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!

Cuban Bread (Pan Cubano)

No matter where we ate in Cuba, the bread was delicious – almost always freshly made, even warm on occasion. Sort of a cross between French and Italian, sometimes like a heavy sandwich bread, sometimes more like a baguette. Then of course, there were those little bite size rolls at El Guarjirito… Needless to say, I came home itching to make bread.

A weekend visit to our cottage in the Endless Mountains was the perfect opportunity for bread making. I have only one cookbook there – The New York Times Cookbook (c 1961)– and as always, it came through, with a recipe for – would you believe it? Cuban Bread!

I don’t know if it’s an authentic recipe or not – I’ve since found others that use a sourdough-type starter. I do know that it indeed tasted a lot like bread I ate one afternoon at a restaurant in Havana. It made us some wonderful sandwiches and toasted up beautifully.

Warning – I am truly a novice bread maker. This post is more a report of my experience and not a lesson in bread making. To hang out with folks who really know what they are doing when it comes to bread making, head on over to The Fresh Loaf or let Bittman show you how he does it (and does it again).

Cuban Bread (Pan Cubano)

This recipe was modified from the James Beard Cooking School. I further modified it because Claiborne did not tell me what to use to grease the bowl (I used Olive oil) and because I did not have corn meal.

1 package yeast
2 cups lukewarm water
1 1/4 tbsp salt
1 tbsp sugar
6-7 cups flour
Olive oil (I assume)
Corn meal

Dissolve the yeast in the water and add the salt and sugar, stirring to dissolve thoroughly, until it starts to foam. Add the flour, one cup at a time, beating with a wooden spoon, until you have a stiff dough. Knead for about 10 minutes till no longer sticky, then shape into a ball and place in a greased bowl and grease the top.  Cover with plastic wrap or a clean dishcloth and place in a warm spot (I used the porch railing in the sun) until it is doubled in bulk.

Turn the dough out onto a floured board and shape into two long, french style loaves or round, Italian style loaves. Arrange on a baking sheet heavily sprinkled with corneal and allow to rise for 5 minutes (I did not have cornmeal, but wish that I did. I love that texture on the outside of bread).   Set a pot of water on the stove to boil while the bread does this last rise.

Slash the tops of the loaves with a knife or scissors, brush the tops with water and place in a cold oven. Set the oven to 400 degrees fahrenheit and place the pot of boiling water on the bottom of the cold oven. Bake the bread until crusty and done, about 40-45 mins.
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Pan Cubano Around the Web

  • Andrea Meyers tells us that my recipe is a “quick” Cuban bread, (as oppoesed to the more traditional method using a starter) and makes a very similar recipe ifrom Memories of a  Cuban Kitchen.
  • Taste of Cuba has the traditional recipe that uses a starter
  • Plantanos, Mangos and Me makes my recipe but in a food processor and with an egg wash. Looks gorgeous!
  • Dino Grrl (does she know Dino Doc?) makes a whole grain bun version.
  • Watch Libby make Cuban Bread in this You Tube video – Nice Job
  • Klaus Tenbergen tell us that authentic Cuban Bread is baked with a palmetto fond atop. (See Lydia’s photo for an example)
  • The Fresh Loaf has a nice thread with lots of Cuban Bread recipes
  • MyBig Fat Cuban Family shares her mothers recipe for use in a bread machine

COMMENTS

Bardiac said…

Wow, that’s interesting that you put water in a cold oven. I wonder what that does? Keep the crust from drying too much?

Now I want to make bread and eat it slathered with butter. :/

AUGUST 07, 2010

Nale said…

I like all sorts of bread. This is new for me, and I will try it. 😉

AUGUST 08, 2010

rlbates said…

Beautiful!

AUGUST 08, 2010

We’re Feeding Dementia Patients with Feeding Tubes???

An article in this weeks NY Times entitled Feeding Demented Patients with Dignity suggests that hand feeding dementia patients may be a better option than tube feeding them.

My God, are we really putting feeding tubes in the elderly demented? When did this happen?

During college, I worked as a nurses aide in a nursing home outside Philadelphia. For 20 hours a week (40 hours in the summer) for two years, I cared for patients in all stages of dementia, from the walking confused through to the end stage, stiffened victims confined to wheelchairs or beds. But in all that time, I never, ever saw anyone with a feeding tube.

As an aide, one of my main duties was feeding the patients. Whether it was solid food cut into small pieces,soft food mashed, or pureed food, we fed them. By hand. Three meals a day, seven days a week. What else did they have to do all day and what else was I there for, after all? Mealtimes were our touchstones, and we marked our days by them. It gave us all something to do.

I particularly recall one elderly woman I helped care for one summer almost every day for two weeks. She was at the worst, end stages of dementia. Stiffened with contractures and moaning constantly. When she wasn’t moaning, she spoke her catch phrases – they all seemed to have catch phrases – strings of words spoken over and over, almost like a mantra. Getting her up and dressed every day took two of us at least an hour. Changing her diaper, cleaning her, rubbing lotion into her skin to prevent dryness and breakdown, getting her into a chair, then changing the sheets, adjusting the lambswool mattress cover.

Then I fed her. It took a half hour or more.

I gave her tiny, tiny amounts of food on a spoon – for breakfast, hot cereal and a mashed soft boiled egg. For lunch and dinner, pureed meat , fruit or vegetables. Sometimes she ate eagerly. Sometimes I had to cajole her. Sometimes I got frustrated, or annoyed – I expect, at those times, she was as well. I remember that we were told to try to make sure they got protein in some form – soft boiled eggs were a god send in this regard, because almost every patient ate them well and eagerly. I tried to figure out what foods she liked and focused my efforts on those, but sometimes, she downright refused to eat or spit the food out. So we stopped – until the next meal.

And then, one morning, I came to work to find that she had passed. I have no idea what ultimately caused her death. But until the end, we fed her.

Are you telling me that today, this poor woman would have had a feeding tube because she couldn’t feed herself? And that it would take a social worker to intervene to suggest that perhaps someone might try feeding her by hand instead? Infants can’t feed themselves, but we don’t put feeding tubes in them, do we?

I ask you again – how in God’s name did we come to this?

I know the answer, of course, as do you. It’s because we have shifted the dollars in healthcare away from those who actually provide the care to those who make the diagnostic tests, the drugs and the devices.

And the feeding tubes.
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Thanks to Info Snacks, which is fast becoming one of my favorite feeds, for pointing me to the NY Times article.

COMMENTS

Eric, AKA The Pragmatic Caregiver said…

Facilities push them to reduce their exposure in the event of aspiration pneumonia, and reduce the number of CNA/caregiver hours required to feed people. Doctors offer them to make it look like they haven’t “given up” on the patient. Families choose them because they don’t want to “starve grandma to death”.. You’re totally right; it’s utterly horrifying, and there’s plenty of blame to go around.

I got an email from someone in my (former) caregiver support group wondering if I had any preference between NG and PEG tubes – in the setting of end-stage Parkinson’s with autonomic dysregulation!

Frankly, I’m a huge fan of tube feeding before it gets to the end-stage of life. My personal favorite method of tube feeding involves a straw with attached parasol, and my favorite formula is a mixture of molasses-derived ETOH, 40% w/v, coconut and pineapple, blended with ice. It helps treat my pesky symptoms such as “being outraged by the inability of others to appropriately care for terminal patients”.

E

AUGUST 05, 2010

Helen said…

Thank you Eric for this comment .. and thank you Dr. P for this post. I cared for my mother during the last five years of her struggle with Alzheimer’s and Lewy Body diseases. Until the end, and for as long as she could swallow …. I fed her. It was spiritual, kind, humane and life-affirming.

AUGUST 05, 2010

Jayme said…

I agree with you! I work as a COTA at a nursing home in Virginia. Tube feeding is also very disruptive to the patient that can remember that they should eat at certain times…but can’t remember that they already got all of their nurtients through a tube…

AUGUST 05, 2010

rlbates said…

Eric, it’s good to “see” you.

Love the post, Dr. P and the above comments.

AUGUST 06, 2010

kathy a. said…

wow. my mother had a stroke a couple of years ago. the cognitive damage was significant — she was not once oriented to time or place after that, had hallucinations, never remembered that she also broke a hip when she collapsed from the stroke, etc. — and there was no improvement after 2 months. it was very like the dementia her own mother had at the end of her life.

that was followed by medical complications: a GI problem they never quite figured out, and she stopped eating. she was a poor candidate for surgery. so i asked the specialist what would happen if she did not start eating again, thinking he would be factual and offer options like palliative care. instead, he snapped, “we’ll just have to put in a feeding tube,” and he bustled away.

really, i was shocked at his response. we were not going to do a feeding tube. i got things straight with her primary, and we got hospice involved right after that. but i really had to advocate for palliative care — i had to know it existed, had to understand that a feeding tube would prolong her suffering, had to flex my power of attorney for medical care.

AUGUST 06, 2010

Joshua Schwimmer, MD, FACP, FASN said…

Thanks for the shout out to Info-Snacks!

Joshua

www.jschwimmer.net

AUGUST 06, 2010

Anonymous said…

Of course, it’s worth pointing out that tube feeding does not, in fact, prevent aspiration. It does cause increased need for restraints to prevent the removal of the tube. Which just makes the whole thing even more inhumane. I know a gerontologist who feels so strongly about this that he will sign off the case if a family insists on a feeding tube.

AUGUST 06, 2010

grapheme said…

This post brought tears to my eyes. Tragic situation in an increasingly difficult world. It has made me think about what I would do in a similar situation.

AUGUST 07, 2010

Daniel F. Kane said…

As the demographics shift from boomer to X/millennial, and the numbers drop to both finance (social security/medicare) and provide care (hand feeding) one can expect more tubes as the same aide in 20 years can hang probably 10 feeding bags per hour but hand feed only two.

Our success at increasing life span (which is a good)co-incident with our success at decreasing birthrate (which is a societal experiment on a scale not seen before in human history) is the root of this issue. Simply stated, if your children can not or will not hand feed you in the winter of your life, in 20 years or so, there will not be anyone to feed you.

A person in a chronic disease state who has the ability to swallow should have the dignity of being fed in a manner that allows them to swallow and live their life to the extent they are capable.

The up an coming demographic, created by us, will likely make this impossible.

AUGUST 07, 2010

Anonymous said…

Good lord, this is outrageous. I’ve never held any clinical position but I’ve hand-fed patients with dementia both as a volunteer and as a ward clerk, back in the 70s. Some of them didn’t really need hand-feeding, just someone to open the cello-wrapped utensils, cut up their food, get them started, encourage them to keep going, and sit with them while they ate. Poor old Violet, it was the only time she wasn’t stressed out over her clothes having been stolen because she thought she was in a pre-War rooming house.

AUGUST 07, 2010

VM Sehy Photography said…

I’m suprised that they don’t have those tubes hooked up to a computer to save time and effort. It’s a sad planet that we live on when people can’t take the time to give things a personal touch. Also, once everthing becomes about money, the soul is sucked out of living. I think I’d rather volunteer for euthanasia then get fed by a tube. I’d be afraid to mention using a tube to feed babies for fear that someone out there will think it’s a good idea.

AUGUST 07, 2010

kathy a. said…

i should clarify that my mom was offered hand-fed food, and sometimes even in the last part she did eat a little. the thought of a feeding tube to force nutrition, though, was awful. she tried to tear out every tube they put in her. we just were not going there.

AUGUST 07, 2010

Cuba – The Food

If I were Ruth Reichl, I’d give Cuba one and a half stars. Because when the food is good, it is very good. And when it is not, the meat and fish are overcooked as to be unrecognizable, or as my friend John called our hotel mystery meat one night  – “some kind of beef”. 

Of course, eating in large hotels and restaurants in groups of over 100 people is not the way to sample a nation’s cuisine. What I was longing to do was convince one of our guides to take us home to their Mom and get me a Cuban home cooking lesson.  But that was not happening on our tight schedule, and it’s not like I had Batali and Bittman to show me around…

It’s also important to remember that this was Cuban food seen through the eyes of an American visitor enjoying the privileges of a four star welcome and with money to spend. For native Cubans, who must live with rations and an extremely limited income, it’s a whole different story. (I”ll be talking about agriculture and food supply issues in an upcoming post.)

All that said, I had some memorable meals in Cuba. Enough for me to know that I did not begin to scratch the surface of Cuban cuisine on this trip. Maybe next time....
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Cafetal Buenavista
Las Terraces Eco-Village
This restaurant occupies the remains of Cuba’s oldest coffee plantation, and is located in Las Terrazas, a restored eco-system in Pinar del Rio. (More on that in a later post..) 
The remains of the terraces where they dried the coffee give the grounds the feel of an old Mayan temple.

At Buenavista, we were served a delicious traditional Cuban meal of fresh fruit, salad, chicken, rice and beans and a crispy fried vegetable – was it potatoes, Plantanos, Yucca? I forgot to ask! 

That’s because I was too preoccupied listening to the music. We were serenaded during our meal by Grupo Polo Mantanez, named for the late Cuban singer-songwriter who was the house act at las Terrazas’ hotels until his tragic death in 2002. The group continues to sing his songs today, and the current female lead singer was amazing. (Click below and enjoy while you read the rest of this post.)

Buenavista’s small kitchen is housed behind the restaurant. 
The views are phenomenal, lending the restaurant it’s name.

This was my favorite meal of the trip.
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Don Lorenzo
Acosta No 260-A e/. Habana y Compostele
Habana Vieje. Tel 861-6733

This restaurant was a gift from a local on a hot Sunday after a long morning spent at the Craft Market. A simple request for a recommendation for a quick bite, and we were led on a ramble through the streets of Habana Vieje to an unmarked doorway, where small but well-maintained stairs led us up to this lovely rooftop restaurant. Our volunteer guide waited downstairs for us as we ate, so as to lead us back to our starting point – in exchange, of course, for a peso or two, which we were more than happy to give.

We were down to our last pesos that day, my friend, but the warm weather kept our appetites small enough to fit our wallets and the spontaneous little meal we shared was one of the best of the trip.

First, a mango, decorated with a small umbrella and a sprig of mint. Then bread with assorted accompaniments – in our case, we chose a simple light tuna salad and a tomato salsa. Washed down with cold agua con gas, it was a delightful small repast on a very hot summer day.

We had the place to ourselves that afternoon, and the service was personal and attentive, despite the fact that we warned the waiter up front how little we had to spend. One day, we’ll return to sample the more extensive Afro-Cuban offerings of the wonderful little restaurant.

We so enjoyed the rooftop glimpses of neighboring homes, each a little vignette of life on this island so close, yet so far far from our American shores.

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La Domenica Restaurant
O´reilly y mercaderes. 
la habana vieja. 860 2918

Located near Plaza de la Catedral in the beautifully restored section of Habana Vieja, La Domenica has been called the best Italian restaurant in Habana. We stumbled upon it, attracted by the outdoor tables shaded by white umbrellas and an amazingly cheap patio menu. (The indoor menu is much pricier.) The umbellas came in handy when the afternoon’s regular downpour occurred halfway through our meal, an event that did little to spoil the meal.

The tuna salad appetizer was perfect, served with the traditional cuban salad of shredded carrots, cucumber, tomato and cooked cold green beans. A few olives reminded us we were at an Italian restaurant, and we washed it down with sparkling lemonade.

The chicken was another Cuban leaning dish, served with rice and beans, at the ridiculously low price of 6 pesos! But the best was the small pizza – unlike any I’ve eaten before, spiced a bit differently and made with a bread that was crisp, light but thicker than the brick oven pizzas I’ve eaten here in the States – Perhaps a little Cuban bread crust?

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El Gaujirito 
Zulueta #658, 2nd floor near Apodaca
Habana Vieja
A bit kitchy, but the service is excellent, and the pulled pork is the best I’ve ever eaten. (It tastes nothing like what we’ve been eating for years at La Caridad here in NYC.) The Cuban rice and beans (Arroz Congri) was also delicious.  The seafood soup was simple – lots of fish in a tomato based spicy broth – and could have been good, but the fish was overcooked, as it was also in the seafood entree. But the bread ! Bite-sized soft balls served along a sombrero brim, with garlic oil for dipping. Enjoy it with a Cuban beer.
You’ll have trouble finding the restaurant, but the cab drivers know it, and will escort you into the unmarked building and upstairs.
Pause and enjoy the art gallery just outside the dining room, and if you’re lucky, you may catch a floor show on the stage there. Don’t let the waitress talk you into ordering too much food, as we did. The portions are large enough to share, so do so.
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El Patio
Plaza de la Catedral, Habana Vieja

Our final night celebration dinner was a feast served to us in Plaza de la Catedral by El Patio, one of Cuba’s most famous restaurants.  Even the downpour that chased us from the square into the restaurant could not spoil the gorgeous setting.  The truth is, I don’t remember much of the meal beyond the mojito, the delicious appetizer – a tower of mango and lobster- the wonderful conversation and the moving speeches and singing. Most memorable moments – singing U2’s MLK – “If a thundercloud passes rain, so let it rain” (and it did…) – and the heartfelt Bawo Thixo Somandla (For you, Sherry…).
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Any Mango Tree 

The mango everywhere was incredible, and the highlight of our daily breakfast. But when we found this mango tree at las Terrazas, we knew we had hit the mother load.

Go ahead – Grab a ripe one down, peel it and enjoy the best fruit you’ll ever eat!  Or, eat it like a native – roll it back and forth between your hands to soften it, then bite off the end and suck out the juices.

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Up next – I try my hand at Cuban Bread

Cuba on My Mind

There is no simple way to describe Cuba to you. Every image, every encounter, every experience evokes a rush of conflicting emotions, because it is a country of such incredible contradiction.

It amazes me to think I actually visited a country whose government suppresses free speech and restricts the freedom of its citizens, and while I enjoyed unlimited internet access (when the router was functioning), Cuban citizens do not.

What amazes me more is that this same government affords these same citizens universal, free medical care, with an infant mortality rate and life expectancy equivalent to ours, a literacy rate of 100%, and an education system so excellent that they are exporting doctors and scientists across South America.

We exit the airpot to see anti-American billboards,

and yet everywhere we go we are welcomed by the people of Cuba with open arms, music, warm hearts (and a Mojito…). 
Cuba’s cities are an ecelectic mix of mid-century and centuries old architecture in colors that brighten the soul,  
and yet many of these same buildings are literally crumbling before your eyes, bringing forth a great sadness. 

It is a place where one cannot get something as simple as an Excedrin, where bathroom attendants dole out small rations of toilet paper like precious jewels and flush the toilets with buckets of water because the plumbing system is unreliable. But the food system is working, and Cuba is now one of the world leaders in successful urban gardening and sustainable agriculture.

We were forced to change our Havana concert venue twice because air conditioning broke down, and the union hall we ultimately performed in, never designed for musical performance but graciously offered for our purposes, had both an out of tune piano and poor acoustics. And yet, in that hall, I heard a flute solo I shall never forget and some of the most beautiful voices I think I will ever hear.

I was told that Cuba was an anachronism, a country trapped in the mid-century, epitomized by the many antique cars we saw on the streets. And while it is true that there are pockets of the past, they exist mostly in the architecture and the automobiles. The people I met were very much citizens of the 21st Century, in many ways poor by our standards, but in some ways rich. Those I met were doing important work in medicine, science, agriculture and the arts, despite what for us might be a crippling lack of resources. And while I remain confounded and disturbed by the harsh realities of their political system, and frustrated by their crying needs for so many of the things we take for granted here, it is the strength, warmth and talent of the Cuban people that I will recall most when I think of my visit there.
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Up next – Cuban Food. 

(Note – I initially wrote maternal mortality up there and meant to say infant mortality. Cuba’s maternal mortality rate is higher than the US’s, but they are aggressively working towards lowering it)

Endometrial Thickness in Post Menopausal Bleeding – Is 3 mm a Better Cutoff?

An abnormally thickened post-menopausal endometrium

A new meta-analysis suggests that the commonly used 5 mm cut-off for endometrial thickness on transvaginal ultrasound may be a bit too optimistic at predicting the absence of endometrial cancer in women with post menopausal bleeding. European Researchers now suggest that 3 mm is a better cut off point, below which there is a 98% reduction in the chance of having cancer of the endometrium.  A thickness of 4 mm gives a 95%, and 5mm a 90% reduction in odds of cancer.

That means if you have post menopausal bleeding (which has a 10% chance of being a cancer among all comers), an endometrial thickness below 3mm on transvaginal sonogram  reduces your chance of cancer from 10% to  0.6%, while the old  5 mm cutoff would have reduced you odds to 1%.

From what I understand, the researchers created receiver operator curves (ROCs) for each study, and them combined then, as opposed to a single ROC from the combined data, which was what had been done in the past to generate the 5 mm cutoff.  Having a pretty rudimentary knowledge of statistics, I have no idea which methodology is better, and will await commentary and guidance from those who know these things better than I.

I do know, however, that in the past few months I diagnosed two patients with endometrial cancer whose endometrial thickness was below 5 mm.  Given that no cut off value is 100% predictive, this of course was bound to happen sooner or later given how long I have been practicing, but it was nonetheless disconcerting. Interestingly, both women had endometrial thickness which would have put them above the 3mm cut off recommended in this new study.

Ultrasound as a Tool for Evaluating Post-menopausal Bleeding

I, for one, have long appreciated transvaginal sonogram as a non-invasive tool for evaluating post menopausal bleeding.

In years past, a single drop of blood more than a year after menopause meant an automatic trip to the OR for a D&C – that’s  a “dilation and curettage”, also known as a “dust and clean” to my mom’s generation. This would include women who bled from vaginal dryness, infection, blood thinners or even the occasional errant menstrual cycle, most of whom do not have endometrial cancer. That’s a lot of D&C’s.

With the advent of office endometrial biopsy, or EMB as we call it,  most women were saved the trip to the OR, trading it for a quick, but rather painful office procedure.  (If you’ve ever had an EMB, you might not consider it such a good trade off..)

Then along came vaginal ultrasound, and we were able to stop even those endometrial biopsies in all but the few whose sonograms did not make the 5 mm cutoff. The OR is now reserved for those women unable to have an office biopsy or who have obvious endometrial polyps on sonogram (which require removal to rule out malignancy, just as colon polyps require removal.)

There’s nothing more satisfying than being able to reassure an anxious woman that her bleeding is a benign process and she does not need to have an invasive test. (Of course, one must interpret the sonogram results in light of the clinical scenario., and sometimes your clinical sense tells you to biopsy regardless of the sonogram results. If it does, trust it. You just may be right, as I was with those two patients I mentioned.)

Now what?

It’s too soon to say, but I’ll be watching this one closely. If we do move from a 5 mm to a 3mm cut off, I predict I’ll be doing more endometrial biopsies in my menopausal patients, something that will make neither my patients nor me very happy.  The question of course, is how many more biopsies, and at what cost (both financial and in terms of complications such as perforation or infection)? I could not glean that answer from the paper.

But if more biopsies is what we have to do, then we will do it. Because the downside is missing a diagnosis of cancer.

And that’s something none of us wants.
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Timmermans, A et al. Endometrial Thickness Measurement for Detecting Endometrial Cancer in Women With Postmenopausal Bleeding: A Systematic Review and Meta-Analysis. Obstetrics & Gynecology: July 2010 – Volume 116 – Issue 1 – pp 160-167.

TBTAM at Women’s Health.gov

I was privileged to be the featured interview this month at the Spotlight on Women’s Health series at Womenshealth.gov, the website of the Office of Women’s Health. Thanks to the editors for their thoughtful questions and  for the opportunity to speak to women about HPV, healthy living and, of course, cooking!

Women’s Health.gov is a fabulous website that  features fact sheets on over 100 various health topics,  drug and drug interaction information links , clinical trial information, health statistics and much, much more. It’s a great first stop for any information you’re seeking on Women’s Health, whether you are a patient or a health professional. It’s a real honor to be featured on the site, especially when I read the interviews with the wonderful women who preceded me in the series.

Embrace Life

Back home, promise Cuba posts coming. In the meantime, watch this gorgeous video from the UK promoting seatbelt use. And buckle up!

Hola de Habana!

I’m here in Cuba on a concert tour with the Yale Alumni Chorus. (No, I did not go to Yale, but when you sing, you meet some amazing folks who extend some amazing invitations…)

Internet access is too unpredictable in our hotel and our schedule is too jam-packed for more than an occasional brief post, but I promise I will tell all when I return next week. I will tell you that last night’s joint concert with the small but brilliant local Coro de Camara de Matanzas was an experience I will never forget.

In the meantime, a little taste of Cuba –

Oh yeah – Zippy’s Here

Zippy* managed to get through customs (maybe he has relatives here?) and is having a marvelous time. He does want Dr Rob to teach him to drive when he gets home.

He also says to tell you all that he loves the Cuban kids – they always have a smile!

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*For those of you who don’t know him, Zippy the Lobster is a crustacean on a mission to see the world and raise money for Children’s Brain Cancer Research, thanks to the efforts of his adoptive father, Dr Rob.  If you’re reading this post, why not donate a few pesos to Zippy’s cause? Maria and Zippy raised over $200 last week when Zippy visited her in New York City. Let’s see if we can top that!

Soft Shell Crabs on a Bed of Leeks with Warm Herbed Potato Salad

It amazes me to think I spent more than half of my life not knowing that soft shell crabs existed. Seriously, I didn’t taste my first soft shell, cooked to perfection by my future mother-in-law on her stovetop in Philadelphia, until I was almost 30 years old. Today, Irene’s simple method – sauteeing flour-dredged and salt and generously peppered soft shells in butter – remains my favorite way to enjoy these amazing delicacies. Actually, I don’t cook the soft shells – Mr TBTAM does. His mom taught him, after all.

Sauteed Soft Shell Crabs on a Bed of Leeks

Mr. TBTAM may cook the crabs, but I present them. And tonight, it was on a bed of leeks, with a side of warm herbed potato salad and some sliced tomatoes. We got our crabs from Fairway, where they were so fresh, they wriggled ever so slightly if you touched them. I think these may be the last of this season for us – the shells were just starting to head towards the hard side on the edges. This short season is what makes soft shells so special.

For the leeks
4 large leeks
1 tbsp olive oil (If you can handle the calories, add also a tad of butter..)
Salt and pepper to taste
White wine to deglaze (optional)

Trim off bulb and dark green parts of leeks, then slice longways. Wash thoroughly in a bowl of cold water, rinsing and refreshing several times until all the sand and grit are gone. Drain on paper towels and blot dry. Cut in half again across and then slice very thin. Heat 1 tbsp olive oil in a large saute pan till hot. Add leeks and saute over medium high heat until softened, about 10 -15 minutes, adding salt and pepper about halfway through.  Remove leeks from pan to a small bowl. If you want, you can deglaze the pan with 1 tbsp of wine and add to the leeks. Cover with foil to keep warm while sauteeing the crabs.

For the crabs
6 soft shell crabs
1/4 cup flour
salt and pepper
3-4 tbsp butter

In the same pan, melt 2 tbsp butter. Lightly dredge the crabs in flour and sprinkle one side with salt and freshly ground pepper. Add to the pan (salted side down) and saute about 2 minutes till brown. Sprinkle a little more more salt and pepper on top before turning, then add another 1-2 tbsp butter to the pan. Cook another 2 minutes or so till done. If you do it right, this is what your soft shells will look like –

To serve, divide the leeks among the plates and place a crab atop the bed of leeks. Serve with a side of potato salad and sliced tomatoes. Split the remaining two crabs for second helpings. Serves 4.

Warm Herbed Potato Salad

12 small red potatoes (Not the teeny-tiny ones)
1/4 cup mayonnaise (Try 1/8 cup first and that may be enough for you..)
2 tbsp rice wine vinegar
1/4 cup chopped fresh herbs (I used tarragon, parsley, chives and a tiny bit of mint)
salt and pepper to taste

Clean the potatoes but don’t peel them. Slice into quarters and place in a stock pot, cover with water, add a tsp salt and bring to a boil. turn down heat and simmer till just cooked, but not too soft (about 15 minutes). While they are boiling, chop your herbs and mix them in a small bowl with vinegar and mayo. Drain potatoes, place into serving bowl, pour on dressing and toss gently.  Serve warm.