See some gorgeous photos of Bharatanatyam, traditional Indian dance, along with a great compilation of posts from the medical blogosphere in this week’s Surgeperiences, hosted by Vijay.
This is what I love about the blogosphere – where else can you get such a wonderful mix of medicine and the arts?
This British comedy sketch about an Emergency Room in a Homeopathic Hospital is damed funny. (Make sure to read the signs on the corridor walls.)
But change the patient from a trauma to a cancer patient, and it’s a tragedy.
The patient still steadfastly refused all surgery, chemotherapy, and radiation. Against all evidence that the course she had chosen thus far had not resulted in the elimination of her tumor that she expected, she nonetheless insisted on continuing with various alternative medicine treatments. Against all evidence to the contrary, she continued to refuse any form of “conventional medicine.” She still believed that her ” healer” could save her life, even though she now had a large, bleeding, stinking mass in her breast stuck to her chest wall that had three years ago been a pea-sized cancer that could have easily been excised with a small surgical procedure. She was well on her way to dying in the horrific way that so many women died of this disease 100 years ago. And the cost was more than just the growth of the tumor. The woman had three small children at the time of her diagnosis.
How to write a bad medical news article –
Lead your article on alternative treatments for menopause with an unsubstantiated anecdote by an anonymous woman who claims Estroven use led to a 20 lb weight loss without changing her eating habits. Show a photo of several brands of “natural” remedies for menopause, none of whose brand name is clearly visible except the Estroven.
Never mention in the rest of the article that there is no good data to support Estroven’s efficacy in treating any of the conditions for which it is marketed, and certainly no data that it leads to effortless weight loss.
I’m surprised – the New York Times usually does a much better job than this.
Pregnancies conceived in a cycle when levonorgesterel emergency contraception (Plan B) was used have no increased risk of adverse outcomes.
In a prospective study, researchers compared the outcomes of over 300 pregnancies in which Plan B was used during the cycle of conception to a similar number of pregnancies in which no exposure to Plan B occurred. Outcomes were the same, with about a 10% miscarriage rate and 1% rate of major malformations in both groups.
The study outcomes are not surprising. Plan B uses levonorgestrel, a progestin component of hormonal contraceptives for many years, long ago shown to be safe if pregnancy occurs despite its use. Despite the fact that plan B uses levonorgestrel doses that are higher than in traditional oral contraceptives, no adverse impact has been reported to date on pregnancies conceived despite Plan B use. Having yet another reassuring study is always good news.
A couple of things to remember when interpreting data from studies exploring the association between exposure to a medication or chemical and pregnancy outcome –
In an attempt to reduce plastic bag waste in Puget Sound, the Seattle City Council has passed an ordinance imposing a 20 cent fee on disposable shopping bags. The fee is optional – you only pay if you decide to use a disposable plastic bag instead of bringing your own reusable shopping bag to the market.
The American Chemical Council, representing plastic manufacturers, has spent almost $200,000 in a signature gathering campaign to force the tax measure onto the August 18 citywide primary ballot.
The Seattle Green Bag Campaign is fighting to get the ordinance passed on the ballot and is looking for donations and publicity to get their message out. I encourage you to spread the word and donate if you can. If you buy your reusable shopping bags at Reusablebags.com between now and August 18, they will donate 1% of their proceeds to the cause.
I think Seattle has the right approach
I’ve done a bit of my own research and agree with the Seattle City Council that taxing bags is the way to go if they want to reduce disposable bag use. That city’s move is just a small part of a national and global trend to reduce plastic bag use and waste.
Speaking as a New Yorker, I can say I had have never recycled plastic bags at the market, and would support a tax on the bags here. When I shop at Costco, a store that does not supply bags, we use old boxes to carry our goods home. At Ikea, I but their reusable tote. But when I hit Gristedes or Food Emporium or even the Farmers Markets, I take the plastic bags they give me without thinking twice. I don’t think consumer behavior in this area will change voluntarily unless it is made either too costly or too inconvenient to do otherwise.
The American Chemical Council is aggressively fighting Seattle’s and other local measures aimed at reducing plastic bag use. In Seattle, they used out of state paid workers to gather signatures against the measure. In smaller municipalities, their tactic is to threaten lawsuits that cities cannot afford to defend.
It’s another case of the big corporation using their financial and political weight to bully local governments. But with the advent of the Internet, individuals now have the resources to counter the corporate giants.
So spread the word. And start using reusable shopping bags whenever you can.
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If you want to cut back on your plastic bag use, you’ll need another bag. Here are some resources –
I find the challenge for us as a busy family is incorporating local foods into a busy lifestyle. Our neighborhood Farmer’s market is only open on Saturdays, and we don’t live near enough to Union Square to go there on a regular basis during the week.
Ramps n’ Taters
Ramps, or wild leeks, are quintessentially American. Appalachian to be more specific. Native to North America and growing wild in the woods, they provide spring sustenance for early Native Americans and mountain folk for generations. Ramps with potatoes and bacon is a traditional Appalachian dish. We cut back significantly on the bacon, but traditional recipes will use up to a pound of it. Add eggs at the end to make it a complete meal.
3 slices Bacon
1 bunch of garlic ramps, thoroughly washed
6 potatoes, washed and cut into bit sized pieces
Salt, pepper and paprika to taste
Wash the ramps well. Cut off the tip of the root and slice into 1/4 inch pieces. Spin or towel dry
Fry the bacon in a skillet till crisp and remove to a paper towel to drain.
Add the potatoes to the bacon fat and cook for 3-4 minutes. Add the ramps and fry till done. Crumble and toss in the previously fried bacon and serve.
Sauteed Chicken with Fennel and Rosemary
This is a modification of a recipe from Food and Wine. I know it is probably a bit more Mediterranean than American in flavor, but we used the Farmer’s Market fennel and that made me proud. This dish has a very light and delicious sauce.
2 tablespoons olive oil
4 bunches baby fennel, cut into 1/2-inch slices
2 tbsp chopped fresh rosemary
1/2 teaspoon salt
1/2 cup chicken broth
4 organic chicken legs, split into thighs and drumsticks
1/4 teaspoon fresh-ground black pepper
2 cloves garlic, minced
2 tablespoons chopped fresh parsley
Heat 1 tablespoon of olive oil is a large saute pan over moderately high heat. Add the fennel, 1 tbsp rosemary, and 1/4 teaspoon of the salt. Cook, stirring frequently, until the fennel is golden brown and almost done. Add the broth and bring to a boil. Cover, reduce the heat and simmer until the fennel is tender. Remove the fennel and the cooking liquid from the pan.
Wipe out the pan and heat the remaining 1 tablespoon oil over moderate heat. Season the chicken with the remaining 1/4 teaspoon salt and 1/8 teaspoon of the pepper. Add the chicken to the pan with the remaining 1 tbsp of rosemary and cook until brown, about 5 minutes. Turn and cook until almost done, about 3 minutes longer. Add the garlic; cook, stirring, for 30 seconds. Add the fennel and its cooking liquid and the remaining 1/8 teaspoon pepper. Bring to a simmer. Cover the pan and remove from the heat. Let steam 5 minutes. Serve, scattering parsley atop the plate.
I love baking any day, but Saturday afternoons are my favorite time to spend in the kitchen. That’s because I get to listen to Selected Shorts while I work. The Saturday I made this tart was no exception, as I listened to “Enough” by Alice McDermott and “Just a Little More” by V.S. Pritchett, both stories about food and life.
I have to admit I am not a short story reader (although I am looking forward to reading Olive Kitterage for my book club this month), so Selected Shorts has pretty much been my main exposure to this genre since I graduated from college. The show is recorded here in New York City at Symphony Space, but occasionally goes on the road as well. Not all of the stories at the live performances make it to the radio program, so it feels pretty special to be there. Not to mention seeing some pretty amazing folks reading – famous names like Signoury Weaver, Alec Baldwin, Leonard Nimoy, Steven Colbert, and John Lithgow, just to name a few. We saw Ann Patchett when we went to hear the show commemorating the stories of Eudora Welty. Pretty cool.
Oh, yeah. Here’s what I was baking –
Apple Crumb Tarts
This recipe from Epicurious has a wonderful shortbread crust that I’m hoping to find additional use for in the future. It is also yet another use for the wonderful homemade breadcrumbs I’ve been making lately. My kids have declared this dessert my “best ever”.
I thought one of the comments on the epicurious website was intriguing – to add a layer of apricot jam under the apples to prevent the bottom of the crust from getting soggy. Maybe I will try that next time, though have to say the simplicity of the flavors in this tart is very appealing, and I don’t know that I’d want to muddy things with another strong flavor like apricot.
The original recipe from Epicurious is for two tarts, enough for 20 people. I was afraid to cut the pie crust recipe in half, so I made the whole thing and used the leftover dough to make some little bar cookies that I pressed and cut out.
Shortbread Crust (enough for two tarts)
This recipe makes two 9-inch tart crusts – You can cut it in half if you want. Let me know how it turns out if you do.
1 3/4 sticks unsalted butter, cut into 1-tablespoon pieces
2 1/2 cups all-purpose flour
2/3 cup packed light brown sugar
1/2 teaspoon salt
Preheat oven to 350 degrees fahrenheit. Combine the ingredients in a food processor and pulse till it starts to form a ball. Take the dough out and press it onto a greased 9 inch tart pan. Bake at 350 degrees till light brown (about 20 mins). Remove and cool.
Filling (for one tart)
2 large Granny Smith and 2 large Macintosh apples
2 tablespoons all-purpose flour
2 tablespoons fresh lemon juice
1/2 cups + 2 tbsp granulated sugar
3/4 cup homemade fine dry bread crumbs (make them this way, but don’t add the olive oil)
1/2 stick unsalted butter, melted
Peel, quarter, and core apples. Cut quarters crosswise into 1/8-inch-thick slices and toss with flour, lemon juice, and 1/2 cup sugar. Toss bread crumbs with melted butter.
Assemble Tart
Add apple mixture to tart pan, arranging prettily and overlapping slices in circles. Sprinkle crumbs evenly over tarts and sprinkle remaining 2 tbsp sugar over crumbs.
Bake tarts in middle of oven until apples are tender and crumbs are golden brown, about 1 hour.
So last week, I’m riding the loop in Central Park with Mr TBTAM, and a woman dressed in period costume crosses our path. I follow her and find a production of King Lear taking place under a nearby tree!
Its the New York Classical Theater doing their annual free Shakespeare production in the park. The show is an interactive experience, as the audience follows the actors as they move about the park from scene to scene. (Don’t worry – they never go very far afield..).
I wish we had had time to stay, but we were in a hurry that day. Good thing we can still catch Lear in Battery Park between now and July 7. Look for us there…
There is a concise, well-written discussion of the findings of the Women’s Health Initiative in this week’s Jama by Steven Hully and Deborah Grady. It’s the best short summary of the issues I have read to date, and I would encourage you to read it. I find that I agree with almost all of it.
As a practicing gynecologist caring for women in menopause, however, I find myseld a little more critical of the original study design, which enrolled primarily asymptomatic women on average 10 years post menopausal, which is not how HRT is generally used.
A residual loose end stems from the fact that the average age of women at enrollment for all 3 trials was the mid-60s, whereas the majority of women who use hormone therapy for treatment of vasomotor symptoms are in their early 50s. Hormone therapy among women aged 50 through 59 years in the WHI trials tended to have more favorable effects on CHD rates than in older women, but even if this finding is confirmed, the concerns about increased risk of stroke, venous thromboembolism, and breast or endometrial cancer remain.
This is a lot more than a “residual loose end” – it is a major flaw in the study design that understandably resulted from the good intentions of the investigators not to do harm by randomizing symptomatic women suffering from hot flashes to a placebo. I would agree that in younger women there remains a concern about thromboembolism and stroke, but the use of transdermal lower dose preparations may mitigate much of this risk. (Notice I say “may” – we still don’t have the clinical data we need.) The other big “loose end” is the issue of bioidentical hormones vs horse estrogens and medroxyprogesterone acetate, the drugs used in this study. Both these issues will require another large randomized clinical trial before we can say we have done this issue justice for menopausal women. Fortunately, such studies are now being conducted, and hopefully we will have some of the answers we need in a few more years.
I’m not sure why the risk for endometrial cancer are mentioned in the editorial – it did not appear in the WHI results, and should not be an issue if progesterone is taken according to recommended HRT protocols.
Still, the WHI answered many important questions about HRT. In particular, the decline in breast cancers that has resulted since hormone use dropped after the publication of its results more than supports this trial as one of the most important in the history of American healthcare.
In conclusion, the story of HERS and WHI is an excellent illustration of the evidence-based medicine tenet that practice guidelines should be based on rigorously designed research—preferably 2 or more randomized blinded trials with disease end points—even if consistent observational and mechanistic evidence suggests that such trials are not needed. Animal studies and clinical trials of surrogate outcomes can be misleading, and epidemiologic studies of preventive treatments are particularly susceptible to confounding because healthier individuals are more likely to seek and adhere to preventive measures. Weighing benefits and harms is especially important when considering the use of preventive interventions in healthy individuals, in whom there is a special obligation to do no harm. (italics mine)
It is so important to remember that before the WHI, we were prescribing hormone replacement to women just because they were menopausal. When a drug is being used in healthy individuals, the bar is raised to its highest in terms of safety.
Primum non nocere.
Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.
But too much folic acid may lead to an increased risk for colon cancer.
So says UK researcher John C Mathers, who summarizes the current evidence for this conundrum in a well-written review article in this month’s Genes and Nutrition, and highlighted in the Chicago Tribune.
Folic Acid and Neural Tube Defects
Folic acid deficiency is a leading cause of spina bifida and other neural tube defects in newborns, and can be prevented by taking folic acid supplementation during pregnancy. The problem is that the vitamin must be repleted early in pregnancy when the neural tube is forming – a time when many women may not even know they are pregnant. While women attempting pregnancy are advised to get enough folate or take an supplement, almost half of pregnancies in the United States are unplanned, and less than a third of pregnant women get adequate folate
So in the late 1990’s the FDA mandated the addition of folate to bread and cereal products in the United Sates. Other countries worldwide have followed suit. The result has been a decline in the incidence of neural tube defects.
Given early data that folate might prevent colon cancers as well, studies were done to assess the use of higher doses for that very reason.
High Dose Folic Acid and Colon Cancer
Randomized trials of high dose folate supplementation were performed in individuals with a history of precancerous polyps of the colon. Not only did the supplementation fail to protect against polyps (in the absence of aspirin, a known protector against polyps), it doubled the risk of recurrent polyps. In addition, there were more prostate cancers among those who took high dose folate.
Epidemiological data from the US and Canada show a blip up in colon cancer cases after the introduction of folate-fortified foods (mostly breads) in these countries, further supporting the idea that high dose folate supplementation may not be such a good idea.
When it comes to vitamins, more is not necessarily better
Along with recent data on the risks of high dose Vitamin E, this folic acid data is yet another warning that when it comes to vitamins, more is not necessarily better, and can actually cause harm. It’s something to remember as we watch Vitamin D come into vogue as the vitamin to end all vitamins.
What should you do?
Stick with the current recommendations for Folic Acid intake, which in pregnancy and in women trying to conceive is 400 ug daily. ( In women at high risk for having a child with a neural tube defect, the recommended daily dose is 1 mg. ) Your maximum daily intake should not exceed 1 mg.
Read the labels of the foods you buy to be certain that you are not exceeding the daily recommended dose. I checked my bread label, and it only has 2% of the RDA for folate per slice, so I’m not concerned. Cereals can be be higher (especially Total), but vary significantly.
If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.
Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.
But too much folic acid may lead to an increased risk for colon cancer.
So says UK researcher John C Mathers, who summarizes the current evidence for this conundrum in a well-written review article in this month’s Genes and Nutrition, and highlighted in the Chicago Tribune.
Folic Acid and Neural Tube Defects
Folic acid deficiency is a leading cause of spina bifida and other neural tube defects in newborns, and can be prevented by taking folic acid supplementation during pregnancy. The problem is that the vitamin must be repleted early in pregnancy when the neural tube is forming – a time when many women may not even know they are pregnant. While women attempting pregnancy are advised to get enough folate or take an supplement, almost half of pregnancies in the United States are unplanned, and less than a third of pregnant women get adequate folate
So in the late 1990’s the FDA mandated the addition of folate to bread and cereal products in the United Sates. Other countries worldwide have followed suit. The result has been a decline in the incidence of neural tube defects.
Given early data that folate might prevent colon cancers as well, studies were done to assess the use of higher doses for that very reason.
High Dose Folic Acid and Colon Cancer
Randomized trials of high dose folate supplementation were performed in individuals with a history of precancerous polyps of the colon. Not only did the supplementation fail to protect against polyps (in the absence of aspirin, a known protector against polyps), it doubled the risk of recurrent polyps. In addition, there were more prostate cancers among those who took high dose folate.
Epidemiological data from the US and Canada show a blip up in colon cancer cases after the introduction of folate-fortified foods (mostly breads) in these countries, further supporting the idea that high dose folate supplementation may not be such a good idea.
When it comes to vitamins, more is not necessarily better
Along with recent data on the risks of high dose Vitamin E, this folic acid data is yet another warning that when it comes to vitamins, more is not necessarily better, and can actually cause harm. It’s something to remember as we watch Vitamin D come into vogue as the vitamin to end all vitamins.
What should you do?
Stick with the current recommendations for Folic Acid intake, which in pregnancy and in women trying to conceive is 400 ug daily. ( In women at high risk for having a child with a neural tube defect, the recommended daily dose is 1 mg. ) Your maximum daily intake should not exceed 1 mg.
Read the labels of the foods you buy to be certain that you are not exceeding the daily recommended dose. I checked my bread label, and it only has 2% of the RDA for folate per slice, so I’m not concerned. Cereals can be be higher (especially Total), but vary significantly.
If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.
I am so proud of myself.
I needed to eat dinner. And fast. Mr TBTAM and I had exactly 2 1/2 hours between dropping my daughter off at the cruise boat at Battery Park for her 8th grade class prom (Don’t get me started on why an 8th grade graduation dance now has to be called a Prom…) and picking her up. We wanted to ride the loop in Central Park.
What could I make quickly?
First, to the herb garden – my container lettuce crop was bursting from the pot, and there was basil, parsley and mint.
Next, to the fridge. There were still artichoke hearts and sun-dried tomatoes from Costco. Those chickpeas I had drained the other night and only used half. A scallion. Two eggs. A few measly almonds in a bag in the freezer. Some leftover homemade lemon vinaigrette in a jar
Finally to the cabinets – Cous Cous! The wonder grain that cooks in 5 minutes! Yes!
Within 10 minutes, I had a meal fit for a king and queen.
I love my herb garden and the opportunities it give me to cook and eat healthy. And fast.
Terrace Garden Salad
You’ll make a batch of couscous, but will only use 1/4 cup for this salad, which serves two. Save the rest of the couscous for tomorrow and make it again. I needed to make this quickly, so I browned the chickpeas on the stove top. But if you have time, roast them instead. Add as many greens as you want for this salad
I had some leftover, so the next day I tossed in some melted Haloumi cheese that I found at the Farmers Market (after melting it in a saute pan with olive oil), refreshed the salad with new lettuce and herbs from the garden and more tomatoes and artichokes, and had a fabulous lunch.
1/4 cup cooked couscous
Mixed salad greens
6 basil leaves, 6 mint leaves, and a few sprigs of parsley torn or chopped coarsely
4 marinated artichoke hearts, drained well and quartered
4 large sun dried tomatoes, drained well and sliced into quarters lengthwise
1 scallion, chopped
1/4 cup canned chickpeas, drained and very dry
1 egg
1 tbsp olive oil
1 tbsp almonds
Lemon vinaigrette (I keep this made and in the fridge most of the time)
Salt and pepper to taste
Start the couscous, and while it is sitting off the heat, do the rest.
Heat 1 tbsp olive oil in a small saute pan. Toss in chickpeas and saute over high heat till browned, tossing several times. Lower the heat and add the egg, stirring it around with till cooked softly.
Toss with the remaining ingredients in a medium bowl and serve immediately
Couscous
1 cup couscous
1 cup chicken broth or water
1 tbsp olive oil
Heat chicken broth with the oil in a medium saucepan until boiling. Add the couscous, stir well and remove the pan from the heat. Cover and let sit for 4-5 minutes. Fluff with a fork before serving.
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This post is my submission to Weekend Herb Blogging, a weekly carnival planted at Kalyn’s Kitchen, now being tended by Cook Almost Anything and hosted this week at Erbe in Cucina
Mr TBTAM and I saw Food, Inc tonight in a packed audience at the Film Forum, and we’ll be taking the kids to see it as soon as we can. But this movie needs to get out of the art houses and into mainstream movie theaters. Because every American needs to see it.
If, like me, you’ve read books like Fast Food Nation, the Omnivore’s Dilemma, and Animal, Vegeatble, Miracle, you already know what Food Inc is going to tell you – that we’ve lost control of our food supply to the interests of multinational corporations. That government subsidies have driven food production from healthful farmed foods and meats to corn-based high sugar and high fat mass produced foodstuffs whose low upfront cost to consumers belies a much higher cost to individuals and society in terms of our long term physical and economic health.
But I think I hadn’t really grasped the power and wide reach of Monsanto until I saw this movie. Nor had I truly understood the struggles of families with limited means trying to feed their families until I watched a mom steer her children away from fruits and vegetables at the supermarket because they were too expensive. The most shocking moment for me was seeing the projected rates of diabetes if we don’t change this now.
What distinguishes this movie from other movies like Fast Food Nation and SuperSize Me is the message of hope and empowerment that comes at the end. We the consumers have the power to change this bad situation and to reclaim the food supply from the agricultural conglomerates who have hijacked the American diet. The recent introduction of organic and local foods into Walmarts supermarkets are just one example of how consumers can drive production towards healthy foods if that is where we decide to put our dollars.
The Food Inc website has 10 simple things you can do to change our food system. In my family, we are already doing more than half of these, but we could do more. For one, we are going to make Farmers Markets more than just an occasional shopping destination.
What can you do?
