microspheres are injected via a catheter to block the blood vessels feeding the fibroids, causing them to shrink in size. This study randomized 197 women 1:1 to either hysterectomy or UFE. Five years later, health-related quality of life was similar between the two groups, although about 25% of those who underwent UFE ended up eventually having a hysterectomy.  I offer both treatments to my patients, along with hormonal options if they exist, but most of my patients choose to live with their fibroids till menopause, when they naturally will shrink.

Ovulation after Medical Abortion

It occurs on average 21 days after start of the procedure. That’s important information to tell patients, and impacts when to start contraception.  (Sober et al ASRM 2010 abstract Fert Steril 2010; 94 (4): S5)

Return to Fertility after D&C vs Misoprostol treatment of Missed Abortion

We are now using misoprostol to help women end pregnancies that have stopped growing but have not yet passed (missed abortion), potentially  saving them from a D&C.  But which procedure allows for faster return to fertility? This is important to know for women undergoing assisted reproduction treatment, as well as for women trying to get pregnant. In this study, the pregnancy test turned negative in about 37 days regardless of which procedure is used to end the pregnancy, and the next fertility cycle occurred about 60 days later. Not surprisingly, about 26% of women using misoprostol end up with a D&C anyway. The ability to obtain material for genetic analysis was predictably higher for D&C. (68% vs 5%) (Cotton et al SARM 2010 abstract Fert Steril 2010; 94 (4): S6-7)

Vaginal vs laparoscopic hysterectomy

Peri-operative outcomes were similar between women randomized to either vaginal hysterectomy or laparoscopic hysterectomy by a single experienced surgical team at this Italian hospital, but post operative pain was better and hospital stays shorter in women having the laparoscopic procedure.  This is an important study because it has been argued that vaginal hysterectomy in experienced hands is as good as the newer laparoscopic procedures. Of course, the study’s findings will have to be replicated by other surgeons and other hospitals before definitive conclusions can be made, and in the end, it is the skill of the surgeon that in my mind, is most important, whether he/she chooses to use the vaginal or laparoscopic approach.

Vaginal probiotics are effective for recurrent bacterial vaginosis

We’ve been looking for a probiotic solution to BV for years, and we may finally have it. These capsules containing lactobacillus rhamnosus, l Acidophius and Streptococcus thermophilus, used nightly every other week for two weeks, were effective at reducing recurrences of bacterial vaginosis from 45% to 15%. The capsules used have very high concentrations of these probiotic bacteria.  This is only the first study of this preparation, so we will need to see if it is replicated by others.

Pelvic Floor Training Works

Even in cases with pre-existing prolapse, the bladder and rectum were elevated and urinary symptoms and bother were reduced after pelvic floor training, with no adverse effects in this randomized parallel group controlled trial. The training regimen was 3 sets of 8-12 muscular contractions daily, supervised by a physical therapist once a week for 3 months, and every other week for another 3 months. The move used is called “the Knack”, in which pelvic floor muscles are tightened before and during increases in intra-abdominal pressure (cough, sneeze, valsalva). What I like about the Knack is that it isolates the pelvic muscle – most women tend to erroneously tighten their abs when we want them to be tightening their pelvic floor.

Whole Wheat-Honey Anadama Bread

On vacation at the cottage for a week, I’ve decided to focus on learning bread making.

My most recent attempt was a loaf of Cuban Bread, which turned out rather fine if you ask me. So, I am sticking with my 1961 edition of Craig Claiborne’s New York Times Cookbook, which I found here in the cottage when we bought it, and where I found this recipe for Anadama Bread.

Anadama Bread is a traditional new England bread made with cornmeal and molasses, thought to have originated in Rockport, Massachusetts. There are several amusing stories as to how this bread got its name, all involving a farmer and his wife Anna, and the words “Anna, damn her!”.

Claiborne’s recipe calls for a mixture of whole wheat and regular flour, unlike most other Anadama bread recipes I’ve since found, which use bread flour. Not having molasses (and not liking it much either) I made mine using honey. Not having cornmeal, I used polenta, which, as Alton Brown so humorously tells us, is essentially the same thing.

The results was a dense, sweet, chewy, moist bread that everyone loved. We used it for Monte Cristos for tonight’s dinner, and I expect it will make some fine toast tomorrow morning.

I was a bit disappointed with my bread’s rise. This was possibly because the day was cool here in the mountains (as opposed to NYC, where it topped the high 90’s), even in the sun, which is where I rose my bread.  Not having a gas range with a pilot, it’s hard to find a warm place to raise bread here, unless I light a fire and place it nearby. I should have done what I did last time I made bread up here, which was to rise it on the dashboard of the car in the sun. (If anyone has any other suggestions for me in this area, they would be much appreciated.) I also may have added too much flour, making the dough heavier than it needed to be.I notice that other recipes use 2 envelopes of yeast, which may be the simple answer given the use of whole wheat flour.

Anadama Bread (adapted from NY Times Cookbook 1961)

1/2 cup corneal
1 cup cold water
1 package yeast
1 1/2 cups boiling water
3 tbsp butter
1/2 cup honey
2 tsp kosher salt
3 cups whole wheat flour
2 1/2 – 3 cups sifted white flour

Mix the corneal with 3/4 cup cold water. Soften the yeast in another small bowel with 1/4 cup cold water.

Add corneal to boiling water on the stove top and stir over low heat until it boils. (This will take at least 10 minutes – you are making grits, after all…) Add the butter, honey and salt and cool to lukewarm.

Combine yeast and corneal mixture and mix. Add whole wheat flour and enough white flour to give a fairly firm, non-stick dough. Turn out onto a floured board and knead until smooth and elastic.

Turn the dough into a greased bowl, grease the surface, cover with a towel and let rise in a warm place (80-85 degrees) until doubled in bulk.

Knead lightly again and shape into two loaves. Place in greased loaf pans. Brush with oil. Cover and let rise until double in bulk.

Bake in preheated oven at 400 degrees Fahrenheit for 15 minutes, then lower the heat to 375 degrees and bake another 35 minutes longer.

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More Anadama Bread Recipes

  • The NY Times recipe adds nutmeg
  • Donalyn tells us her recipe has 2 WW points per slice. She does not cook the corneal first, justs adds it to her dry ingredients. Gorgeous photos!
  • Epicurious has a quick whole wheat version made with buttermilk
  • James gets a gorgeous rise with his version
  • Simply Recipes has a lovely loaf – and the nostalgic comments are a fun read.
  • Jude makes Peter Reinhart’s recipe – takes two days. I thought my version took a long time!
  • Pinch My Salt has some gorgeous shots of Reinhart’s method.
  • The Spice Garden tops her Anadama bread with oats and flaxseeds
  • GirliChef makes Anadama Rolls

Cleaving and Craving Braised Short Ribs

What do you do if you are Julie Powell, author of the Julie-Julia Project blog turned best selling book and blockbuster movie, after all your dream comes true?

You do your best to f– it up.

Then you write about it, in a book called Cleaving: A Story of Marriage, Meat and Obsession.

Don’t expect to like Julie very much as she has an affair on her saintly husband Eric, then proceeds to obsessively crave her lover even as she remains in her marriage, which she further strains beyond anyone else’s breaking point by living part-time in upstate New York for 6 months while she learns the art of butchery.

It’s okay, though, because Powell doesn’t like herself much either.

Powell is brutally, painfully honest in this chronicle of her journey into self-absorption, obsession, selfishness and stupidity, even as she is clearly excelling at butchery while making dear friends at Fleisher’s Meats in Kingston, NY. She is also often brilliant as she draws beautifully written analogies between her screwed up life and her work. Tales of her repeated  failed attempts to sever her relationship with her lover Damien are juxtaposed with detailed descriptions of the difficulties separating the tenderloin from its surrounding muscle and the skirt steak from its membrane. And after it becomes clear that Damien will no longer take her back, Powell begins to wonder if the detritus that builds up on the outside of an exquisitely aged beef steak, and which must be cut away to be able to enjoy the exquisitely tender steak beneath, represents her obsessive love, her or her marriage?

I listened to Cleaving as an audio book, and I would recommend that you do the same. I’m an impatient reader, and imagine that I might have skimmed many of the long descriptions of butchery –  which would have been a shame, because they are really so well-written and a fascinating listen. Powell does an excellent job narrating her book and I enjoyed most of it immensely, even as I found myself occasionally yelling “YOU’RE AN IDIOT!” at the car dashboard.

Unfortunately, Powell finally lost me, when, finished with her butchery training at Fleisher’s, she heads off on Eric once again, this time to find herself among the slaughter yards in Buenos Aires, and then to the Ukraine and Tanzania. A travelogue of no real importance, and no great moments of realization, just a gradual return to her husband, as if Julie had finally gotten as tired of herself as her readers have become.

What rescues Cleaving from being merely the story of an idiot is the meat.  Grass-fed, locally farmed meat, prepared and sold by the endearingly warm, funny, and wonderful group of folks at Fleisher’s, who are at the forefront of a movement that will surely save our food supply from certain doom. The great news for my fellow New Yorkers is that Fleisher’s is now delivering in Manhattan, and at quite reasonable prices. Powell’s book must have been great for business, and for that alone she deserves immense credit.

I wish her well.

Braised Short Ribs

You’re sure to find yourself craving meat while reading this book. The one cut of meat I found myself thinking about most, other than roast beef (which Fleisher’s cooks it on a bed of marrow bones and topped with butter), was braised short ribs.

Powell gives us a rather simple, traditional braise recipe in her book. I made it using top rib, a short rib cut that produces small rectangles of meat, as opposed to the English slab or the Flanken long cut. Adding carrots, thyme, a bit more garlic and some tomato paste seemed right to me. Celery would also been nice had I had some around, so I’ve added it here.

3-4 lbs short ribs (8 pieces)
4 strips bacon, cut into 1 inch pieces
salt and pepper
2 tbsp chopped fresh thyme
2 tbsp chopped fresh rosemary
1 large onion, diced
2 large carrots, diced
4 cloves garlic, thinly sliced or chopped
2 stalks minced celery
1-2 cups red wine
1-2 cups beef broth
2 tbsp tomato paste

Preheat oven to 325 degrees Fahrenheit.

Render the fat from the bacon in a large cast iron or other oven-proof deep-sided skillet or Dutch oven. Remove the bacon bits and save for a salad or something. While the bacon is rendering, rinse and pat dry the meat, then season well with salt and pepper and sprinkle with the chopped thyme and rosemary. Brown the ribs on all 4 sides in the skillet on high heat. Do it in batches so you don’t over-crowd the pan, removing the ribs to a plate when browned. This is a most important step, and requires patience so as to get a well-formed caramelized crust on the ribs.

Once the ribs are browned, remove all but 3 tbsp of fat from the pan and lower the heat to medium. Cook the onions, carrots and celery till softened and slightly caramelized, at least 10-15 minutes, adding the garlic in the last 4-5 minutes so it does no over brown.

Deglaze the pan with the wine, then add the broth and tomato paste. (Start with 1 cup each wine and broth, adding more depending on how deep your pan is. I ended up using about 1.5 cups of each.) Add the ribs back in carefully so as not to spill any broth. Cover the pan with foil and place on a baking sheet in the oven to catch any spills.

Cook for at least 2 hours,until the ribs are tender and falling off the bone, turning halfway to be sure they do not dry out. Remove to a serving dish. Skim any excess fat off the gravy, and boil down a bit if needed (mine did not need it). Pour gravy atop the ribs and serve.

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More Braised Short Rib Recipes from Around the Web

Having a Party? Invite Mr Pimm’s!

Mr TBTAM and I been hosting my chorus’s annual Rooftop Bash for the past 3 years, using the summer sky as an excuse to gather my fellow Collegiate Singers for an evening of food, friendship and song. We’ve been blessed every year till now with good weather, so I guess that sooner or later, it was bound to rain.

On the day of the party, after it became clear that the thunderstorms would not be gone by evening, more than one person called to see if the party was still on (it was).And as evening approached, I found myself becoming increasingly nervous. Could we pull this off without the rooftop? Would everyone be disappointed? Would we all fit inside the apartment? Would the party last more than an hour without the siren call of the evening sky over Manhattan? Would anyone have fun?

I should have known better. It was a wonderful party, possibly the best ever. After all, what makes a great party is the people – and these folks are the best!

Especially our newest guest – Mr Pimm’s. Most of us had never met him before, and let’s just say he fit right in. Andrew brought him along in a bag, along with lemonade, an apple and a cucumber. I supplied the mint and some ice and Mr Pimm’s made friends in no time. From now on, he’s No. 1 on my guest list!

Pimm’s and Lemonade

It’s called a Pimm’s Cup, and it’s what the Brits drink to get them through Wimbleton, or on a warm afternoon watching cricket or punting on the Thames. Think of it as a British version of sangria – a perfect cocktail for a summer party, and mild enough that one can sip all afternoon without losing one’s dignity. There are about as many ways to make a Pimm’s cup as there are British dialects (see below for just a few). This is the version Andrew taught me to make, and now it’s mine.

1/2 bottle Pimm’s
1 quart lemonade
1 apple, cut into small slices or wedges
1 medium cucumber, cut into 1/4 inch slices
Ice
fresh mint leaves

Fill a 2 quart pitcher half way with ice, then add the apple and cucumber. Pour in Pimms and lemonade, give a stir and serve. If you refrigerate it a bit before serving, the fruit has a chance to flavor the drink (and vice versa).
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Mr Pimms is a very popular!

  • The Guardian holds forth on the history of the Pimm’s Cup
  • Slashfood makes their Pimm’s Cup with ginger ale, lemonade, orange and strawberry
  • Don’t have Pimm’s? Michelle Leon makes her own using vermouth, sherry and Triple Sec
  • Science of Drink makes an American version using Sprite or 7-up
  • Domestic Daddy does his version of the Zin cup, created in NYC
  • Mr Pimms is well loved by NYC restaurant bartenders.
  • Looks as though Mr Pimm’s was at Ed Bruske‘s party just a few days before mine. He certainly gets around!
  • The Unexperts show you how it’s done – great photos!
  • The Kitchn.com makes a Pimm’s cup for one – perfect way to end a day of gardening.
  • Coconut and Lime makes Pimm’s Cup Jelly and serves it with a spoon
  • Well-fed takes the Pimm’s cup down to it’s basic ingredients by making it using homemade ginger beer and lemonade – impressive!
  • The Saucy Sisters do a Cajun Pimm’s – with tabasco of course!

The Best Turkey Sandwich in the World

Original Turkey with Provolone
from the The Original Turkey, Reading Terminal Market, Philadelphia

This is what this sandwich does to you. For hours after eating it, you find yourself saying, “That sandwich was good!”  You remember it’s flavor, the warmth of the hand-carved, just cooked turkey, the softness of the fresh bread (OMG, the bread..), the juices as they mingled with the mayonnaise. Your mind keeps coming back to it, and not because you are craving another sandwich. No – The one you had was plenty filling – I could only eat half mine. In fact, your realize that you are entirely and utterly satisfied, so much so that you don’t think you need  to eat anything else ever again – you’ll just live on the memory of that one sandwich.

It’s not just me, I swear. I brought the uneaten half sandwich back to my Dad. By the time he ate it, the meat was no longer warm. And still, about 30 minutes after he had finished eating it, he paused during our conversation, which at that moment had nothing whatsoever to do with turkey, sighed, and said – “That was a really good sandwich”.

(Leftover) Lamb and Mango Salad

A few leftover broiled lamb loin chops were the inspiration for this wonderful salad Mr TBTAM invented for tonight’s dinner. The chops were from Costco, and we had broiled them last night after topping with salt, pepper, Worcestershire sauce and garlic powder. Mr TBTAM picked up the rest of the ingredients at Golden Boy’s Natural Foods, a wonderful local food shop on Broadway at 98th st, while waiting for me to finish my voice lesson around the corner. (I’m working on the Queen of the Night Aria from the Magic Flute – I plan to use it on my daughters whenever they need hollering at…)

Golden Boys is one of my fave local food stores, and I stop in whenever I can before my lesson. They have the most gorgeous fruits and veggies, lovely bean sprouts (which are hard to find fresh) and also carry Bilinski’s chicken sausages, which I love.

What made the salad taste really special were the olive oil and raspberry balsamic vinegar Linda gave us from Lebherz Oil and Vinegar Emporium in her home town of Frederick, MD. Thanks, Linda!

I’m thinking maybe we should have added something for a bit more color – maybe a tomato? Maybe red onion instead of scallion? – yeah, that would work….

Lamb and Mango Salad

Sliced broiled lamb
Fresh ripe mango, peeled and sliced
Red Leaf lettuce
Cucumber, peeled and thinly sliced
1 scallion, sliced thinly crosswise just into the green part
Bean sprouts
Thinly shaved parmesan
Fruity balsamic vinegar
Olive oil

Rinse and dry lettuce leaves and arrange on plate. Top with lamb, mango, cucumber, sprouts, parmesan and scallions. Sprinkle with salt and generous amount pepper. Lightly top with vinegar and oil, toss and serve.

Eat, Pray, Love and the UTI

I really did not expect to like Eat, Pray, Love.  In fact, since its publication in 2006, I’d been avoiding it like the plague. “Typical, New-Agey, Oprah-y, Grrl-book”, I thought. Nothing in it to speak to me.

Then I saw the trailer for the movie, and I was hooked – probably because I, like mostly everyone, love Julia Roberts. I immediately downloaded the book on my IPhone using the Kindle App and began to read.

First, let me say that Elizabeth Gilbert writes exceptionally well, and the book is actually a joy to read. I of course loved the Italy eating part. But more surprising to me, I wasn’t turned off by the whole yoga, Guru, find yourself stuff. This is because Gilbert writes it all with a reporter’s curiosity and a skeptic’s eye, and frames it not as a belief system, but as a tool for self-discovery and peace. (Plus I’m really good at skimming if I get bored….)

Too bad Gilbert’s curiosity and skepticism does not extend to the healthcare she receives while in Bali. She accepts the curative powers of a warm leaf placed on an oozing, infected cut without even wondering what leaf it might be or how it might have worked. Was it the heat (most likely), or something else (possibly)? – I was dying to know. She xeroxes pages and pages of traditional medical treatments without sharing a single one with us in any meaningful way. While I’m pretty sure 99% of what was in there was bunk, but there might be a few gems that would serve medical science. Unless Lizzie made a second copy, we’ll never know, will we?

But it was the UTI that really got to me… Continue Reading

Las Voces de Cuba

It was one of those perfect moments that I shall never forget.

A sweltering hot summer night in Matanzas. The windows of the Biblioteca Gener y del Monte open wide to the city spread out below. Birds soared above in the rafters, their voices joining those of the members of the Coro de Camera de Matanzas, an absolutely brilliant choir whose purity of vocalization and musicality was awe inspiring. We sang that night as well, but it is the voices of these young Cubans, singing Shenandoah as I have never heard it sung before, that I will remember most of all.

Welcome to My New Home

Okay, so it’s only taken 6 months, kept me from blogging for the past 3 weeks, cost me a few hundred bucks, sent me through at least 3 different hosting sites and 5 different paid wordpress themes, but I finally did it. I moved from Blogger to WordPress.

Of course, in the meantime, Blogger has upgraded itself to have almost (but not quite) everything I needed to make my site what it is today.  I think if I had realized what was coming, I probably would never have left – because this migration business has been hell. Not to mention, Blogger made me a “Blog of Note” last month – It’s like they knew I was going to leave…

So let me go on record and say that if you are currently on Blogger, and wondering if you should make the move to WordPress- stay where you are. Blogger is a great platform, and only getting better.

So – wadda’ you think of the new digs, huh?  I designed it all by myself, thank you very much, in a theme called Headway. There are now pages – Recipes, Travel, Women’s Health, NYC . You can click through the categories on the sidebar there if you’d rather use that to navigate around.

You should update your feeds to my new url (http://www.tbtam.com), although if you land back on the old site by mistake, you’ll be automatically redirected here.

If you have comments or suggestions on how to make the site better for your viewing, do let me know. (I’m still working on the blogroll, that should be up later today.) Is there is a feature you’d like to see here? Is something on the site is not working in your browser?  Is the font easy to read, can you see the whole page, is it enjoyable or annoying? Let me know. Because as much as I love the new site, it has to work for you , the reader. After all, without you, there’s no point in blogging, is there?

Enjoy!