TBTAM Does Italy – Part 3. Mercato Centrale, Firenze

The Mercato Centrale (Central Market) in Florence is filled with a seemingly endless array of vinegars, cheeses, meats, fruits, vegetables, all stunningly gorgeous, fresh and wonderful, in surroundings a bit prettier and a little more self-conscious that I’d expected.

But I’ll let the photos speak for themselves…





Vinegar tasting bar

These were the best sun dried tomatoes I have ever had.



Here’s what we made with what we bought.

Ricotta, arugula and sundried tomato sandwiches

Ricotta cheese
Sundried tomatoes
Arugula
Salt (only if tomatoes are not salted)
Good bread
Olive oil

Cut bread into clices. Spread ricotta on bread. Top with tomatoes and arugula. Drizzle olive oil. Salt only if tomatoes are not salted already.

Figs wrapped with Proscuitto

Fresh figs
Prosciutto Crudo

Cut figs in half. Wrap with Prosciutto. Eat.

Cooked Scamorza Cheese

Cut the scamorza cheese in half lengthwise. Place in a preheated pan for a few minutes till soft, warm and bubbly. Eat immediately.

When do you eat scamorza? Well, it could be a second course at dinner. Or, according to Wanja, you keep it around at all times, “And when you get home late on Sunday night and you’re hungry and too tired to cook anything, then you make yourself a scamorza.”

TBTAM Does Italy – Part 2

Florence

The high speed train from Rome to Florence takes under 2 hours, and Wanja packed us sandwiches for the ride. We walked from the train station in sweltering heat down the narrow, treeless streets of Central Florence to our apartment on Borga Pinte.

Tucked away behind the tall stone walls are apartments, gardens, schools, hotels, you name it. It all seems so very secret. So it should come as no surprise to you that behind the unassuming door of our building was this entryway…

Go through that gate and down the hallway…

And you are in the main garden!

Our apartment is a modern renovation on the ground floor…

and has a small private garden.

We rented the partment through a European site called Hidden Italy. I highly recommend it.

The best part about staying in an apartment vs. a hotel is discovering the little things that make life abroad different from home. For example, the Italians dry their dishes in a cupboard above the sink lined with open-grated shelves. Now you see ‘em…

Now you don’t!

But enough domesticity – on to Florence.

This is the Duomo. It was closed by the time we arrived, but open for Mass, so we decided to attend the Mass in order to see the place. We were a rather motley crew – one ex-Catholic, one Jew, 2 Quakers, and 2 kids raised without a formal religion. No one seemed to mind.

We liked the Fake-David in the Piazza near the Iffizi Galleries. The lines were too long to see the real one.

We strolled the streets, stopping to buy sandals, watercolors and other small things.

Dinner was at a rather touristy place near the Ponte Vecchio, a meal during which the waitress ran out of the kitchen screaming when a large bird flew in. The food itself was non-descript, save for a single dish – Pecorino cheese served with honey and pears. We decided then and there to make it ourselves the next day. (recipe below)

We stumbled upon a concert by the Santa Barbara Choral Society in the Chiesa San Stephano al Ponte Vecchio.

The entire first half of the concert was accompanied by a solo bird singing along somewhere in the eaves of the church! The highlight of the concert was Lux Aeterna, a modern choral piece by Morten Lauridsen that I had never heard before.

To get a little sense of the experience do this – Close your eyes, imagine you are in a church in Italy and listen to this excerpt. (Requires real player, give it a second to load.) You will understand why my face was covered in tears by the end of the piece.

After the concert, it was gelato and a leisurely walk home. At night, many of the stores outside the tourist areas shutter up, giving the place a bit of an eerie feeling.

But don’t be frightened. Madonna is there on almost every corner watching out for you…

The restaurants are still open…

And there is plenty going on behind those walls. One evening, we walked past an open door, and looking in, saw that the whole neighborhood was in a large coutyard watching an old movie being projected on the walls!

Tomorrow – More Florence (and more recipes)…

Pecorino Cheese with Honey and Pears

1 wedge good pecorino cheese – Goat’s (oops I mean sheep’s) milk is best
1 pear, not too soft
Honey
1 Tiny sundried tomato (Or a small piece of dried pepper if you are daring)

Place honey in a small bowl for dipping, Garnish with a small sundried tomato or pepper.
Cut cheese into small wedges. Core and slice pear. Dip cheese or pear into honey and eat. Hmm…

TBTAM Does Italy – Part 1

To see Italy through the eyes of those who live there is to truly experience that country.

It is the difference between standing in a café stranded by the lack of language and knowing that you order one way when sitting at a table and another when standing at the bar, and never cappuccino after noon. The difference between getting lost on the Autostrade and knowing that the road you are driving on took years to build because each kilometer had to be contracted separately with the Mafia family assigned to it. The difference between wandering around the Palatine Hill with a tourbook in the sweltering heat and having a picnic there. Between feeling like an outsider and belonging.

And so first, I want to thank our dear friends Wanja and Fabrizio for hosting us during this trip and our new friends Martina and Federico for making us feel as if we belonged in their wonderful country.

Now on to your visual trip through Italy, complete with a recipe or two. First stop…

ROMA

Our friends live in Trastevere, which means “Across the Tiber”. Trastevere is Rome’s Left Bank, and is a vibrant neighborhood that has been gentrified from its seedier predecessor. Graffiti still abounds, but the area is safe and like New York, there are people out till the late hours. Visitors tend to stick to the same main streets, which can be very crowded at night. But just stray off the beaten path by a single block, and it is peaceful. Needless to say, we felt right at home.

For this one night stay we split up between Wanja’s apartment and that of their friends in Monte Verde, which is on one of Rome’s seven hills. The apartment came complete with terrace garden, great views of the city and a four flight walk up. There was an air conditioner, but we did not discover it until the next morning. Oh well, what’s another bath or two when the tubs are deep enough that the water covers your shoulders while you read.

Now that we’re settled, how about a walking tour through the cobblestone streets of Trastevere? (Since I am contemplating painting my living room orange, you will see a lot of orange buildings in these photos…)

The Piazza Santa Maria Trastevere is the heart of the neighborhood, and until recently, it was where all the school kids hung out at night, till the cops had them move on to another Piazza.

Check out the floors in the Church of Santa Maria Trastevere…

Even though I no longer am a practicing Catholic, I light a candle for my Mom whenever I visit a church. Here, we also wrote a request to St Anthony to take away Mom’s post-herpetic neuralgia. We tucked our paper in near the top, hoping this would get her priority attention.

Piazza Navona. They used to fill it with water and reenaact naval battles there.

Speaking of water, there are freely flowing fountains everywhere. The Romans are very proud of their water, which rivals New York’s in terms of taste. You can cup your hands under to get a drink,

or do as the Romans do, plug the bottom and and lean in for a sip from the top.

We all share a few bites of a pizza Blanca (pizza dough without sauce), sandwiching a few slices of meat.

The gelato looks delicious,

as does the apricot torte…

But it’s too hot to eat anything else but fruit.

The Pantheon was not really as crowded as this photo makes it appear. We strolled right in.

The top of the Pantheon is open, but the floors are slanted so the water runs away from the center when it rains.

Wanja’s daughter’s school is across the street from the Pantheon. Can you imagine looking out your window during class and getting an eyeful of ancient Roman History every single day?

Speaking of school, Italian kids get real food at lunch. There is no institutional food. Only fresh pasta, meat, salad or veggies and fruit, home made by the school cooks. Apparently the best school food in Italy is in Modena.

Back for a nap and a bath (loving that tub…), then out for dinner to Corallo, a restaurant in Centro (the center) near Piazza Navona.

Tables from the restaurants flow out into the narrow cobblestone streets on these hot nights, and we eat bathed by street lamps and serenaded by passing vespas. We had pastas and a delicious fennel-orange-peach salad with shrimp.

Italians care very much where their food comes from, and eat it in season. They are suspicious if they are offered food that they know is out of season or not grown in the region. So, when we were offered artichokes, which are in season near Rome in June and August, our friends knew they were not local. Indeed the waiter admitted that they were from Brittany.

After dinner, we wandered back to Trastevere, stopping at Tre Scalini for gelato (supposedly one of the best places for gelato in Rome), and strolling along the banks of the Tiber for the Estate Romana (Roman Summer) Festival.

This is one of the many summer evening activities around the city for visitors and those poor Romans who haven’t yet gone to the seaside to escape the heat.

What we did not do, and should have, was go to Isola Tiberina, where you can have a drink or eat while reclining Roman style on pillows or rugs on the inclines.

Tomorrow, it’s off to Fierenze (Florence)

Fennel, Orange and Peach Salad
Here’s a recipe we came up with and made the following night.

Fresh fennel
1 Blood orange
1 peach
Fresh basil leaves
Olive oil
Salt and pepper to taste
Pesto

Shave the fennel thinly (It should look like a thinly sliced onion). Place into a large bowl. Peel and section the orange; core and section the peach. Add both to bowl. Make sure you get any extruded juice, it serves as the “vinegar” for your salad. Scatter fresh basil on top. Add a small amount olive oil, and salt and pepper to taste. Serve with a dollop of pesto on the side.

Greetings from Italy!

Just a little something to tempt you…..

No internet access all week, and now just for a few minutes. Promise to post much, much more sometime soon. Ciao!

Passport Help!


Okay, so we are leaving for Italy on Saturday night. We applied for our passport renewals in MARCH. My youngest daughter’s passport is still in process.

We have done everything we know to do. We had to wait until 14 days prior to our travel date to begin the rush process. Since then, we have called daily. We cannot get an appointment at any of the passport offices within 200 miles. We called the office of Carol Maloney, our state rep,and her guy in her office has been on the phone with the passort processing center in New Hamphshire on a daily basis for us every day this week. Every time he calls us back, it is the same news “Not ready yet. But they have moved your request up to urgent”.

So I am putting it out to the blogosphere…

I’m praying that someone in the passport office in New Hamphire reads my blog and can see it in their heart to help us.

Or someone reading this blog knows someone in the passport processing center in New Hampshire. Or knows someone at the state department. Or is someone really, really important who can get my daughter’s passport processed for us tomorrow.

In the meantime, we are heading up to Norwalk Connecticut so that we can get online at 5 am tomorrow in hopes that we can get an appointment and get a passport. I will be checking me email continually, so if you can help, please email me at tbtam@rcn.com.

THANKS, whoever you are!

UPDATE: 9am We are in line at the passport office in Norwalk. They could not be nicer. We got here at 6am and were 2nd in line. However, it is clear that they are triaging by urgency of travel and passport status, so we are hopeful. The mantra seems to be “We will help you”. Here’s hoping…

UPDATE:
We have a passport!

Thanks to all of you for your great suggestions, you are so wonderful. And thanks most of all to the wonderful folks at the Norwalk Passport Center, who treated everyone there like human beings, always had a smile and a kind word, and know how to handle a crowd, triage and move the work. Everyone of them embodies what a civil servant should be.

BOTTOM LINE: IF YOU LIVE IN THE NEW YORK METRO AREA, AND YOUR PASSPORT APPLICATION IS BEING DELAYED AS WAS OURS, AND YOU NEED A PASSPORT WITHIN 2 WEEKS, GO TO NORWALK.

A Picture Worth a Thousand Words

A literary project from Maria – She asked us to write a medically-related story, 1000 words or less in any genre, referring to the picture below. Here’s my submission. Thanks, Maria, for inviting me to participate.

The woman moved quickly through the crowd, weaving expertly between the carts and stalls of the marketplace, the sleeping child held close beneath her robes. She hoped to go unrecognized for just a few more precious hours before giving her child to the fate into which she had been born.

Had it not been for the Bronwin midwives she would surely have died giving birth to the infant. For 2 days and nights she had labored, the child pressed against her ribs with no sign of descent. They had broken her waters to no avail, and pressed her with herbal infusions, but the child would not come.

When the morning of the second day dawned, the elder midwife had been summoned. Wondera did not remember her face, only the smell of the burning weed she had passed over her swollen abdomen. The aroma was silken and light, and as the smoke entered Wondera’s nostrils, she felt it enter her forehead, flowing straight to the small pit which drove her labor. In that same instant, her lower womb relaxed and the upper womb embraced the breech, urging it into the birth canal as the mouth of her womb softened and spread wide to deliver the infant from between her legs into the arms of the second midwife. Then the elder midwife had pulled the weed away, and as the cold air of the room hit Wondera’s nostrils, her womb closed tight, the pain ascending and then withdrawing for a final time.

Afterwards, Wondera shook violently, unable to control the chattering of her teeth and the trembling of her limbs. They had washed her with warm water infused with chamomile, and she fell into a deep sleep from which she did not awaken until sunset. Only then did she ask to see her daughter.

As foretold, the child bore a mark gracing her right eye and cheek, passing over the bridge of her nose to tease the left eye at its inner corner. Even now, Wondera reached beneath her robes to brush the mark with her lips.

The mark was, she knew, the exact mirror of the one which graced the face of a male child born five years ago to a Mechabian woman. It was said that a male child born with a mark that crossed onto the other side of his face would grow to be the leader of the two tribes. But instead of rejoicing when the child had been born, the Bronwins had risen in jealousy against their Mechabian brethren, with the rallying cry. “No Mechabian shall lead us!” And so the Great War had begun, a war in which half the men of both tribes lost their lives, including Wondera’s husband.

In the fifth year of the War, the seers foretold that a girl child would be born at the next harvest, a girl child bearing a mark exactly mirroring that of the Mechabian prince. From these two children so marked would arise a nation of princes born of both tribes, who would bring peace, prosperity and unity for generations to come.

For the first time in five years, there was peace, as men came home from the battlefield to their wives, in hopes of fathering the child. And for the first time in history, families prayed for a female child. Mothers scanned their child’s face almost hourly, rejoicing with every new nevus, praying that it would spread in the right direction. Wondura had heard tale, true or not, of women who had taken burning charcoal to their infant’s cheeks, branding them. More likely, they had only rubbed the charcoal into their infant’s skin day after day, hoping that the pigment would stay and mark their child as the one.

When Wondera’s daughter had been born bearing the mark, the midwives feared that the child would be taken from her and so they had kept her hidden among them. This had been easy, since they lived in a small commune outside the village, and were rarely visited. For six months, Wondera and her child lived peacefully and happily in the commune. Wondera cooked and kept house for the midwives, who were called upon constantly to witness the many births that had been conceived among the Bronwin people.

But as the months passed and the prophesy remained unfulfilled, the men began talking again of returning to war. Wondera knew that the time had come to return to civilization and her daughter’s fate.

And so she made her way now through the marketplace to her family’s lodges. She had been away so long that she did not realize what day it was – the day of the harvest celebration. The village center was teeming with carts and people, the children running from stall to stall while young men and women danced through the square to the harvest songs.

Wondera strode quickly through the crowd, moving softly so as not to wake the child. But the child heard the music, and began to struggle in her arms to see its source. She grabbed at Wondera’s robes, pulling them apart and revealing her face to the light.

A murmur arose from the crowd.
____________________________________________

Four other bloggers also took Maria’s challenge. There’s some great writing in this bunch below…
– Intueri
– poeMD
– All Sounds to Silence Come
– Emergiblog

Total Inhibin – A New Ovarian Cancer Screening Test?

If researchers in Siena, Italy, are right, measurement of Inhibin, a hormone molecule produced by the ovary, could be an effective ovarian cancer screening test.

In a study published this month in The Journal of Clinical Endocrinology and Metabolism, the researchers measured total Inhibin levels using an Elisa-based assay, comparing results in women with ovarian cancers to those of normals and those with benign ovarian tumors and other cancers. Total Inhibin levels were highly sensitive and specific in detecting ovarian cancers. When combined with Ca125 levels, the results were superior to either test alone. (See graph above).

The percentage of cancers detected at 95% specificity varied according to the histological subtype but was always improved by the combination of total inhibin and CA-125. In detail, the detection rate of all tumors raised from 84–87% with single markers to 99% with combined markers (P < .05). The addition of total inhibin increased the CA-125 detection rate for mucinous tumors from 14 of 17 (82%) to 17 of 17 cases (100%) without loosing specificity (95%). Remarkably, the detection rate of clear cell adenocarcinomas increased from 59–68% with single markers to 96% with combined markers (P < .05)

The next step is a large multicenter trial.

Inhibin has been on the radar as a potential ovarian cancer marker for some years now. The problem has been that there are various Inhibin molecules, and the different kinds of ovarian cancers make one or more of these in any combination. Most Inhibin assays are specific to one or more of the subtypes, which limits them in detecting all ovarian cancers. It seems that the total Inhibin assay used in this study may have worked so well because of its lack of specificity, making it more useful as a screening test.

What I found most exciting is that the inhibin assay used is one that is already commercially available, meaning that, if these results hold true, then we won’t have to wait very long to implement screening.

Stay tuned…

Get a Blog Already!

My friend Schruggling (whom you may know if you read the comments section of my blog) and my sister the OBS Housekeeper, both of whom clearly need to get back to work already, have created parodies of my blog. (That’s OBS’s up there) They thought they could just email them to me and have that be the end of it.

Well, Schruggling, it’s just the beginning. Enough already. YOU NEED TO GET A BLOG.

To that end, I have created your own blog for you. Here it is – I put up your parodies as your first posts, now it’s up to you.

For those of you who don’t know him, Schtruggling is a marketing VP for an unnamed internationally-based pharmaceutical company. He has lots to say, is extremely well-informed and very, very funny. So go to his new blog, give him some comments and see if together we can’t get him blogging on a regular basis.

As for you, OBS, I’ll deal with you another day..

Caprese Salad

How gorgeous is this? Who knew that my sister the OBS Housekeeper could make something so delicious and yet so casually arranged? Note that the mozzarella slices are not exactly the same size, and that the basil is scattered rather, shall we say, capriciously, and yet, there is a symmetry to the dish that pleases the eye. And of course the palate.

Did you know the OBS Housekeeper made this recipe up all by her little old self? Who knew she was so talented? I’m just a little verklempt here, give me a second….

Okay, now I’m fine. OBS wanted me to be sure I told you about the history of the Caprese Salad, which, in case you haven’t noticed, contains the colors of the Italian flag.

The History of the Caprese Salad

The Caprese Salad, or Inslata Caprese as we Italian affectionados call it, originated from the Isle of Capri in the Campagna region of Italy in the 1950’s. The traditonal Insalata Caprese uses cow’s milk mozzarella, tomatoes, and olive oil garnished with oregano and arugula. Elsewhere in Italy, basil is used as the garnish.

Tradition dictates that only olive oil be used in the Caprese Salad, but here in America, what do we care about tradition? We love balsamic vinegar, and so we use it.

OBS Housekeeper thinks I’m nuts, but I think the Caprese Salad was really invented as a homage to the big rocks of the Isle of Capri. They remind me of big mozarella slices. See?

The basil is the green stuff growing on the rocks. If you zoom in you can see it there on the big rock on the left.

Now, all that is missing are the tomatoes…

And there you have it! Thanks, OBS, for a delicious salad.

OBS Housekeeper’s Caprese Salad

2 – 3 large tomatoes
16 oz. fresh mozzarella
Lots of chopped fresh basil
Olive oil
Balsamic vinegar
Salt
Pepper

Use an apple corer to core the tomatoes. Slice them about ¼ inch thick. Drizzle olive oil over slices and set aside. Slice the mozzarella into slices about ¼” thick.. Layer the slices alternately on a plate or in a low dish. Drizzle olive oil and balsamic vinegar over top. Sprinkle lots of fresh chopped basil over all. Salt and Pepper entire dish. ENJOY!

It’s Clear Where I Stand…

Patient: Hello?

Me: Mrs Patient? It’s Dr TBTAM returning your call.

Patient: Oh dear. I’m on the other line with my insurance company. (Pause) Can I call you back?

Performing the Pelvic Exam


This week’s NEJM online has a video on how to perform a pelvic examination. I thought they did a really nice job. Of course, since I do this all day, I have a few additional tips:

1. Make sure you have the right tool for the job. That means long narrow Pederson specula for postmenopausal ladies and large Graves specula for the more ample women, along with standard sizes of both for most patients.

2. For anxious patients and little old ladies, I apply lidocaine jelly to the introitus a few minutes before the exam (Step out and see another patient while it does it’s job). This is also useful for transvaginal sonos in the same crowd.

3. I use two separate slides (not one as shown in the video) for KOH and wet smears. Putting both of these on the same slide invariably leads to cross contamination by the KOH.

4. I still occasionally use the endobrush for paps, even when doing thin preps, because sometimes the larger cyto-broom does not enter the endocervical canal. Just rinse it in the vial like the cytobrush.

5. Get everything ready, including adjusting the light, before you start. I didn’t like seeing the doc in the video touching everything in the room with the gloved hand she was going to be using for the bimanual. If I find I have to use that hand, I change the glove before doing the bimanual. God knows how many hands have been on that light before yours!

6. Specimens for GC/Chlam PCR testing can be obtained from the vagina as well as the cervical os, and this is useful if blood or excess cervical mucus are present at the endocervix, since these can interfere with the sensitivity of these tests. Urine specimens are also appropriate for screening using PCR.

7. The video recommends asking the patient is she wants a chaperone present. I would not ask – just have one there, especially if you are male. The second pair of hands is helpful as well.

8. If you are going to be seeing older women, you’ve got to get good at the one finger exam. This is where the rectal part of the exam is critical – one finger in the vagina and the other in the rectum, and you’ll get a decent exam in most patients.

Questions?….

Zaftig vs. Hollywood Thin

Dr Deb has a fabulous post on the new Fit Light Yogurt campaign in Brazil, which places ample women in classic Hollywood poses to shame them into losing weight. Problem is, I think it does the opposite – these women look great!

Head on over for more photos and join the discussion, which too is ample…

Grand Rounds

This week’s Grand Rounds is hosted over at Wandering Visitor. It’s a fabulous compilation of the best of the medical blogosphere. This weeks theme is “Things that Inspire Us”, and the format is that of a journal article. Very clever and well done!

Head on over for a little inspiration.

Grand Rounds

This week’s Grand Rounds is hosted over at Wandering Visitor. It’s a fabulous compilation of the best of the medical blogosphere. This weeks theme is “Things that Inspire Us”, and the format is that of a journal article. Very clever and well done!

Head on over for a little inspiration.

Sauteed Broccoli

My good friend W taught me how to make this dish while we were vacationing with her family in Maine last summer. She lives in Rome and this is the way she makes broccoli at home. I’m doing this from memory, so I hope I got the ingredients right. We’ll be visiting W and her family in Rome in a few weeks, so I’ll double check the recipe then. Even if I left something out, this was delish!

Sauteed Broccoli wth Garlic, Red Pepper and Croutons

1 head broccoli
5 cloves garlic, chopped
Day old bread
Olive oil
Salt
Pepper
Red Pepper Flakes (Start with 1/4 tsp, add more if you like it hot)
(Optional: Grated Parmesan Cheese)

Wash broccoli, and cut the florets from the head. (If you want to use stalks, trim them and cut into thin slices for quicker cooking.) Cook broccoli in boiling salted water till crisp-tender, but still bright green. Drain well.

Cut bread into small cubes. (1-2 cups of croutons for a head of broccoli) Toss with olive oil and season with salt and pepper. Toast in large skillet over low medium heat on top of stove, or in a 400 degree oven till browned, turning several times. Set aside.

Heat 2-3 tbsp olive oil in skillet till hot. Add garlic and cook, stirring constantly, just enough to soften but not brown. Add broccoli and cook, stirring and chopping it up into small pieces with the side of the spoon or spatula while it cooks, till it is soft. Season with salt and red pepper flakes while it is cooking. Add croutons, stir and serve. If you are my daughter, sprinkle parmesan cheese on top.