Tartine’s Basic Country Bread

I think I finally got this sourdough thing down.

Check out this boule made using Tartine’s Country Bread recipe, the holy grail of sourdough. It’s the first sourdough recipe I ever tried, and now the best I’ve ever made.

For those of you as new to this whole sourdough thing as I was just 6 months ago, Tartine is the bakery run by Chad Robertson in San Francisco, turning out small batches (only 240 loaves a day) of what many say is the best bread you’ll ever taste. Following in the footsteps of bakers like Nancy Silverton at La Brea Bakery in Los Angeles, Chad helped to put artisan sourdough on the map beyond San Francisco. By graciously sharing their expertise, he and others have inspired a whole crop of bakers across the nation and around the world who are making artisan sourdough bread. (Check out this UK local bakery just opened by a 15 year old baker and her dad who make sourdough using a starter “blossomed from a single apple in our garden”.) Add in folks passionate about using locally grown heritage grains to make healthier, more digestible bread (yes, gluten ain’t so bad if you make it right) and you’ve got a movement to bring healthy bread back to the masses.

I’m still in love with Jim Lahey’s No knead yeast bread, and if my time is limited, it’s my go to, never fail me bread. But given a free weekend and time to fold and shape, I’ll be tweaking my sourdough. I can’t wait to see what kind of rise I can get in the warmer weather, and I want to start using heritage grains, adding things like olives and sun dried tomatoes and cheese to my breads, and playing with the starter and leaven to get a sweeter flavor.

From what I’ve seen and am learning, sourdough bread baking is a never-ending journey. So stay tuned.

Requisite Crumb Shot

Tartine’s Basic Country Bread

Don’t even think of making the bread for the first time using just this blog post. But Robertson’s recipe make two loaves, and I wanted to have my own one-loaf version and also record my experience making this loaf. I’ve also added little tweaks that work in my kitchen, so I’ll remember them next time. (Welcome to sourdough, the perfect bread making technique for those with OCD.)

If you really want to learn how to make this sourdough, you are best off working directly from Chad Robertsons’ book Tartine Bread. If you don’t want that kind of initial investment, the NY Times Tartine Bread recipe is a nice way to start. (That’s how I got hooked.).

To make this loaf, I started the leaven at about 8 am, then packed it loosely in the car to allow it to ripen on the ride and at the cottage (temps were in high 60’s – very low 70’s). After dinner, I mixed the bread and did the first rise and folding for 3 hours. I rested and shaped the dough around 10:30, then placed it in a covered basket in the fridge and went to bed. I heated the oven, scored and baked the bread starting about 7:30 am the next morning.

My traveling leaven and bread making supplies

Make the leaven (Saturday 8am)

  • 1 tbsp starter (My starter is fed with sprouted rye)
  • 100 grams warm (78 degree) water
  • 100 grams of a 50/50 blend whole wheat and bread flour

Disperse the starter in the water with your fingers, then stir in the flour till there are no dry parts. Cover and let rise at a coolish temp overnight or for 8-10 hours. I had temps in the high 60’s to very low 70’s, Robertson recommends 65 degrees.

Mix and first rise (Saturday evening starting about 7 pm)

  • 100 grams leaven
  • 450 grams white bread flour (I used King Arthur)
  • 50 grams whole wheat flour
  • 350 grams warm water (80 degrees) + 25 grams more (added with the salt) I used Brita-filtered water from the fridge pitcher + a little warmer water straight from the tap to get it to the right temp.
  • 10 grams sea salt

This is a 75% hydration dough. In a large bowl (mine was ceramic), disperse 100 grams leaven in 350 grams of warm water with your fingers. Whisk the flours together and add to the water/leaven till there are no dry bits of flour. It will be quite thick – but not to worry you are adding more water in a bit.

Let dough rest 30 mins. (Robertson says 25 -40 mins). After the rest, lightly stir the salt into the remaining 25 grams of water (it does not need to dissolve) and add to the dough using your fingers. The dough will come apart, then come together again.

First (Bulk) rise

Let rise for 3 hours, covered with a tea towel moistened with warm water after each turn. Every 30 mins give the dough a turn, becoming gentler as the dough becomes more billowy and aerated to avoid pressing out the gases.

Here’s video I made of the amazing Sarah C Owens turning her dough at a sourdough class I took with her on Far Rockaway last month.

When the dough is risen and ready, it’s time to pre-shape, bench rest and final shape it.

Pre-shape, Rest and Final Shaping (10:00 pm)

Pull dough out of bowl onto a very lightly floured surface. Fold the four sides of the dough onto itself, incorporating as little dough as possible into the dough. Roll the dough over, folded side down, and pull it around, tucking it under as you go to make a neat round package with a nice tight skin. Let it rest for 30 minutes to allow the gluten to loosen up for the final shaping,

Now slip the bench knife under the dough, flip it over and shape into a boule shape using a series of folds as you’ve learnt them. An explanation of this is beyond the scope of this post, but here’s a great video that shows pretty much exactly how I pre-shaped and final shaped my dough. (Shaping starts around 2:45 min.)

Using the bench knife, flip the shaped dough seam side up into a pre-floured unlined banneton, cover loosely with plastic wrap and then a tea towel and place in the fridge over night. You can use a cloth lined banneton if you prefer, but you won’t get those nice flour lines.

Score and bake (Sunday 7:30 am)

Preheat a covered dutch oven in an oven set to 500 degrees. Take out and uncover banneton, letting it sit on the counter while the oven preheats. When the oven temp reaches 500 degrees, lightly dust the surface of the dough with rice flour and turn out gently onto a sheet of parchment paper. Score as desired. I used kitchen shears to score this loaf, having left my bread lame (a hand held razor blade thingy) at home in NYC, and was pleased with the results.

Carefully pull the hot dutch oven out and uncover. Holding the parchment paper, gently lower the dough boule scored side up into the dutch oven. Cover, turn the heat down to 450 degrees and bake for 20 mins. Remove the cover and bake another 30 mins.

Lift the bread out of the pot onto a rack to cool. Let the bread sit and sing for at least an hour, and ideally for 2-4 hours before cutting into it.

What I learned from making this loaf

  • I can make one loaf of Tartine bread at a time.
  • It’s much easier to work with lower than higher hydration dough
  • I think I need to check my oven thermostat, and if it’s correct, keep it at 500 degrees the whole bake – while the top caramelized nicely, I expected a darker lower crust and bottom.
  • I may try Jim Lahey’s trick of dusting the bread with wheat bran – it darkens very nicely.
  • I LOVE SOURDOUGH!

Noirmoutier Potatoes with Fleur de Sel

As promised, here is recipe for the wonderfully delicious potatoes we served with La Cagouille’s Sea Scallops with Warm Vinaigrette. It’s a method of cooking potatoes totally new to me – in a pot on the stove with nothing but butter or olive oil, salt and garlic. So very French, don’t you think? Not to mention, a great tactic if you find yourself without a free oven to roast potatoes, and don’t want to mash them.

The recipe comes from Patricia Well’s Paris Cookbook, where we learn that when you buy first-of-the-season baby potatoes at the avenue de Saxe Market

Each sack of precious potatoes comes with a tiny bag of the equally noble fleur de sel, the fine crystals of sea salt that are hand-harvested on the island of Noirmoutier, not far from the Nantes on the Atlantic coast.

They’re practically telling you how to cook little new potatoes, and who are we to do differently? So get thee to your nearest Farmers Market and do what needs to be done.

I wish I could say we used Noirmoutier fleur de sel in our potatoes, but sadly we did not. Even more sadly, we had recently used the last of our box of Maldon Sea Salt. This left us with just the Fine Sea Salt we buy from Costco, which for almost any purpose is more than fine. And the potatoes were delicious. But this recipe demands a good finishing salt. I really want to make them again, and I really want to use the eponymous Noirmoutier.

A bit of searching landed me on the website of The Meadow, a wonderfully tiny store on Hudson street in the West Village that specializes in salt, and which carries Noirmoutier. Now I recall we visited the Meadows a few years back as part of a gastronomic tour of the Village, where I’d purchased a small block of Himalayan Salt that I still haven’t figured out how to grind. (The tiny hand grater I got with it doesn’t really do the trick) I’m pleased to see the place is still in business. On my to-do list now is a trip there to pick up some Noirmoutier salt and a better grater for my pink salt.

In the meantime, feel free to make these potatoes, as we did, with whatever salt you happen to have around.

Noirmoutier Potatoes with Fleur de Sel

This recipe serves 4. We used a mix of olive oil and butter – next time I will try just the butter. Do use the garlic – those soft cloves are a gift. I increased the quantity of garlic from 3 to 4, so everyone gets a clove. By leaving the garlic unpeeled, their flavor does not overwhelm the potatoes.

  • 2 pounds baby potatoes (fingerlings or small Yukon gold). Get the very smallest new potatoes you can find, and if not equally sized, cut up larger ones to match the smallest.
  • 3 tbsp unsalted butter (or eEVOO)
  • 4 plump, fresh cloves of garlic, unpeeled (optional)
  • Coarse sea salt to taste
  • Fleur de sel

Rinse and pat potatoes dry. Place the potatoes in a large pot. (This is important – it should be a nice large pot, so that the potatoes are spread around the bottom. Though not necessarily in a single layer, close to it.) Add butter, garlic an coarse sea salt.

Cover and cook over lowest possible heat, turning from time to time, until the potatoes are tender when pierced with a fork and are browned in patches. Cooking time will vary depending on the potato size. Those potatoes up there took about 40 minutes, and I ended up turning up the heat just a tad from the lowest possible setting, which for us was practically off.

Using a slotted spoon, transfer the potatoes to a serving bowl. Serve, making sure everyone gets a clove of garlic with their potatoes, passing a small dish of fleur de sel at the table.

Resources

La Cagouille’s Sea Scallops with Warm Vinaigrette a.k.a What to do with Those Chives

This potted chive has survived every winter since I first planted it over 20 years ago, and is always the first plant to return in spring to our terrace herb garden. A few years ago, it sent some seed over to another pot, which now joins in its spring awakening. I’m forever amazed at it’s stamina and stability, not to mention those delightful purple flowers.

This evening, looking for a recipe to enjoy this little spring harvest with more than just my eyes and nose, I picked up one of my favorite cookbooks, The Paris Cookbook. by Patricia Wells. I’ve loved Patricia’s books ever since Jeffrey Miller, our wonderful wedding caterer, gave me her Food Lovers Guide to Paris as a gift on our wedding day. It was the perfect gift – our honeymoon was in Paris and Jeffrey knew we were foodies. This past summer, in one of those circle of life moments, Jeffrey happened to cater the wedding of my husband’s cousin’s son – who I had delivered with forceps some 20 odd years ago. (Before you ask, he graduated from MIT – so no harm was done by the forceps…) Anyway, I was hoping Jeffrey would be there for the wedding, but his catering business, which was just getting off the ground when I was married, is now long established and I’m sure he rarely attends the weddings he caters.

But I digress – back to Patricia Wells and The Paris Cookbook. This lovely little cookbook reads like a private tour of Patricia’s Paris – the chefs and restaurants she loves, the food markets and shops she frequents, the regular French folk and the foodie friends she has made over the years. Each recipe has a story and every one of them makes me want to move to Paris.

My chives found their perfect use in La Cagouille’s Sea Scallops with Warm Vinaigrette by chef Gerard Allemandou. Its a simple preparation that perfectly balances the richness of the scallops with a barely acidic sherry vinaigrette. Minced chives mingle with parsley and tarragon as a little show of spring.

Patricia recommends serving the scallops with Noirmoutier Potatoes with Fleur de Sel, and that’s what we did. I’ll post that recipe tomorrow.

La Cagouille’s Sea Scallops with Warm Vinaigrette

This recipe serves 4 as a first course and 2 as a main course, which was how we served it. If you want to serve four as a main course, I would increase the scallops to 16 ounces, but not the herbs or vinaigrette, as there will be plenty of both. Ms Wells uses a non-stick pan to saute’ her sea scallops. Not having such a pan, I used a stainless steel skillet with a little olive oil. Slicing the scallops in half horizontally is a nice trick to ensure that the scallops cook through and brown as well. Not to mention it doubles the amount of browned surface one gets to eat!

INGREDIENTS
6 large sea scallops (about 8 ounces total)
Sea salt
Freshly ground pepper
About 2 tbsp finely minced fresh chives
About 2 tbsp minced parsley
About 2 tbsp finely minced chervil or tarragon
Fleur de Sel or fine sea salt
Freshly ground white pepper (I only had black pepper)

The vinaigrette
1 tbsp sherry wine vinegar
Fine sea salt
8 tbsp extra virgin olive oil

DIRECTIONS
Rinse scallops and pat dry. Cut in half horizontally and set aside.

Prepare the vinaigrette: In a small jar, combine the sherry and the sea salt to taste. Cover and shake to dissolve the salt. Add the oil, cover and shake to emulsify. Taste for seasoning and set aside.

Heat 1 tbsp olive oil in a large saute pan. Add scallops and sear until they are just browned around the edges, about 1 minute each side to cooke them through, less if you like them less cooked. Season with salt and pepper after the first side has cooked.

Spoon 1-2 tbsp of vinaigrette and 1/2 tsp herbs onto each warmed dinner plate (I admit I did not warm our plates, but you’ll do that, won’t you?..). Transfer scallop halves to each of the prepared plates. Sprinkle with the remaining herbs. Season with Fleur de Sel and white pepper, and serve.

Caramelized Onion, Fennel and Mushroom Soup – Umami in a Bowl

What do you make when you want something hearty but light? Something that will warm the cockles of your heart but not make you feel stuffed? That will work for a light and early pre-theater dinner after a not so light afternoon lunch with your sister who was just in for the afternoon? (What a treat!)

You make this soup.

The Umami is strong with this one

I love onion soup, but never found it satisfying on its own without being topped with a ton of cheese and bread.

This soup is different. Between the mushrooms, fennel and beef broth, it’s packed with umami. Add some shaved parmesan and you’re in an umami paradise, and satiated beyond what you might have expected from something this light.

What is Umami?

Umami is the so-called fifth taste, imparting a savoriness that harmonizes with other flavors and enhances the deliciousness and satiating effect of foods.

I love this definition of umami – It describes what all good food should do, and exactly how I felt after eating this wonderful soup.

“It’s something that’s kind to the body.. “It’s mild, and, after eating, it’s not heavy on your stomach. It helps you wake up better in the morning. That’s what deliciousness is about. It’s about feeling good after eating.”

The chemical in food responsible for umami is free glutamate, which occurs naturally in certain foods, especially Japanese kelp and seaweed, but also tomatoes, aged cheeses, fish and soy sauces, shrimp and certain other fish. Mothers milk is also rich in glutamate. Food proteins are rich in glutamate, but this glutamate cannot be tasted. However, if you ferment protein, proteolysis frees up the glutamate – so fermented foods are also rich in umami.

5′-Inosinate and 5′-guanylate have also been found to have umami. They are synergistic with glutamate, such that their combination with glutamate is much stronger than any of the the three are individually in triggering umami. It’s why beef broth (an inosinate source) made with glutamate rich foods such as onion, tomato and carrot tastes so much better to us than just plain beef broth.

Dried mushrooms are rich in 5′-guanylate. But soaking them in boiling water, as many recipes dictate, decomposes the guanylate. So soak them in cold water if you want them for umami. (Some argue mushrooms are best soaked in cold water overnight in the fridge, but that’s more advance prep than I can do.) Pair them with beef broth or onions to get that umami synergy.

Probably the richest Umami you can get is in the Kombu Dashi – a Japanese broth made from dried seaweed. Typically, dried tuna (bonito), sardine flakes or dried mushrooms are added to the broth – these foods are rich in 5′-Inosinate acid and 5-guanlylate. So Kombu dashi is pure umami.

Salt enhances umami, but only to a point, so don’t over-salt your foods.

Umami rich foods may enhance satiety, as evidenced by the fact that women eating soup enhanced with glutamate eat less at a subsequent meal than those whose soup does not have glutamate. (I can attest to this – this soup filled me so much that I was not hungry for much that entire evening.)

Glutamate rich foods may have other effects beyond mouth taste, mediated via glutamate receptors in the GI tract. For this reason, researchers in Australia are proposing a new category called “alimentary tastes” for newly discovered tastes such as umami and fat.  Given that even the basic tastes of salt and sweet also have actions throughout the body as well as in the mouth, I’m not sure that makes sense. But its an interesting point of view.

What about MSG?

Glutamate is the main ingredient in MSG (monosodium glutamate), a popular food additive.

Unlike natural glutamate-rich food, MSG has gotten a bad rap as a cause of migraine headaches and the so-called “Chinese restaurant syndrome”, though this connection has still not been entirely proven or debunked. In general, I take the approach that more is not necessarily better, and extracting and concentrating any food ingredient is never as good as getting it in its natural form. Plus, I suffer from migraines. So no MSG for me.

One of the strongest arguments against MSG use in my opinion is a recent study showing that use of MSG may attenuate natural umami taste, making eaters less sensitive to detecting the lower levels of natural umami in food.

Go for the Umami

This list of umami-rich foods is a great reference. I for one am going to be referring to it again to find ways to enhance the deliciousness of my foods.

In the meantime, enjoy this soup!

Carmelized Onion, Fennel and Mushroom Soup

I tweaked a recipe from Farideh Sadighen in Saveur by adding dried mushrooms and their broth (hello, umami…), substituting butter for half the olive oil for caramelizing, and suggest substituting vermouth for white wine. Next time I plan to use a beef broth made with some nice short ribs that I will cut up when cooked and add back to the soup.

Ingredients

  • 1 ounce dried porcini mushrooms
  • 1 cup water
  • 3 tbsp. olive oil
  • 2 tbsp butter
  • 3 large yellow onions, thinly sliced
  • 1 large bulb fennel, halved and thinly sliced lengthwise, fronds reserved
  • 2 cloves garlic, minced
  • 8 cups beef stock
  • 1 lb. mixed mushrooms (I used shitake and crimini, roughly chopped)
  • 1⁄4 cup dry white wine or vermouth
  • Salt and freshly ground black pepper
  • Shave Parmesan cheese for garnish (optional)

Instructions

Soak the dried mushrooms in 1 cup hot water for 20-30 minutes till softened. (If using cold water, you may need to soak up to 2 hours.) Remove the mushrooms, reserving the soaking liquid, and roughly chop them. Strain the liquid through a paper-towel-lined sieve before using.

In a large saucepan, heat 2 tablespoons olive oil and 2 tbsp butter over medium-high heat. Add the onions and fennel and cook, stirring, until soft and caramelized, about 45 mins to an hour. (I found this post and this video helpful in learning how to caramelize onions.) Add the garlic and cook, stirring, until fragrant, 2 minutes. Pour in the beef and mushroom stocks and bring to a simmer over medium heat.

While the onions and fennel are caramelizing, heat 1 tablespoon olive oil over medium-high heat in a 12 inch skillet. Add the mushrooms and cook, stirring, until golden and giving up liquid, about 5-10 minutes. Add the wine or vermouth and cook until slightly reduced, about 5 minutes. If onions still caramelizing, turn off the heat and let rest till next step.

Scrape the mushrooms and wine into the soup and cook, stirring, for about 5 minutes. Season the soup with salt and pepper, ladle into bowls, and garnish with some shaved Parmesan and the reserved fennel fronds.

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More on Umami

Split Pea and Celeriac Soup – Perfect.

If you want to know my perfect Saturday in NYC, here it is…

Wake up latish – 8 am. Shower and have a cup of coffee while you plan tonight’s dinner. Make a shopping list, set up a loaf of bread to rise, then hit the streets with Mr TBTAM on the bikes. Ride across town, through Central Park, chatting a bit on the phone with your little brother who often calls you on Saturday mornings  (love my wireless airpods),

across the West Side to Riverside Park

and the West Side Greenway.

If it’s a cold day in November, dress warmly – scarf, gloves – and don’t let the wind bother you, especially if the sun is out and the wind is keeping the crowds off the Greenway.

It’s just you and the joggers and bikers. And the folks debarking from their cruise ships.

No worries, you’ve mastered the bob and weave of biking the Greenway and the streets of NYC.

Turn off the Greenway at 16th St and head under the High Line

to the Grey Dog for breakfast.

(An alternative here, if it’s warm enough, would be to park the bikes, pick up coffee to go from Blue Bottle and head up to the High Line to see if you can snag a recliner facing the Hudson. But today you need warmth, so it’s the Grey Dog.)

But wait – Look! There’s a new and marvelous antique garage across the street! What a find!

So much to see!

Wonder where you’d put those bendy manikins (maybe the living room sofa?)

or if the cast iron painted cow is too heavy for the ride home (yes it is).

Text a few pics to your friend Amy, who makes jewelry from found objects, to see if she wants you to buy anything for her. No – unfortunately the bakelite button molds have no holes for stringing. But you promise to see one another soon.

Now you head into the Grey Dog. Your latish start and antiquing detour means there’s a bit of a line. But it moves fast, and the gay couple sitting nearby has a one month old baby, so there’s plenty to ooh and aah about, and before you know it, you’re ensconced at a table with your Cappuccino and avocado, poached egg and salmon salad and the Saturday crossword, which promises to be a bear.

By the time you leave, crossword only halfway done (it is indeed a bear), the line is wrapped all the way to the door. Yep, you gotta go early to the Grey Dog…

Back on the bike, fighting to keep your eyes on the road and not on the gorgeous autumn sky,

your next stop is the Union Square Farmer’s Market. At the market, you pass Linda Rodin, but decide not to stop and pay homage. You are, after all, both New Yorkers. Plus, there was that time you ran into Bill Cunningham at the Union Square Market, and he seemed none too pleased to talk…

In addition to celebrity icons, there are cranberries and apples, of course.

And the root vegetables are everywhere.

But mostly you are here to find celeriac, which is technically not a root vegetable though it sure looks like one, for tonight’s soup dinner.

There’s plenty of celeriac to be found, and you exchange soup recipes with the young man selling you yours. His co-worker tells you she eats raw celeriac like an apple, and that you can cook it like a potato if you want to. The most fun part of the farm market is talking with the growers and their staff, and today everyone’s in a talkative mood.

You also grab a honey nut squash to roast for tonight’s salad, along with some greens.

Then it’s back on the bike, to head east to the protected bike lane on First Avenue, then north towards home, with a quick detour to the Fairway on 32nd and 2nd for a slab of ham and some dried peas. It’s always a thrill to drive past the UN building (which looks great after its multiyear renovations),

and you’re pleased to realize that all those long bike rides this past summer have left you with the leg muscles to tackle the hills up to 42nd and 57th streets with nary a break.

Home at last, where the sun is streaming under the doorjamb and hits you square in the eye as you enter your apartment. The bread you put up to rise before you left is ready to be shaped, and it’s a perfect afternoon to spend in the kitchen, making the perfect pea soup. If you’re lucky and they’re home, you’ll even talk to your girls while the soup cooks.

This evening, your friends will be coming over for dinner. You’ll serve said soup with the bread and a salad and then you will all walk to the neighborhood cinema for a movie (Can You Ever Forgive Me? – fabulous!). You’re home well before midnight, early enough to clean up the kitchen together before heading to bed for a well-deserved night’s sleep. Tomorrow is another big day – Chorus sectional in the morning, then brunch and theater with your book club (Gloria: A Life – I highly recommend it, and I’d see Christine Lahti in anything.)

So there you have it. A perfect Saturday. It doesn’t happen often, but I’m gonna’ do my best to be sure it happens again. And for sure I’m making this soup again.

Hope your Saturday was as fun as mine. What’s your idea of a perfect day?

Split Pea & Celeriac Soup

This is not that thick, meconium like paste most of us think of as pea soup. It’s what pea soup should be –  light, flavorful and satisfying. You don’t puree all the soup, so you get to taste all the individual ingredients, and the peas remind you from whence this soup comes. The celeriac acts like lemon does in a dish – brightens and enhances it. I’ll never make that goopy, heavy stuff again.

The recipe is modified from the Greens Restaurant Cookbook. I adjusted the oil and spices, replaced their croutons with ham and skipped the parmesan topping since I was serving it in the salad. If you’d rather forgo the ham, make the optional croutons at the end of this recipe and pass the Parmesan.

We served this with a salad of arugula, roasted honey nut squash, shaved parmesan, salted red onions and a lemon vinaigrette. And homemade bread.

Serves four to six.

Ingredients

  • 1 cup dried green split peas
  • 3 tbsp olive oil
  • 1 bay leaf
  • 1 tsp coarsely chopped fresh rosemary
  • 2 garlic cloves, sliced
  • 1 large yellow onion, cut into small dice
  • 3 inner stalks celery, cut into small dice
  • 1 celeriac, trimmed and cut into small cubes
  • 1 tsp salt
  • Fresh pepper to taste
  • 1/2 cup dry white wine (I used a Savignon blanc)
  • 6 cups chicken stock
  • 2 cups water
  • 5 ounces cooked ham, cut into small cubes (I used smoked Italian ham)
  • (Optional croutons) – 2-3 slices white bread, cubed. 4 more tbsp olive oil and a rosemary branch.
  • (Optional garnish) Grated parmesan and chopped parsley or chervil

Directions

Sift through the peas and pick out any stones or debris. Rinse well, place in a bowl and cover generously with boiling water. Soak for an hour.  (If you have time to soak the peas overnight, no need to boil the water and more power to you. I’ve never had enough foresight to overnight soak anything).

Gradually warm 3 tbsp olive oil in a soup pot with bay leaf and rosemary for about 3 minutes to flavor the oil. Add the garlic and cook over low heat another minute without letting it brown. Add the vegetables, salt and pepper and cook 5 minutes, stirring occasionally, over medium heat.

Add the wine, raise the heat and reduce.

Drain the peas and add them to the pot, tossing for a few seconds before adding the stock and the water. Bring to a boil, cover, and simmer until the peas are soft, about 1 1/2 hours.

Blend a few cups of the soup in a blender (or, as I did, transfer it to another smaller pot and puree using an immersion blender). Add the puree back to the soup pot, stir and season again if needed with salt and pepper.

Keep the soup warm while you saute the ham in its own fat in a small frying pan.Serve the soup, passing the sauteed ham around to be added to the bowls of the carnivores at the table.

Croutons and Parmesan for topping (optional for vegetarian version)

Warm 5 tbsp olive oil in a small skillet with a rosemary branch. When the oil is hot and fragrant, remove the rosemary and toss in crouton squares cut from 2-3 slices of white bread. Fry till crisp and golden. Remove to a paper towel to cool.

Save the oil to serve with the soup. Top with croutons and freshly grated parmesan. A little chopped parsely or chervil wouldn’t hurt either.

Should You Get a Mammogram?

Leda Derderich wishes she had.

Dederich had stage IV breast cancer diagnosed at age 45, two years after she and her doctor discussed and dismissed the need for a routine screening mammogram while breastfeeding at age 43. That decision to delay screening mammograms may have meant that she lost the chance to find and treat her breast cancer before it had spread beyond the breast. It’s a decision she regrets now, and blames on the confusion around mammogram guidelines.

I have had a much harder time accepting that I was not screened for breast cancer before it was too late. Not because I couldn’t be bothered, was too anxious, or didn’t have health insurance, but because the guidelines for screening women in my age range are one hot mess of a controversy, and I fell through the cracks.

Two years before my diagnosis, when I was 43 years old, I asked my doctor if I should get a mammogram. I had a vague understanding that breast cancer screening protocols were in flux, but I wanted to be sure. My risk profile for the disease was very low. I was nursing my infant daughter, and I really did not want to stick my breasts in a vice grip (it’s not really that bad, but that’s how I was imagining it). My doctor told me that if I didn’t want a mammogram, I didn’t need to get one.

Her counsel was based on a set of widely used guidelines at the time that say having a mammogram is an “individual” decision for women under 50 at average risk for breast cancer. She had no reason to believe I was at risk, and I had no reason to believe I should question her judgement.

What I didn’t know, at the time, was that there are multiple and conflicting breast cancer screening guidelines for women between the ages of 40 to 49.

Dederich is right. There is controversy around what’s best for women in terms of screening mammograms, a controversy that began in 2009 when the US Preventive Services Taskforce rocked our world with their recommendation against knee-jerk, routine mammogram screening in all women between ages 40 and 49.

Now, almost a decade later, the guidelines for mammogram screening still vary, though not as much as you might think. With one notable exception. Allow me to summarize for you.

Screening Mammography Guidelines – Not as Out of Sync as You Think

With some minor differences in wording and nuance, the US Preventive Services Taskforce, American College of Physicians (ACP), American Academy of Family Physicians and 2017 ACOG guidelines in essence recommend that women at average risk for breast cancer be offered mammogram starting at age 40, but make informed, individualized decisions about having mammograms depending on their individual risk, personal values and concerns. The frequency of mammograms, if women choose to have them, varies between one and two years. The American Cancer Society guidelines recommends individualized choice between ages 40 and 45, with all women starting screening at age 45.

Wrapped into those guidelines is the fact that delaying mammograms to age 45 or age 50 accepts a small but real increase in breast cancer deaths – on the order of around 1-2 extra deaths per thousand women. In return for delaying mammograms, women get less false positives and less unnecessary biopsies. It’s estimated that if you have an annual mammogram starting at age 40, you have a 60% chance of a false positive and a 7% chance of having an unnecessary biopsy, compared with a 40% chance of false positive and 5% chance of biopsy if you wait to age 50 to start routine mammos.

Also considered in the guidelines are the fact that mammograms do not prevent breast cancer and do not find all breast cancers at an early, curable stage. They miss about 10% of cancers, and may not detect rapidly growing cancers that arise between routine mammograms and spread beyond the breast almost from the get go. In addition, the cancers mammograms do find may be the slow growing kind that would never kill you anyway, or are not really cancer (we’re talking DCIS), but can lead to surgery, radiation and even mastectomy.

The American College of Radiologists continues to recommend annual mammograms for all women starting at age 40

The one group still recommending routine annual mammograms for all women starting at age 40 (ie, no individual choice) is the American College of Radiology (ACR). The ACR is now on a campaign to re-inform women about mammogram screening, putting their own spin on the data to get their message out to the public that the everyone else’s guidelines are just plain wrong.

Is the ACR right? Should the US medical profession just go back to telling all women to have a mammogram starting at age 40 ? If so, we’d be at odds with most of Europe, where women at average risk of breast cancer are not invited to screening till age 50, and where breast cancer deaths are not higher than those in the United States.

As a compromise, the ACP and ACR in 2012 issued a joint statement on points of agreement designed to ensure that mammograms remain affordable and available to all women starting at 40 who want them regardless of risk. But the differences in recommendations between the ACR and other organizations remains.

Which brings us back to the fact that when it comes to mammograms, for now, women have a choice to make.

It doesn’t matter what the guidelines say if the decision you make about having a mammogram is the wrong decision for you.

Dederich regrets the decision that she and her doctor made, and feels that she did not have the information she needed to make the right choice for herself.  She feels that because the medical community is conflicted, our patients are confused and therefore misinformed.

Smart, dedicated people are deeply engaged in this issue. But while they compare data sets, grapple with the statistical significance of lives like mine, and churn out conflicting guidelines, far too many women are left confused and misinformed about what is best for our health and long-term survival.

This is exactly why my colleagues and I created Breast Screening Decisions*, a free website and Iphone App designed to help women make an informed decision about screening mammograms. Using BSD, a woman can determine her own risk of breast cancer (which, even among low risk women, is not zero), explore her own personal values around screening, learn about the benefits and harms of screening mammograms, and see for herself what the difference is between starting annual mammograms at 40 vs waiting till 50 or having them every other year vs. annually. There is a real difference in mortality, but it’s small, and we’ve created visuals to help you see it accurately.

Some women don’t care a hoot about false positives or unnecessary biopsies or the fact that their mammogram might detect a cancer that would never kill them but results in them undergoing surgery, even mastectomy. It will all have been worth it if they catch a cancer early. And even if they don’t catch it early, at least they feel they did everything they could have done to do so.

On the other hand, there are women who want to avoid mammograms at all cost. Perhaps they or a loved one had a bad experience with a false positive, or a biopsy that resulted in complications, or they just believe they will not get breast cancer and don’t want the harms of mammography.

What’s important is that women feel they’ve been given the information they need to make the choice that’s right for them.

Decisions are Not Easy

The hard thing about making decisions is that the decision we make today might be different than the one we’d make in hindsight, when we know how those odds we considered actually played out. I try when I can to tell my patients who are making choices to project themselves into future, having either a false positive, DCIS or a breast cancer diagnosis, and ask themselves if they would then regret the choice they are making today, whatever that may be. If their choice remains the same, it’s probably the right choice for them. If not, then they may want to rethink it.

____________________________________________________

* Breast Screening Decisions (BSD) is completely free as well as ad-free, was built using funding from the NIH, and is maintained using private unrestricted institutional donations.  I have no financial interest in BSD. 

More from TBTAM on Mammograms

Healthy, Low Calorie Cauliflower Breadsticks

Do you think whoever named the cauliflower plant knew that one day we would evolve into overweight, carbohydrate-overloaded, gluten-intolerant creatures, who, in searching for a suitable lo-carb substitute would find their holy grail in that crucifer whose name is homonymous with the ground product of the very thing we both crave and shun?

Think cauliFLOUR.

Then go grind up a head of cauliflower in the food processor (or be lazy like me and buy Trader Joes riced cauliflower), steam or microwave it for 10 minutes, strain out the liquid in a tea towel, pour into a large bowl and add two egg whites, 1/4 cup hemp or flax seeds, 1/2 low fat grated cheese (Trader Jose’s Lite Mexican Blend works perfectly) and a tbsp of minced fresh herbs (I used thyme, rosemary, basil and oregano). Spread out onto an 8 x12 inch rectangle on a parchment paper-lined baking sheet. Bake it in a 450 degree oven for 15-20 minutes, toss a little more cheese atop and bake 5-10 mins more and Voila! You’ve got a delicious, healthy, low calorie, if somewhat floppy breadstick. I cut mine using a pizza cutter while still warm, and got 32 cracker size pieces at 25 calories apiece. (If you want yours crisper, after cutting them, turn the oven off and put them right back in for 1-2 hours to crisp up as the oven cools down.)

I served these tonight to accompany Cream of Mushroom Soup. The flavors complemented each other well.

Maternal Use of Estrogen Hormonal Contraception Just Before Pregnancy – A Risk for Childhood Leukemia?

In a well done and very interesting study in Lancet Oncology, Danish researchers have identified an association between use of estrogen-containing oral contraceptives in the three months prior to pregnancy or during pregnancy and the risk of childhood leukemia in the offspring of that pregnancy.

The study’s conclusions are strengthened by the fact that the data come from three reliable nationwide Danish databases –  one registering births, one registering cancers and the other registering prescriptions –  and included over a million children born between 1996 and 2014, with a median of 9 years follow up from birth.

How high is the risk?

The hazard ratio for childhood leukemia was about 50%-70% higher among children born to women taking estrogen-containing contraceptives in the three months prior to or during pregnancy, compared to that in the offspring of women not using these contraceptives immediately before or during pregnancy. The risk was confined to non-lymphoid leukemias.

Because the overall risk of leukemias is low (most children do NOT develop leukemia), the actual risk translates to one extra case of leukemia for every 50,000 potentially exposed children, or in Denmark, about 4% of leukemia cases over the 9 years studied.

That’s not a large risk, but it is worth looking at.

Which hormonal contraceptives were implicated?

The risk for childhood leukemia was only found for use of estrogen-containing oral contraceptives in the 3 months just prior to pregnancy or during pregnancy. No association was found for non-oral preparations, but there were few cases of these.

No increase in risk was found for ever use of any hormonal contraceptive prior to the 3 months immediately preceding pregnancy.

No risk was found for use of non-estrogen containing hormonal contraception (think the mini-pill, levonorgestrel IUD and Depo-Provera) at any time, even immediately before or during pregnancy.

Is this really true?

Let’s be clear. Association is NOT causation. But it is a signal that warrants further study and a plausible explanation.

In this case there is a biologically plausible mechanism, in that estrogens can inhibit certain enzymes that protect DNA from cancer causing mutations. There are also other proposed mechanisms.

But there could be alternate explanations for the study’s results. For example, what if the mother carries and transmits to her child a genetic predisposition that not only increases the risk of leukemia, but also causes her to have heavy periods that necessitated her use of birth control pills? Or if by chance, in this study, more women with a genetic predisposition happened to take birth control pills? The researchers did not have genetic information on both mother and child, and that’s important.

Results of other studies exploring the birth control pill-leukemia link have been mixed.

So we need further studies.

But still, it begs the question – what should we do until we have the results of these further studies? After all that can take years, and women are getting pregnant now.

What should you do with this information?

What you should NOT do is let this study scare you away from using birth control pills to prevent pregnancy. Oral contraceptives continue to be among the safest, most effective ways to prevent pregnancy. Not to mention their benefits in treating irregular, painful or heavy menses, endometriosis, acne, hirsutism and in some women, PMS.

But until we have further data, I don’t see any harm in playing it safe – which means stopping estrogen-containing hormonal birth control and using either the mini-pill or a barrier method of birth control (such as condoms or diaphragm) in the 3 months prior to attempting pregnancy.  (Theres no reason to change to a long acting method such as Depo-Provera or the IUD for just 3 months.)

If you’re an inconsistent oral contraceptive user worried you may become pregnant due to missed pills, this may be another reason why you may want to change to a more effective method such as the IUD for long term use.

As they say, talk to your doctor.  

With my own patients, I tend to take an “If it’s not broken, don’t fix it” approach to birth control. Which means, if you are happy and healthy using estrogen-containing birth control, don’t let this be a reason to stop using it. But do have a plan for transitioning off when you want to become pregnant.

_______________________________________

References

  • Pombo-de-Oliveira MS. Maternal hormonal contraception and childhood leukaemi. Comment. Lancet Oncology 19:10. p1261-1262. Oct 1, 2018.
  • Hargreave M, Mørch LS, Andersen KK, Winther JF, Schmiegelow K, Kjaer SK.
    Maternal use of hormonal contraception and risk of childhood leukaemia: a nationwide, population-based cohort study.Lancet Oncology. 2018; (published online Sept 6. http://dx.doi.org/10.1016/S1470-2045(18)30479-0.)

Bread – Let it Sing

Listen closely.

That crackling sound you hear is the bread “singing”.

It’s why you should never cut into a piping hot loaf of bread fresh from the oven, tempting as that may be. Let it rest and sing for awhile as it finishes the process of baking all by itself.

Here’s what Jim Lahey has to say about singing, in his book My Bread, which is where I get my bread recipes and technique –

Just after you take a loaf out of the oven, something strange often happens: it begins to make wierd noises, a rapid-fire crackling sound, one pop after another. This “singing” as some bakers call it, is especially loud and obvious in the professional bakery, where dozens of loaves may be pulled out of an oven at the same time and placed together in a basket. They become kind of a snapping chorus. The singing lasts for several minutes – the temperature of the room will determine how long – as the bread cools.

This singing is evidence of the last phase of cooking, which takes place out of the oven- and is why you should always given a loaf time to cool before slicing it. The exterior of the loaf is very dry at the moment it’s removed, but the interior is still wet. During cooling, the two elements of the bread start to even out somewhat, although the crust will remain brittle and the crumb soft. The crust is shrinking and cracking. Steam escapes through the cracks, which is the racket you hear, as it forces its way through, while the crumb solidifies. At this moment, the bread seems alive.

I know its a romantic idea, but it’s how you get to feel when you fall in love with a simple, but beautifully baked rustic loaf.

So wait till the song is over before you cut into that loaf of bread. It’s well worth the wait.

The Best Easy Dinner You’ll Ever Make

Okay. Maybe I’m being hyperbolic about this meal because I’m back on my food delivery diet (I still have a few more pounds to go..) and so all I could do was have a small taste after watching Mr TBTAM cook it. But I really don’t think I’m overstating it.

Skillet Chicken With White Beans and Caramelized Lemon. One of the easiest amazing dinners you can make.

What makes it special is what Alison Roman at the New York Times calls “the liquid gold in your skillet“, that secret ingredient Jewish grandmothers have been sneaking into their children’s vegetables for centuries – chicken fat.

I admit to keeping a jar of the stuff in my freezer, but this is the first recipe I’ve seen that uses every drop of chicken fat right in the skillet in which it was formed.

Its a one pan dinner, less than 30 minutes from start to finish. Add a side of rice or potatoes if you want, or some crusty bread, but you really don’t need it.

You’re probably thinking you could pour a little of the chicken fat off to keep the calorie count a bit lower. Well don’t. Its perfect just as it is.

The Recipe is here. You’re welcome.

Title X – Free Speech Under Fire. Again.

It’s deja vu all over again, as the current administration, borrowing a never-implemented move from the Reagan administration, attempts to gag physicians who provide reproductive care to women.

New proposed regs would forbid Title X funded providers from freely providing information about abortion to their patients, limiting such conversation to the provision of a list of names to women who have already decided to have an abortion.

Given that close to 50% of pregnancies in the United States are unplanned and that a significant proportion of women with unplanned pregnancy are unsure what they will do at the time of diagnosis or presentation to their doctor, the ruling is effectively a gag rule for any encounter around unplanned pregnancy. Or a planned pregnancy that goes wrong. Or that occurs in a woman with medical issues placing her health in danger during pregnancy. Or anytime when a pregnant woman is unsure what she wants to do regarding her pregnancy.

There’s more to the ruling that just the gag, much of it targeting Planned Parenthood, which provides reproductive health services to 41% of Title X clients.

By imposing extensive physical and financial separation requirements, the proposed rule effectively excludes from Title X any safety-net health center that provides abortion using non-federal funds. Specifically, Title X-funded entities would have to maintain separate accounting records, physical spaces (such as waiting and exam rooms, entrances, and exits), workstations, phone numbers, email addresses, staff, patient health records, educational programs, and signs.

The Ruling also lowers the bar and redefines family planning to allow Title X Funds to flow to programs that don’t actually offer medically approved contraception, but instead focus only on fertility awareness (rhythm), adoption or abstinence.

If you, as I do, oppose the proposed Title X changes, then I urge you to submit a formal comment and make your voice heard.

You’ll be joining the AMA, AAP, ACOG and ACP and almost 600 bipartisan elected officials in opposing this attempt to limit the free flow of healthcare information to women seeking to make choices among legal medical options. If you’re not great with words, head over to PRH Website for some more freely given text.

Here’s the comment I submitted today. Feel free to share, copy and paste.

Dear Secretary Azar, Senior Advisor Huber, and Deputy Assistant Secretary Foley:

I am writing you at this time to express my strong opposition to the proposed changes to Title X funding rules, which would limit Title X-funded providers in dispensing information or referrals for abortion services.

The proposed rule effectively gags both health care providers and their patients, limiting free speech within the patient-provider relationship.

Many, many women at the time of pregnancy diagnosis are unsure of their plans for that pregnancy, and wish to discuss their options with their provider. Limiting abortion discussion and referrals to women who have already decided to have an abortion is tantamount to malpractice, as women who are unsure of their options are not provided by their clinician with the critical health information they need to make a choice between the legal options available to them.

As a practicing physician I vehemently oppose this attempt to dictate medical care. Abortion is a legal medical procedure, safer than carrying pregnancy to term when performed by qualified providers, and information about it must be freely available to women, who need unbiased, factually correct, evidence-based information to make the choices that are safest and best for themselves and their families.

The proposed regulations unfairly and unconscionably impacts low income women, who frequently have no other options for reproductive health care other than that provided by Title X providers. The proposed rule changes create a two tiered system of reproductive education and care – one for women of means, who are given the information and counseling they need to make decisions about their reproductive health, and the other for poor women, from whom information about legal, safe reproductive options is deliberately withheld. If the legislation has its intended impact, women will lose trusted providers such as Planned Parenthood, which currently provides care to 41% of Title X patients.

Finally, the government cannot, though its funding mechanisms, require physicians to deliberately withhold information about completely legal health care options from our patients.  This violates our free speech, promotes unethical behavior and violates the patient-physician relationship.

I urge you to withdraw the proposed changes

Thank you for allowing me to comment.

Sincerely,

Margaret Polaneczky, MD

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More reading

Blackened Shrimp with Citrus and Roasted Fennel

It’s been quite a long hiatus from blogging, and I for one am glad it’s over.

Nothing special made me stop blogging, just the overwhelming business of life and work. It’s a good life, but one that for the past year or two has lost the balance between work and private life that I seem to have achieved when I was blogging more frequently.

At any rate, things in general have settled down a bit and I find myself actually having free time again to write. And so the blog is back!

What’s new, you ask?

Well, I am about 30 pounds thinner, that’s one big thing.  Nothing magic or amazing, just a food delivery diet that let someone else do the work for me. I still have at least another 40 pounds to go, but decided to see if I could take myself there without the crutch of a delivery diet. And so, I’m on a mission to find a stable of light and healthy but delicious meals that I can begin to incorporate into our life and my diet. It’s only week two of this new on-my-own diet and I am pleased to tell you I have found one amazing dinner that I know I’ll be making over and over again.

Try it, and I predict you will be too.

Blackened Shrimp with Citrus and Roasted Fennel

This recipe is a modification from a recipe found in Cooking Light, a magazine I highly recommend for anyone, not just dieters, who is looking for great recipes. The recipe written here is with my modifications, mostly made to accommodate my larder, which did not at the time include fresh herbs or more than one shallot. I also made my own rice/grain mix. (The original recipe called for a box mix.).

Next time I will add an additional fennel bulb – found myself wanting more! You could also add a few more shrimp when serving 4, as this only gives about 7 per person. Farro would make a nice alternative to rice.

Ingredients

  • 2 oranges
  • 2 medium fennel bulbs with stalks (about 7 oz. each)
  • 2 tbsp olive oil
  • 1/2 tsp sea salt
  • 1 large shallot, quartered
  • 6 cloves garlic, peeled
  • 1/2 large sweet onion, peeled and cut into quarters

For Shrimp:

  • 2 teaspoons paprika
  • 1 teaspoon chopped fresh thyme (or 1/2 tsp dried thyme)
  • 1/2 teaspoon garlic powder
  • 1/4 teaspoon dried oregano
  • 1/4 teaspoon red pepper flakes
  • 2 tbsp olive oil
  • 1 pound large shrimp, peeled and deveined, tails on

For Rice-Grain mix

  • 1/2 cup basmati rice
  • 1 tsp olive oil
  • 1/4 tsp salt
  • 1 cup water
  • 1/2 cup quinoa (I used a red/white quinoa blend)
  • 1/4 tsp salt
  • 1 cup water
  • Reserved orange rind

Instructions

Preheat oven to 425 degrees Fahrenheit

Grate one orange to equal 1 teaspoon rind; reserve for use in the rice/quinoa mix. Cut oranges crosswise into 1/3-inch-thick rounds. Remove stalks from fennel; chop fronds to equal 2 tablespoons and reserve for garnish. (Save the stalks for future use in a salad, broth, meat braise or fish dish.) Cut fennel bulbs into 1/2-inch-thick wedges. Combine orange slices, 2 tablespoons oil, 1/2 teaspoon salt, shallots, garlic, onion and fennel wedges on a rimmed baking sheet, spreading them out in a single layer to cook. Bake at 425°F for 25 minutes or until fennel is tender and lightly charred.

While veggies are cooking, make the rice/quinoa mix.

Cook the rice: Rinse rice well under cold running water; drain. Boil 3/4 cup water in a pyrex measuring cup in the microwave. Heat 1/2 tbsp oil in a small pot till shimmering. Add rice and salt, stirring well while sauteing over medium high heat for about 2 minutes, till slightly toasted. Add the boiling water, cover and simmer over a low heat until done.

Cook the quinoa: Rinse quinoa well under cold running water. Add to saucepan with water and salt. Bring to a boil. Reduce heat and simmer, uncovered, for 15 minutes or until done.

While rice and quinoa are cooking, combine 1/2 teaspoon salt, paprika, thyme, garlic powder, oregano, red pepper in a small bowl. Toss with shrimp, being sure it is evenly coated with the spice mixture. Hold in the fridge if veggies and rice mix are not yet done. (You’ll be cooking up the shrimp at the last minute before serving.)

Toss cooked rice and cooked Quinoa in serving bowl with the reserved orange rind. Cover to keep warm while shrimp cooks.

Heat 2 tablespoons oil in a large skillet over medium-high heat. Add shrimp; cook 3 minutes, tossing frequently, or until done. Arrange fennel orange mix on serving platter. Top with shrimp and garnish with fennel fronds.

Serves 4. Shrimp/fennel/orange mix has 141 cals per serving. Adding 1/2 cup cooked rice/quinoa brings it to 428 cals per serving.

TBTAM’s Top Ten Podcasts of 2017

You know you’re a radio junkie when you find yourself scribbling not just prescriptions, but lists of podcasts for your patients to listen to on their long plane flights or drives to Florida or wherever else they are heading for the winter months. I figured if I wrote them all down, I could save myself the scribbling and just share a link to the list.

And so here, in no particular order, are the podcasts I found myself recommending over and over again this past year.


S-Town

Part mystery, part bizarre tale, part crazy sad but also totally wonderful and addicting. I fell in love with this guy John B McLemore, quirks and all.  Not to mention this is one gorgeous website.

And some great theme music.


Here’s the Thing with Alec Baldwin 

A veritable who’s who of modern media and culture sit down for one-on-one’s with Alec. He’s not the worlds best interviewer, and sometimes I wish he’d shut up and stop trying to impress us, but the truth is I love him. He’s not afraid to seek common ground with his guests, who range from Judd Apatow to Kristin Wiig to Patti Smith to Jerry Seinfeld.


Fresh Air

Terri Gross is a true national treasure, and her interviews just get better and better with time.

She makes me so proud of my hometown, Philadelphia. And WHYY, still my fave radio station ever.


More Perfect

Thanks to my daughter for introducing us to this podcast about the Supreme Court, that branch of government no one but Nina Totenberg seems to understand. Until now. Learn about the cases that define the court and the nation. The Imperfect Plaintiffs and Object Anyway, from season 1, are must-listens for every American.


The Axe Files

David Axelrod, former Obama campaign strategist and White House Advisor, interviews key figures in the political world. Broadcast from the University of Chicago, where Axelrod heads the Institute of politics.

Naturally, a highlight was his interview/discussion with Barack Obama (12/16/16), but if you’re a political junkie, you won’t stop there. Great listening, this.


The New Yorker Radio Hour

Somehow I never find time to read the New Yorker, but I do listen to the podcast. The episode on how Oxycontin was sold to the masses is a tour de force, and David Remick’s conversation with Hillary Clinton is one of her best post-memoir interviews she’s given.

 


Freakonomics Radio

Stephen Dubner hosts this wonderfully creative and interesting podcast, exploring ” the riddles of everyday life and the weird wrinkles of human nature”. A three-part series “Bad Medicine: explores the underbelly of medicine and the drug industry. The July 5 episode tying the fracking boom to local population explosions and the decline of marriage is fascinating. And “When Helping Hurts” will change forever the way you think about what “doing good” can really mean.


This American Life

Of course.

 

 

 


Missing Richard Simmons

One day Richard Simmons, fitness guru, weight loss coach and darling of the aerobics set, just up and disappeared from public and private life. Dan Tuberski wants to know why. If you think it’s none of his or your business, don’t listen. Or rather, try not to listen.

 


Number Ten 

Actually, I only have 9 top podcasts of 2017.

I’m still searching for number 10, which I hope to listen to on drives back and forth to Philly over the holidays.

Contenders are :

  • 36 Questions (a three part podcast musical);
  • Dirty John (True crime mystery, supposed to be riveting); and
  • Sincerely, X (Anonymous Ted type talks about things no one really talks about- including one doc’s medical error that lead to a diagnosis of burnout).

Let me know in the comments which you think I should listen to first.

And if I’ve left your favorite podcast off the list, tell us what it is and why it’s your favorite.

Happy listening, everyone!

Acupressure App – Does it really alleviate menstrual cramps?

The media is abuzz over a study reporting that use of a cell phone app to train women in self-acupressure is effective as pain medication for treating menstrual cramps.

The Android app is called AKUD and is written in German, so unless du sprichst Deutch, it won’t do you much good. But let’s ignore that for now. Here’s the study intervention:

The study intervention

Participants received a menstrual tracking App that included instructions on acupressure for cramp relief. They also got one-on-one instruction on the location of specific acupressure points and use of acupressure using drawings and video. The App reminded them to apply acupressure starting five days before the anticipated menstruation. Control participants received a version of the app that did not include acupressure info and got usual care.

Both groups reported a reduction in menstrual pain, but participants who used the acupressure-containing app had a greater reduction in menstrual cramps compared to those who did not get the app to use, and use of birth control pills to control cramps was higher in the non-app group. Note that menstrual pain was not eliminated by use of the app,

So does acupressure help menstrual cramps?

I don’t know. Why? Because the study did not include an appropriate control.

The right control would have been to give controls a sham app that taught them ‘acupressure’, but used the wrong acupressure points.  This would have controlled for what may be a significant placebo effect of the use of the acupressure app.

A Cochrane review of acupuncture and acupressure for menstrual cramps concluded that there is insufficient evidence to recommend the practice. I would say this new study does not change that conclusion.

Could it hurt? 

Probably not. Although a few users of the acupressure app reported bruising and pain at the acupressure sites, only one user stopped the app due to these symptoms.

Bottom Line

For milder menstrual cramps, a lay down with a hot water bottle or a nice tub soak may be all that’s needed. Or ask a friend or loved one to massage your lower back. And don’t be afraid to exercise during your period if the cramps are not debilitating.

NSAIDs such as ibuprofen, naproxen and mefaminic acid are first-line medications for treatment of more bothersome menstrual cramps. Midol (combo tylenol, caffeine and an antihistamine) may work for milder cases.

Your doctor can prescribe stronger doses of NSAIDs or a cox-2 inhibitor such as Celecoxib if needed. And if you also need birth control, birth control pills and the hormonal IUD are good treatment choices.

Save your phone space for a good podcast

In my opinion, your phone app space would be better spent downloading a good podcast. In fact, I think my next blog post will be some podcast recommendations. Stay tuned…

It’s not gonna’ kill you to take hormone replacement

It’s not going to kill you to take hormone replacement therapy.

That’s the take home message from the latest analysis of the Women’s Health Initiative, the largest and longest randomized trial of hormone replacement therapy (HRT) in menopausal women.

After almost 18 years of follow up in the WHI, there was no increase in overall mortality, including death rates from cancer, in women taking HRT for up to 5.6 years (estrogen plus progestin) or 7.2 years (estrogen alone). There was a non-significant reduction in mortality among those who started HRT between ages 50 and 59, the group most likely to be prescribed hormone therapy for menopausal symptoms.

I’ve blogged before about the results and limitations of the WHI, which found, on balance, that the health risks of HRT (breast cancer, blood clots, stroke) about equaled its health benefits (protection against colon cancer and osteoporosis). The study (and the US Preventive Services Task Force) concluded that there was no reason for women to take HRT for preventive health reasons.

The biggest criticism of the WHI was that 70% of its participants were 10 or more years post-menopausal. The study did not include women most likely to benefit from taking HRT – those with hot flashes, night sweats, insomnia and other menopausal symptoms – or enough women in the 50-59 year age group. These women start HRT at menopause, not a decade or more after it’s over. In this younger group, more recent research suggests there may be a reduction in heart disease risk not captured by the WHI. Or not. It’s an ongoing debate among health experts not likely to be decided very soon.

In the meantime, millions of women enter menopause every year, some of them with significant symptoms that impact the quality of their life (and sleep), who must decide whether or not to use HRT to treat their symptoms.

For these women, this newest update from the WHI is reassuring.

The breast cancer mortality data from the WHI are complicated, and based on a small number of cases in the study population. Let’s just say there was no statistical increase in deaths from breast cancer among users of estrogen and progestin. Since the breast cancers occuring in HRT users are not inherently less aggressive, its more likely the lack of increased breast cancer mortality is because most breast cancers are not lethal, while those that might become lethal are effectively treated. Paradoxically, there was a significant decrease in breast cancer mortality among users of estrogen alone, perhaps related to the fact that estrogen, when taken after a long hiatus, actually inhibits breast cancer growth. (I told you, it’s complicated. You can read more about this here.)

Will this new information matter to women deciding about using HRT?

The use of HRT has plummeted in the years since the WHI results were published in 2002.

In my practice, the reason for the decline is clear – women don’t want to increase their chances of getting breast cancer, however small that increased risk may be.

I tell my patients this : “If you take HRT for 20 years, your risk of breast cancer will be about 1% higher. Use it for 2-3 years for menopausal symptoms, and that increased risk is less than a quarter of a percent”.

After considering this, the majority of women thank me for the information, and decline to use estrogen. Their symptoms are just not bad enough to entertain even that small a breast cancer risk. (I’m happy to prescribe HRT or non-hormonal therapies for those who opt to use them.)

This new study won’t change that conversation much, but I will now add that taking HRT for a few years around menopause to alleviate its symptoms will not increase mortality. I’ll also tell them that the data on breast cancer mortality, while complicated, seem to suggest no overall impact. That’s most likely because the overwhelming majority of breast cancers are not lethal, either due to their inherent behavior or our improved treatments.

I’m curious to see if this changes the choices they make.

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