CHOICE: Not all it’s cracked up to be.

It’s about time for a little rant. It turns out that having lots of choice is not the end-all of freedom, as much as promoters of democracy, freedom and the American Way would like us to believe.

Take toothpaste, for example. I recently went to the drugstore to buy some toothpaste. Sounds simple, doesn’t it? I ended up walking out of the store totally frustrated.

I’ve been a loyal fan of Colgate toothpaste for easily forty-five to fifty years. I tried Crest for a while, dabbled with Tom’s, but mostly it’s been Colgate. Colgate was just fine. Simple, white, plain toothpaste with some fluoride. No problem. I’ve watched with trepidation over the years, the introduction of different looking boxes with the Colgate logo on them, but bypassed them completely, knowing where to direct my eyes on the shelf, to the red and white box of the regular brand. I think I must have loaded up last year during a sale.

Then, this year the plain red and white box with the plain white toothpaste became extinct, replaced by some twenty different varieties on the shelf. Now Colgate makes TOTAL; PROCLINICAL WHITE PASTE (in the blue box); PROCLINICAL GEL; ADVANCED WHITENING; ADVANCED CLEAN; GUM DEFENSE; ENAMEL STRENGTH; MINT STRIPE; MAX WHITE (with mini bright strips); MAX CLEAN WITH SMART FOAM [[[smart foam?]]]; MAX FRESH with mini breath strips; LUMINOUS CRYSTAL CLEAN MINT—Ahhhhhhh!!!—SENSITIVE MULTIPROTECTION; SESITIVE ENAMEL PROTECTION; SENSITIVE WHITENING; SPARKLING WHITE MINT ZING—God help us!!!!—SPARKLING WHITE CINNA MINT; TARTAR PROTECTION WHITENING CRISP MINT PASTE or CRISP MINT GEL; ULTRABRITE ADVANCED WHITENING. And those don’t include the brands for kids.

What marketing MBA did Colgate hire to come up with all those registered and trade-marked brands? Please! Let’s 'up' the lithium dose a bit. It’s like, how many different models of a VW bug do we need? Is this what the world of facebooking tweeters want?

Okay, I'm finished with the rant.

Way down that list, I discovered CAVITY PROTECTION GREAT REGULAR FLAVOR. Eureka! Might that possibly be a re-branded version of what I was hoping to find in the first place? I’ll give it a try if I can find it on the shelf, buried beneath the other varieties.

SHINGLES (Herpes Zoster): New Progress in Prevention!

see also: IT'S YOUR SKIN: Treat it Well!,  at http://www.itsyourskintreatitwell.blogspot.com/


Shingles is a household term these days. The medical term is Herpes Zoster. Take anyone older than sixty and that person likely knows someone who has had a case of Shingles. An estimated 500,000 Americans per year get Herpes Zoster, and up to one per hundred adults per year if you are older than 65. Worldwide, it's a huge problem that, while usually non-fatal, can cause terrible suffering.

The amazing development is that advances have been made in the vaccine arena that could almost make Herpes Zoster a thing of the past. See end of this posting.

In my 25-plus years in dermatology, I’ve consistently been impressed by the fact that Herpes Zoster (Shingles) is often misdiagnosed, even by dermatologists, and is often treated too late to have any benefit, which leads to protracted and debilitating pain. The pain and suffering that comes from Herpes Zoster is underappreciated by doctors and patients alike (except those who have it). Furthermore, patients with suppressed immune systems (AIDS, organ transplant patients, certain malignancies) can develop life-threatening illness from Herpes Zoster when it spreads throughout the body.

Fortunately, if caught early enough, there are excellent treatments for Herpes Zoster. Diagnosing it early is not always easy. In addition to treating the ‘rash’ after it starts, there is a new vaccine that promises to prevent cases of Herpes Zoster. For us aging baby boomers, that is a real advance.

So, what is Herpes Zoster and how can it be recognized, treated, and prevented?

Herpes Zoster comes from the reactivation of the chickenpox virus, called Varicella-Zoster Virus (VZV). After childhood chickenpox, the Varicella viruses (probably millions of them) become dormant and retreat to nerves in the spinal cord where they remain for the rest of our lives. With aging, or in the setting of certain diseases, immunity against VZV weakens, and the virus can become reactivated. When it does, instead of reactivating throughout the entire body, it reactivates in one nerve ‘root’ only. This single nerve root reactivation is what causes Herpes Zoster.

Herpes Zoster blisters along the inner arm

cluster of blisters on the neck

DIAGNOSIS: Because only one nerve root is involved, the rash of Herpes Zoster happens on one side of the body along the path of a nerve, hence, one side of the face, across one side of the trunk, down one side of the arm, etc. In dermatology, we learn that with any new rash on one side of the body, we MUST consider Herpes Zoster as a possible diagnosis. Even with new-onset of pain without a rash along the path of one nerve, we have to think about early Herpes Zoster. The reverse is also true: any new skin rash involving both sides of the body or multiple limbs is probably NOT Herpes Zoster. Typically in Herpes Zoster, pain/burning/tingling usually comes first, followed in 24 to 48 hours by small red bumps and fluid-filled blisters where the nerve branches up to the skin.

TREATMENT: Early treatment limits the severity of Herpes Zoster in most cases. Once the rash of blisters and pain are established, it is too late, and treatment can only be directed toward reducing pain, not preventing it.
Three anti-viral drugs exist to treat Herpes Zoster: acyclovir, valacyclovir, and famciclovir. The latter two achieve much higher blood levels orally and are the treatments of choice. The first drug, acyclovir, has excellent anti-viral activity against the other Herpes virus called Herpes Simplex, but is less effective as an oral drug against Herpes Zoster. Patients with poor kidney function require lower doses.

The key to successful treatment is to treat early. This means patients need to seek help early and doctors need to have a high index of suspicion and institute treatment based on probability, not proof of the diagnosis. There is little to no risk to patients in treating in this manner, but delaying treatment can lead to months or even years of misery, pain, and disability. Doctors who see emergency or walk-in patients are the ones best able to help patients with evolving Herpes Zoster.
In severe or untreated cases, patients are often left with protracted pain called ‘postherpetic neuralgia’. Although it usually improves slowly over time, it can be excruciatingly painful for weeks to months, sometimes years. Treatments can be helpful, but often require sophisticated combinations of pain killers, gabapentin-like drugs, anti-depression drugs, and occasional use of nerve blocks.

disseminated VZV

In patients with suppressed immune systems for any reason, Herpes Zoster can trigger a more wide-spread illness throughout the body that can be life-threatening. Again, early diagnosis and treatment with anti-viral drugs is life-saving.

PREVENTION: Back in 2006, a live vaccine against Herpes Zoster was approved in the U.S. The vaccine, called Zostavax®, is basically a larger-than-normal dose of the Chickenpox vaccine used routinely in children. Zostavax® has been shown to reduce by 50% the risk of getting Herpes Zoster. It also reduces the risk of the protracted postherpetic neuralgia by two-thirds. Every individual age 60 or older who qualifies should request and receive Zostavax®.

The new development: Shingrix® is a new vaccine made from molecular subunits of the chickenpox virus plus an immune enhancer.  It has been shown to be safe (no accidental infection) and highly effective for up to three years (so far) of protection. Two doses are given a few months apart, and the injection into the deltoid can produce significant pain. The cost is around $300 but because it is so effective, it is likely that insurers will cover the cost, and countries with drug coverage will negotiate lower prices and cover the cost for their citizens. Cost savings will follow when fewer individuals will have need for medical care of their shingles.

ALOPECIA (HAIR LOSS)

                                      James Channing Shaw, MD

 Some of the most worried patients in a dermatologist’s practice are those who are losing their hair. The medical term for hair loss is ALOPECIA. The most common type of alopecia is male balding, but there are many conditions that lead to hair loss, some temporary, some permanent. In this post, I discuss only the most common causes.

Hair growth cycles. To understand hair loss, you have to understand hair growth cycles. 80% of hairs on the scalp are in active growth-phase (called Anagen phase), which lasts for years. When growth-phase is completed, the hair stops growing, the root becomes small and round, and the hair goes into a resting-phase (called Telogen phase). After about ninety days in resting-phase, the hair falls out, and a new hair root begins making a new hair. Only 20% of human hairs are in resting-phase at any one time. By comparison, some animals ‘shed’ seasonally because all hairs go into resting-phase at the same time.

Growth-phase (anagen) roots are the ones most vulnerable to illnesses or medications. The prime example is cancer chemotherapy. Chemotherapy destroys rapidly growing cancer cells and growth-phase hair roots get damaged as innocent bystanders.

Androgenetic alopecia. The most common form of hair loss is male pattern balding (medical term: ‘androgenetic alopecia’). It is a genetic response to the male hormone testosterone which men have in abundance and women have in small amounts. Androgenetic alopecia usually happens gradually with no noticeable shedding of hair, just a relentless thinning and shortening of existing hair until (in worst cases) there is complete balding of the top of a man’s scalp. Women with androgenetic alopecia usually do NOT go bald, just thin. The growth-phase hair roots become smaller and smaller over years until they are too small to make visible hair.




Androgenetic alopecia





Treatments for androgenetic alopecia. It is now known that the naturally modified form of testosterone called dihydrotestosterone (DHT) is the culprit of androgenetic balding. Without DHT, there is no balding whatsoever in men. (We know this from studying families that cannot make the DHT). Therefore, the drug finasteride (Propecia®) was designed as the first effective drug for male balding because it blocks the conversion of testosterone to DHT. Unfortunately, Propecia does not grow new hair, it merely slows the balding process. In post-menopausal women, sadly, it has very little positive effect.


Minoxidil (a blood pressure drug) was discovered to have the side effect of hair growth, so a topical product Rogaine® was developed which can be a helpful adjunct to treatment but rarely produces a full head of hair. Statistically, about one third of men see benefit after a year, slightly higher in women.


For women with androgenetic alopecia, hormonal treatments are the most effective, though limited. In young women, birth control pills plus antiandrogen drugs (spironolactone) are used together, along with Rogaine® topically. Occasionally Propecia® is added but no large studies have proven its effectiveness in women. In older women, hormone replacement therapy (HRT) plus spironolactone are most commonly used.

Telogen effluvium

Telogen effluvium. Shocks to the system cause hair to fall out by converting growth-phase hair to telogen (resting) hairs. A high fever or general anesthesia during surgery can trigger many hairs to stop growing. They don’t fall out right away but go into the resting phase for 60 to 90 days and then fall out. Pregnancy is another example. Many of us know women who delivered a baby, and three months later started losing their hair. Fortunately the hair usually grows back. This kind of resting-phase hair shedding is called ‘telogen effluvium’. Other stresses that cause telogen hair loss are surgery, blood loss, or any severe illness.

Chronic telogen effluvium. This is the diagnosis when increased shedding lasts for months. Thinning of total hair mass occurs in worst cases. In young adult women, low iron has long been thought to contribute by triggering growth-phase hairs to convert to resting-phase hairs, and if thirty or forty percent of hairs are constantly in resting-phase, shedding increases, in the shower drain, on brushes, on clothes. Since women lose blood every month with menstruation, and if iron intake is inadequate, healthy growth of hair may be impaired. The diagnosis requires a specific iron test called ferritin which indicates the total body iron stores. The ferritin level should be above 40 for adequate hair growth. Eating more red meat or taking iron supplements can reverse the problem. The iron theory has recently been challenged in new studies, and further investigations are needed.


Many drugs can trigger ongoing hair loss of the ‘chronic telogen’ type. Fortunately it is not permanent, but it is often difficult to identify the medication causing the problem when multiple medications are being given. Stopping or changing medications requires careful monitoring by a physician.

Other diagnoses:

Alopecia Areata

Alopecia Areata. AA, though not as common as the types described above, is a huge topic that goes beyond the scope of this posting. Briefly, it is immune-mediated (autoimmune) hair loss. It can be mild, occurring in localized areas of the scalp, or in the worst cases, it can affect every hair follicle on the body. Patients with AA should be screened for other autoimmune conditions such as diabetes, thyroid disease, and anemia. All treatments for AA are designed to turn off the immune destruction of growth-phase hair follicles. Treatments range from local injections of steroids all the way to internal immune-suppressing drugs. Results are frequently unpredictable.

Tinea Capitis (ringworm)

   Ringworm (medical term: tinea capitis). This is a fungal infection of the scalp, common in children. It is contagious through direct contact, combs and brushes. Any child with patches of hair loss should be seen by a skilled nurse or doctor to make the diagnosis and treat with anti-fungal drugs.



Lupus. A more severe and different autoimmune disease, Lupus erythematosus can affect hair, leading sometimes to permanent scarring hair loss. Treatments also range from injections to serious immune suppressants.

Natural approaches, vitamins, nutrients. Iron and protein are probably most important. Iron is discussed above. Modern western diets frequently do not have enough protein for healthy hair. While not studied scientifically, individuals should eat three portions of protein per day for optimal hair growth.

Too much vitamin A (greater than 25,000 IU/day) can cause hair loss. Biotin deficiency causes hair loss, and supplementation with Biotin can be beneficial in telogen type hair loss. Research has shown that ingredients in Chinese green tea block 5- reductase and could lessen androgenetic alopecia, although no large scale clinical studies have been done.

Finally, a word on commercial hair care products. There is no hair care product that penetrates deep enough to influence hair growth at the level of the roots. Most products are washed off and even those that remain on the scalp cannot penetrate deep enough to influence the roots. No matter what they claim about roots, hair care products can only affect the shape and texture of existing hair and the top layer of scalp skin. If too harsh, they cause breakage over time.

Winter Itch and Winter Dry Skin

Dryness of the Skin: Xerosis (pronounced Zerosis)


James Channing Shaw, MD

If you look with a magnifying lens at very dry skin, it looks like a dry lakebed, with multiple shallow cracks. The medical name for this dryness is xerosis. How does xerosis happen, who gets it, and what can be done to treat it?

Normally the skin acts as a barrier to evaporation; water is prevented from escaping by the top most layer of the skin called the stratum corneum. In this layer skin cells are stacked on top of each other, each one overlapping the ones below. Each stratum corneum cell contains material called keratin that is nearly impermeable to water. Between the cells is a mixture of lipids (fats), called the lipid layer.



This multlayered sandwich of cells and lipids creates an armor that protects against water loss. However, since we are all different, some individuals have better functioning stratum corneum than others and are better protected from drying out. Those of us who are genetically unlucky in this regard are susceptible to dry skin, primarily from two environmental causes. One is decreased humidity in the air and the other is a damaged lipid layer. Low humidity pulls water from the cells of the stratum corneum, making them brittle, curled at the edges, and separated. Add wind to the dry air and the problem gets worse.


Damaged lipid layer comes from chemicals on the skin that wash away the lipids. Our hands are the most susceptible to this kind of damage because they have the least amount of lipid in the stratum corneum layer. Ironically it is our hands that get most exposed to chemicals such as soap and detergents. Solvents like alcohol, cleansers, and ammonia are even worse. With the amount of hand washing we have all been taught to do, it is no surprise that dry cracked hands are a common problem in the winter.

Severe xerosis: this case has become erythema craquelé

 
Why is winter air such a problem? Two reasons: 1) cold air holds less moisture than warm air, and 2) artificial heat in our homes dries the air to extremes. Indoor humidity of less than 10% is common during a cold winter. Only the heartiest of stratum corneum can withstand this desert-like effect without becoming dry and cracked.

When skin dries out, most people start itching. The shins and the lower back are the most common places for ‘winter itch’. Faces and lips can also become dry, flaky and cracked. The hands are different: finger tips can split and are very painful. While this can be annoying and uncomfortable, the good news is that very little serious illness comes from skin dryness.

So….what to do? There are basically two ways to minimize the problem: 1) increase humidity in the air, and 2) provide skin barrier protection against water loss. A vacation in the tropics returns skin to normal within a week or two. The increased humidity in the warm air of the tropics stops water loss from skin. A humidifier, while not as good as a tropical environment, can be helpful in your home. For dry cracked hands, a lesson from feet is instructive. Feet don’t dry out as commonly as hands because they are protected all day in warm humid shoes and socks. Gloves provide the same protection for hands that sox do to for feet. Soft comfortable gloves, not rubber gloves, are best. The goal is to increase humidity, not cause perspiration and soaking.

For more skin barrier protection, additional ‘lipid layer’ needs to be applied. There is an important lesson here concerning lotions, creams, and ointments. Lotions are mostly water with some oil (lipid) and when applied to the skin, the water evaporates leaving a small amount of oil remaining. This gives the false impression of 'absorption', but lotions help only in the mildest cases of dryness. Severe dryness calls for thick creams (less water, more lipid), or ointments like petroleum jelly (all lipid, no water). The greasy ointments give the best protection but take some getting used to.

The worst cases of dryness may require professional help and prescription treatments. For splits in the hands, cover with tape or a bandage which helps the pain and speeds healing. Soaking hands in warm water for 10 minutes puts some moisture back if a thick cream or ointment is applied immediately, followed by gloves. The same is true for the whole body: a plain water soak for 10 minutes followed immediately by greasy creams or ointments can help the driest skin. The secret is to not let the water evaporate before applying moisturizers. Apply the cream or ointment within 60 seconds. It takes a while to get used to the greasy feel but the improved moisture in the skin should be apparent within a few days.

Finally, two common misconceptions deserve mentioning:
1. Applying moisturizers does not shut down your skin’s ability to make its own oil. It is safe to use moisturizers as much as needed; the skin will not become dependent on them.
2. Moisturizers per se will not prevent aging of the skin unless they contain sunscreens.

The Business of Healthcare: A Runaway Train

This just in. A doctor who works at an academic hospital in Texas reports that he recently received a letter from the CEO of the hospital congratulating him for the high number of MRI scans he ordered during the prior month. He had never seen such a letter before, and wasn’t in the habit of ordering MRIs on patients unless they were medically indicated. In this case, it was coincidental that he had ordered so many that month.

Citizens of the United States: Do you know what this means? It means that the profit motive in healthcare delivery no longer hides behind a veil of professionalism and respect for patients. It is now openly accepted, even in academic centers, that patients are viewed as nothing more than walking ATMs. At least in Texas.

He goes on to tell about how the new dean hired a firm to come in and teach the administration and doctors how to maximize their use of revenue producing services and minimize those that don’t. Specialists were encouraged to take on new patients just long enough to run a slug of expensive tests and quickly discharge the patients back to their primary care doctors as soon as they had extracted as much revenue as they could. I don’t know if there are kickbacks for ordering tests, but it wouldn’t surprise me.

After twenty years of practicing medicine in the U.S., I now live and practice in Canada. I don’t miss the American system in the least. In Canada, healthcare is considered a moral enterprise. Even so, doctors earn as much or more than their counterparts in the United States. MRI machines are purchased by the Ministry of Health, paid for through tax revenues, and are used as needed with no charge to patients.

Many Americans may find it sad that no profits are to be made off an MRI machine in Canada, or unconscionable that their tax dollar might be going toward someone else’s MRI. Personally, I view both as doing the right thing. No conflict of interest for doctors, fewer unnecessary tests ordered, no concerns that patients won’t get the test, and so on. The same applies to doctor visits, other tests, surgeries, chemotherapy, hospitalizations, and most drugs for those qualified by age or infirmity.

None of this is new, just a reminder. Obama’s reform may be a step in the right direction, but for-profit healthcare is a runaway train in the U.S. and will require more drastic changes than Obama’s to slow it down. Read Atul Gawande’s fine article in the New Yorker to get the whole picture.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

God willing, you know!

So I just watched Ann Curry on NBC interviewing a minister who attributed his surviving yesterday’s massive tornado in Mississippi, to ‘The Lord this and The Lord that…His only comment about those that were killed in the storm was that The Lord still loves them blah blah blah…

I have been extremely fortunate. I've never had to suffer through the tragedy of losing a loved one in a tornado or a plane crash. I have a hard time, however, imagining anything more offensive than hearing from a survivor that 'God was watching over me’. I understand the ‘why me?’ question, but attributing one’s survival to God's selective protection is tantamount to blaming the dead for causing their own deaths.

It is the height of misguided indoctrination and arrogance for a person to believe that he or she could be individually selected to live through a natural or humanitarian disaster. Delusional ideation—that’s the medical term. Being selected to live implies that those who died were not merely ignored by God, they were selected by God NOT to live. It couldn’t be negligence or oversight, right? Since God is omniscient and all-powerful, right? It must be that God hand-picked half the airplane's passengers to die a scorched painful death. And to think that people go to churches, synagogues, and mosques to worship this God? Something is amiss here.

This all-seeing God must also have had little interest in watching over the events that led to the tornado or plane crash in the first place: the weather, how much fuel was in the tanks to burst into flames, the pilot's skill (you've seen priests bless pilot's hands, surgeon's hands, and the like). Apparently God was too busy protecting that minister, or that small group of passengers in rows 21 to 29 who survived the crash, to pay attention to other details.

Similarly, God must have had it in for six million Jews in World War II, but was fine with protecting the Nazi German murderers who lived out their natural lives after the war. They moved to the United States and were protected for their anti-communist stances. God Bless America, you know. "Ohhh, that's different", Christians say. "Nazi Germany was an example of free will and self determination—God-given, like Adam and Eve, the serpent, the apple. They’ll get theirs in the end, sort of thing."

How about the brave crew of the space shuttle Challenger, or the 200,000-plus who died in the Tsunami of 2004? God must have decided it was their time to die—fathers, mothers, kids, everyone. The millions murdered by Pol Pot and Stalin?—God must have been just fine with those two charming fellows practicing free will, since both had the luxury of living out their natural lives. God willing, you know. That’s the popular phrase these days. How about the passengers of Pan American flight 103 over Lockerbie, Scotland? They must have been really bad or really good for God to have selected them for early admission to the afterlife. Meanwhile, the perpetrators who planted the bomb still walk today, no doubt because God ordained it. And so on.

If there were something that should shatter the whole concept of faith, and bring into serious question the entire notion of an overseeing, all-protecting higher being, it would be any one of the atrocities above, or any of thousands of similar disasters over the millennia where innocent people were dashed against the rocks of misfortune or eviscerated by the swords of their fellow man.

Sadly, the concept of 'God watching over me' will not likely disappear any time soon. No matter how uncivilized or unsubstantiated, once beliefs are labeled as faith-based, the rest of society becomes reluctant to challenge or reject them.

Journalists, on the other hand, and their editors and producers should at least recognize how irresponsible it is to broadcast or publish comments from survivors who claim to have been 'saved by God'. The implications of blame for the victims and the added insult to victim’s families are totally unjustifiable.

In corporations we trust: health reform in America

by James Channing Shaw

I have practiced medicine in Canada and the United States. I know both systems well. My mother-in-law recently spent 12 hours in the emergency room of an academic New York City hospital. She had suffered a small stroke. She received excellent care, I.V. fluids, an MRI, and close observation over night. I asked approximately 20 of my American friends what they thought the cost of her ER visit might have been. Assuming I was searching for a high number, they guessed between $3000 and $9000. The actual bill: $19,800.

A little more than a year ago, my stepfather-in-law underwent abdominal surgery, an emergency second surgery, spent two weeks in intensive care and two months of rehab in hospital. The total bill for his three months of first rate inpatient care: $25 (for the television in his room). The difference: he lived in Canada.

Well-informed Americans continue to be confused about health care reform. Even the most highly educated have fear that reform will reduce what they get now. Institutions that oppose reform have been remarkably effective in instilling fear of change, of systems like Canada. Clarification and understanding are sorely needed if change is to occur. While no one knows precisely what reform will look like, everyone should at least know the principles that drive the current U.S. system.

1. Most health care in the U.S. is all business. Americans seem to view medical care not as a societal priority similar to, say, police and fire protection, but as a commodity. Insurance companies have a responsibility to their stock holders, not patients, doctors, or hospitals. It is good business for them to reject applicants with pre-existing illnesses. The system is analogous to fire departments that charge for putting out your fire, or don’t come at all if you have had a previous fire.

2. For-profit medicine does not translate to best medicine. The U.S., while having by far the most expensive per-capita health care in the world, ranks 37th internationally overall, 14th in preventable deaths, and 24th in life expectancy. Over-treatment is routinely practiced by doctors as a source of revenue production. While any health system is susceptible to abuses, the American structure enables such ethically corrupt practices through its acceptance of entrepreneurialism in medicine. Most countries that fund health care out of tax revenues try to restrict entrepreneurial ventures in medical services.

3. American insurance companies usually limit the dollar amount they cover. Catastrophic illness, for all but the most affluent, still results in bankruptcy. In 2007, over 60 per cent of bankruptcies in the U.S. were medical, either from medical debt or loss of income from illness.

4. For-profit health care generates enormous administrative costs that could otherwise be spent on the delivery of care. Picture a large hospital with thousands of patients, each with different insurance red tape, versus one standardized plan for billing. Administrative costs are factored into the fee schedules and passed along to patients in the form of premiums or exclusions. Stock holders win, patients lose.

The rest of the world does it differently and, according to most sources, better than the United States, for less cost. The two main questions are whether Americans wish to provide health care insurance for everyone, analogous to police and fire protection, and whether they think for-profit insurance companies can be trusted to broker such a service. Republicans put their trust with corporate insurance companies, the same ones that have exercised their power to derail reform. Republicans in Congress have given a clear signal that they care more about corporate America than health care for Americans.

Surprisingly, many Americans who would be best served by health reform, and are in most need of it, continue to go along with the distorted arguments and anti-reform rhetoric from conservatives. That was true in Saskatchewan in the 1960s when a public system was first introduced and insurance companies were, by decree, eliminated from the government insurance plan. The new system was so successful and popular that it later was implemented throughout Canada.

If Americans who oppose reform could get over their aversion to centralized insurance funded by taxes, and embrace health care as a moral enterprise instead of a business venture, the United States could begin the process of improving overall quality of care, and at the same time start to reduce its per capita health care costs.

James Channing Shaw is an American physician currently at the University of Toronto.

Grapefruit and Erectile Dysfunction

by James Channing Shaw, MD
There is something you should know about grapefruit. It could change your life.
One week after Mr. Andersen (patient’s name changed) started drinking grapefruit juice every morning, his wife noticed a difference. He had very little interest in sex. At first he passed it off as aging variation, but it persisted into a second week. He had no libido whatsoever. Never before had he experienced problems with low libido or erectile dysfunction. He eventually clued into the grapefruit juice, stopped drinking it, and after two weeks, was ‘back’, just like the ads in the subway.
I knew about grapefruit’s role in altering drug metabolism in the body, but couldn’t find any studies suggesting a direct hit on testosterone, the main determinant of sex drive. Something in that grapefruit juice must have interfered with Mr. Andersen's testosterone for him to have such a rapid response and recovery.
Serendipitously, one month later, I read an article in the British Journal of Cancer(BJC) of a study showing that women who consumed as little as ¼ of a grapefruit per day had a 30 per cent higher risk of developing breast cancer than those who didn’t. This risk was as high as from taking HRT (hormone replacement therapy). The culprit in HRT is estrogen, well known to increase breast cancer risk. Perhaps estrogen was the link to Mr. Andersen's grapefruit scare. It made sense. I probed more.
It turns out there are strong links between grapefruit and estrogen. First, grapefruit contains estrogen-like compounds called flavanoids, also found in green tea and soy products. Flavanoid effects are identical to those of synthetic estrogen, and if you give a man estrogen, his libido drops to near zero.
The other link is the drug metabolism effect. Grapefruit juice is known to inhibit the breakdown of estrogen as well as many drugs, the most notable being cholesterol-lowering drugs called statins. A single six-ounce glass of grapefruit juice is enough to raise blood concentrations of statins.
There is more. In 2007, a study in Nutrition and Cancer found that daily intake of ¼ of a grapefruit increased natural levels of estrogens by about 30 per cent in post-menopausal women. When researchers looked for a link between grapefruit and breast cancer, the 2007 BJC study showed a 30 per cent increase, but a subsequent letter to the editor and a 2009 study in Cancer Causes & Control showed no increased estrogen or cancer risk with grapefruit consumption.
More research is needed to prove the cancer link, but grapefruit’s potential effect on estrogen seems probable.
One thing is certain: testosterone drives libido, and estrogen turns it off. It is highly plausible that a widespread estrogen-like phenomenon from grapefruit juice has been overlooked.
The relationship between grapefruit, estrogen, breast cancer and libido needs further characterization. In the meantime, readers be forewarned.

Baby stroller derby

Strolling can be hazardous to your baby’s health. James Channing Shaw

All summer in my elm and mapled neighborhood, ten minutes walk from central Toronto, scores of little white babies in strollers are pushed around all day by scores of little Filipino nannies. I rarely see anybody that resembles a mom or dad behind those oversized wheels. The parents must be hard at work, or yoga. I’ve witnessed stroller gridlock. Someone is going to get hurt.

So what is the reasoning behind baby-strolling? Is it about baby getting outside, a constitutional, or is nanny stepping out for emergency milk rations and can’t leave junior home alone?

Schlepping junior I understand. The morning constitutional makes zero sense. We’re talking infants here. Air quality is better inside than out these days, so giving the kid 'fresh' air has no great health advantage. Carbon monoxide levels on my street are probably toxic. And how healthy is being in a stroller wrapped entirely in plastic in the rain? I wonder what an infant gets from lying flat on its back, bumping along under leaden skies anyway.

So it must be about nanny, not pudge-face. If mom and dad are the ones behind the stroller, maybe it's to show off their parenting chops to the neighbors. I admit it's a nice look: mom, dad, blackberry, and baby.

But the hazards of strolling on my street could easily outstrip the benefits. The fight for right-of-way gets vicious. SUVs jump right up on the sidewalk. I feel relieved when somebody slows down at a stop sign. The city's budget deficit would disappear if a few patrol cars snagged the offenders. It is only a matter of time before a stroller gets taken out.

But we’re not the only ones with stroller derby. Where I currently live in Manhattan, nannies and mothers stroll off to the side, blindly two-abreast down 5th Avenue, their free hand texting or nursing a grande-chai-latte. It drives the poor merger and acquisition guys into the street.

But designers are on top of the problem. I’ve seen the new strollers with cup holders and single steering sticks like postman buggies. Rumor has it that next year’s models have air bags and e-movies on built-in screens.

Easy Chicken strips, grilled

by James Channing Shaw




Grilled chicken strips Prep time: 1 - 2 hour marinade; Cook time: 10 minutes; Serves: 2 to 4

Everyone knows the problem with chicken breasts: they get too dry. This recipe is guaranteed to come out moist and tender. It is an easy summer success story. The inspiration for this dish came from out of the clear blue. There had to be a way to grill chicken breast meat without drying it out. Surprisingly, the recipe came out beautifully the first time and I’ve not made changes to the original. It’s a winner every time.

MUSIC: This can be a lazy summer thing with just the sound of the breeze in the leaves or lapping waves at the shoreline. If you are into more intensity, go all-out with Sanctuary, off Miles Davis' Bitches Brew album while you prepare the marinade.

HERE'S ALL YOU NEED:

• 2 or 3 Chicken breasts. Bone-in breasts are less expensive, but you'll be taking the meat off the bone, so boneless is also fine.
• Olive oil, extra virgin, ¼ Cup
• Dry white wine, ½ to 1 Cup approximately
• Juice of lemon and/or lime, ⅓ to ½ Cup total
• Salt, small palm (close to ½ teaspoon)
• Herbs de Provence, total approximately 4 Tablespoons
• Black pepper (or mixed peppercorn), 5 or 6 big twists of a pepper mill.

HERE'S WHAT TO DO:

1. De-bone the breasts. Remove skin but put aside. Cut chicken into strips approximately ½ inch to 1 inch wide, the full length of the breast. You must have a knife at least 10 inches long, and very sharp. You can get 4 or 5 strips per breast. Remove any tendons.


2. Slice the skin into strips, a bit wider than the chicken so they don't fall through the grill.


3. Place chicken and skin in a large mixing bowl and add olive oil, white wine to cover, lemon and lime juice, herbs, salt and pepper. Use enough herbs to lightly cover all sides of the meat. Stir to mix and let sit at room temperature for 1 hour minimum but a 2 hour marinade is better. Stir occasionally and smell how the mixture takes on a richness that goes beyond the ingredients alone.


4. Cook on a gas grill or with charcoal. Medium-hot (not the hottest) is best. The strips cook rapidly, within 5 minutes usually. Lay them across the grill, turn once or twice as needed, but monitor firmness with your tongs or cut one in half after a few minutes to determine doneness. They will not brown (except the stripes of the grill- see photo) because of the wet marinade. The goal is to have them just done, pink just fading. See photo.


5. The skin takes longer than the chicken, about 10 to 15 minutes. Cook together with the meat, but in a separate area of the grill because it will cause flames. Cook until crispy, maybe even a little carbonized (blackened). Then let cool, chop up like bacon bits and sprinkle as a garnish over the chicken when served.

CADENZA: The chicken is good plain or with a small amount of aioli or light mustard sauce* The dish (and the sauce) goes very well with grilled eggplant or, of course, sweet corn on the cob.

WINE: Red or white Burgundy, big buttery oaky chardonnay, red Bordeaux, Beaujolais, or even beer go well with this summer dish.

About marinating at room temperature: Are you worried about not refrigerating? There is enough citric acid and alcohol with the lemon/lime juice and wine that nothing will grow in the marinade, even if you left it out for days. No refrigeration is necessary while you are marinating this dish.

*About the mustard sauce: 3 parts mayonnaise, 1 part Dijon mustard.

About chicken skin: The skin, because of its fat content, absorbs many flavors. I suggest marinating the skin along with the rest, and grilling separately. The fat content from the skin of two or three breasts of chicken, chopped into bits and spinkled over the chicken, is well worth it when divided among a party of four .

Hormonal Acne in Women

by James Channing Shaw, MD

It is common for women to get acne in their 20s or 30s for the first time. The cause usually centers around hormonal issues.

A common scenario is the woman who gets acne within a year of stopping birth control pills. Women often take birth control pills for years in their teens or early 20s, and their acne is controlled. When they stop taking birth control pills, hormones return to having fluctuations that lead to acne.

Another cause comes from irregular ovarian activity that causes hormone fluctuations. These women often have irregular periods or acne that gets worse a week before each period. Any woman can have this problem, and at its worst, it is part of polycystic ovarian syndrome. There are other diseases that lead to hormonal acne, but fortunately they are rare.

The hormone that causes acne is the male hormone testosterone and its metabolites. Women produce testosterone in small quantities, but several conditions lead to increased testosterone effect. An increase in body weight, for example, shifts hormones toward more testosterone effect. Ovaries or adrenal glands can spontaneously overproduce male type hormones. Stress causes acne mainly through overproduction of hormones by adrenal glands.

This photograph shows a typical woman with moderately severe hormonal acne. Women with adult hormonal acne commonly have pre-menstrual worsening, and involvement of the lower face and jaw-line. Their acne is usually larger red pimples instead of blackheads on the forehead. Increased oiliness on the face is common. Some women have unwanted hair growth on the face. Irregular menstrual periods are common as well.

Standard topical acne treatments can be effective in women with adult acne, but most need hormonal treatments for optimal control. Even Accutane® is less effective in women with hormonal acne. The best treatments for adult women are birth control pills and spironolactone.

Birth control pills not only provide a steady state of hormones, they reduce overall testosterone effect through a protein called SHBG (sex hormone binding globulin). The net effect (in addition to not ovulating, i.e. prevention of pregnancy) is less stimulation of the oil glands and facial hair follicles. Many women can achieve complete control of their acne with birth control pills alone. Health risks from birth control pills are fortunately very low, but certain women have higher risks of blood clots, and full discussion with the prescribing doctor is essential. Brands of birth control pills differ by country, and some are marketed for acne.

Spironolactone is an oral drug that blocks the receptor for testosterone and prevents hormonal stimulation of acne. This drug is mainly used as a diuretic in older patients. The acne benefit was discovered as a side effect years ago. Spironolactone is well tolerated by itself, with a 40 year track record of safety in young women, but works best when given together with birth control pills. Side effects include menstrual irregularities when it is given alone.

This photograph is the patient above after a year of combination hormonal treatment. Her acne is much improved and the hair on her lip has reduced. Many women achieve excellent control within a few months with hormonal treatments, but ongoing treatment is necessary in most cases. It is important to find a doctor who is familiar with the use of these drugs for purposes of monitoring.

Finally, two recent developments in acne: 1) Cosmetics have been shown not to aggravate or cause acne in most cases. 2) Dietary influences of a western diet high in carbohydrates and dairy products may worsen acne through complex hormonal mechanisms, so a reduction in carbs and milk products may be beneficial.

Lugubriously yours,

I've been catching up on my classic lit lately (remember classics?–the books?), and after several sightings, I've concluded I dislike the word lugubrious.

Lugubrious is not used much in writing these days (who would ever use it in conversation?), but it peppers older literature aplenty. When deep into James Joyce or Dickens, and I stumble onto lugubrious, I get derailed. 'Loo' followed by 'goo' is simply bad pairing of syllables. It brings to mind bodily unpleasantries.

Also, the definition, 'excessively mournful', says it all, with little need for a synonym. A case could be made for onomatopoeia, if lugubrious meant slimy or droolingly inebriated, but it doesn’t.

Despite its four-syllable cadence like so many lovely words, what gives me trouble with lugubrious is the hard G.

Lu-joo-brious would be more palatable, but we can't just go making up new pronunciations every time we are too lazy to look up words in the dictionary, can we? Maybe we can. George W. got away with it, though most of us ignore the nuke-u-lator and his entire approach to English. But similar examples abound. Take basil (the herb) and gala (the party), two lost causes for precisely that reason: the historically correct pronunciations are baa'-zul (almost rhymes with dazzle), and gay'-la (yes, that's right), but now everyone says bay'-zul and gal'-uh. One must ultimately choose between having grammar, or friends.

It is surprising, though, how changing a letter or two can improve a word. With minor adjustments to lugubrious, one gets salubrious, a scrumptious word with a definition to match. The first two syllables roll off the tongue nicely, and the full word is luxuriant like a big chardonnay. Salubrious evokes its definition, 'full of health', and brings to mind pleasing images of waterfalls or Angolina Jolie's lips.

Of course this kind of thinking could get us into trouble. With a bit more manipulation we easily arrive at lascivious, and from there things deteriorate rapidly, so let's stick to slamming lugubrious.

This discussion may be irrelevant, since internet lingo is totally replacing English. Even the smallest of words are now parts of acronyms: FYI… BTW…CUL8R! I recently saw BFF in the headline of a newspaper article, and had to re-read the whole piece to decipher 'best friends forever', a girl's thing apparently.

So it looks as if lugubrious doesn't have a chance— it will fade into obsolescence, and I'm FWD (fine wi'dat). Mournfully though, salubrious will likely disappear as well, and that will be a real loss. Lascivious, on the other hand, will likely carry on. TTFN!

Ingrown toenails: the myth of cutting toenails straight

by James Channing Shaw, MD

Twenty-five years of practice in dermatology has taught me that ingrown toenails have little or nothing to do with whether nails are cut straight across or with a curve. What you mostly read is 'cut toenails straight or you'll get ingrown nails'. The message comes from supposed experts such as podiatrists and doctors. Every child on the face of the earth grows up thinking this. And why not? They hear it from grown-ups who must know everything. Grown-ups, after all, are supposed to know stuff.

Once again, I am here to dispel another myth: the myth of the straight-cut toenail. There is no evidence to support the notion that cutting nails with a curve causes ingrown nails, or that cutting straight prevents them. Those who preach straight-cut are merely perpetuating unsubtantiated traditional beliefs. Studies have not been done and closer examination of the rationale exposes its faults.

In every case I've seen, and there have been many, patients have always done exactly as they were told: they cut their toenails straight across and still developed ingrown toenails. Ingrown nails are more about an individual's own anatomy, plus, in some cases, trauma from shoes.

The photograph below shows a typical ingrown toenail. The nail is straight-cut, but the ingrown nail goes nearly to the cuticle. The manner in which the nail was cut couldn’t have influenced the ingrown nail close to the cuticle.



What, then, is an ingrown nail? Most importantly, it appears NOT to be an infection in the true sense, i.e. caused by bacteria. Most cases of ingrown nail don't respond at all to antibiotics. Instead, an ingrown nail results when the tissues at the side of the nail get irritated, inflamed, and swollen, leading to redness, pain, and tissue breakdown with oozing and pus. There is one exception: if you cut too close and injure the skin, you can introduce real infection, but it behaves differently: more rapid in onset, more painful, and responds to antibiotics.

It is thought that the sides of the nail must play a role in ingrown nails, that the edge 'digs' into surrounding tissue, either naturally or from shoe pressure. We know this because the problem goes away when the lateral sides of the nail or excess nail fold skin are permanently removed by surgery. Whether from the nail itself, or excessive surrounding skin, the individual's reaction to microscopic trauma is probably a key factor.

What makes NO sense is the belief that cutting the nail influences how a nail grows. If that were the case, we might expect to see it happen with finger nails, but we don’t: fingernails and toenails grow out regardless of how they are cut. Nails grow by sliding horizontally outward from the cuticle area. Whether you cut straight or curved, the nail still slides toward the tip in the way it is genetically programmed to do. The white part that gets clipped away has already separated from its base (the nail bed), and even if you cut too close, it cannot influence how the nail grows.

The big question is whether we have ANY control over preventing ingrown toenails. My suspicion is that we do not. Reasonable hygiene (but not too aggressive) is as much as we can recommend. Plenty of toe space in shoes also seems wise (but not proven). All definitive treatments, however, involve surgery, although many devices and practices to flatten out the nail have been tried with mixed results.

It would be good if someone did a scientific study of curved cut versus straight cut, but since this is a non life-threatening condition, it’s not likely to happen. In the meantime, if you would like some contour with your pedicure, give it a try. If you have never had ingrown nails, the odds are in your favor. Go easy at first. A little rounding of the edges of the big toenail won't hurt you.

Robertson Davies Quotations: Literary Riffs, or...Scripture for Secularists

The world is so full of published quotations telling us how to successfully conduct our lives that it is a wonder we haven’t all reached a perpetual state of contentedness and wisdom. Judging from the current state of world affairs, I can only surmise that perhaps some people are reading the wrong quotations.

The following quotations, from The Quotable Robertson Davies, are my favorites, the ones I keep returning to. The book contains over 800 from the Canadian novelist and playwright Robertson Davies.

I had a revelation of sorts while compiling Davies's quotes for the book. I have always been annoyed by fundamentalist thinking and behavior. Reborn Christians were the worst: they were endlessly reciting scripture! While extracting passages from Davies’s books, more and more quotations were at the tip of my tongue during conversation. A Davies quote seemed to be apropos to almost any subject being discussed. After collecting more than half of the quotations in the book, it suddenly struck me that I was doing exactly what I disliked about scripture-quoting Christians. I was quoting Davies by chapter and verse! Davies had become my secular scripture! Alone in my study, I blushed with embarrassment when I made this discovery, and have since become more discreet with the use of the quotes.

Nevertheless, here are 25 of my favorites.

Quietness is a great beautifier. –Tempest-Tost

No man should ever assume that he will be able to get the immediate and undivided attention of a woman who has children. -Leaven of Malice

Music is like wine; the less people know about it, the sweeter they like it. – A Mixture of Frailties

One of the secrets of life is that one must give up caring too much about anything. – A Mixture of Frailties

I, as a skeptic, am committed to non-belief in everything, including my most cherished philosophical ideas. –The Rebel Angels

Too much orthodoxy can lead to trouble; a decent measure of come-and-go is more enduring. –The Rebel Angels

Nobody gets through life without a broken heart. -What’s Bred in the Bone

A happy childhood has spoiled many a promising life. -What’s Bred in the Bone

Nature and nurture are inextricable; only scientists and psychologists could think otherwise. -What’s Bred in the Bone

Genius is the only true aristocracy. –The Lyre of Orpheus

Canada…. the Home of Modified Rapture. –The Lyre of Orpheus

Who really knows his father, or his mother? In our personal dramas they play older, supporting roles, and we are always center stage, in the limelight. – Murther & Walking Spirits

In my experience snobbery sometimes means no more than a rejection of what is truly inferior. – The Cunning Man

Shakespeare in printed form should be kept from children; if they cannot meet him in the theatre, better not meet him at all. One might just as well ask children to read the symphonies of Beethoven. – The Cunning Man

Don’t miss a chance to acquire an ancestor. – The Cunning Man

Longing is some of the best of loving. – The Cunning Man

A doctor’s treatment is always a reflection of himself, to some degree. – The Cunning Man

If we were all robbed of our wrong convictions, how empty our lives would be. – The Diary of Samuel Marchbanks

Children never forgive their elders for their ignorance. It is obviously a grown-up’s business to know. – The Table Talk of Samuel Marchbanks

My dullness is so complete and all-embracing that it constitutes a kind of mystical experience – the merging of the Null with the Void. – The Table Talk of Samuel Marchbanks

It takes two to make charm. . – Hunting Stuart

The good life is lived not widely, but deeply. It is not doing things, but understanding what you do that brings real excitement and lasting pleasure. – One-half of Robertson Davies

If one regards oneself as a skeptic, it is a good plan to have occasional doubts about one’s skepticism too. – One-half of Robertson Davies

Everybody can share in grief, and grief can be feigned; but laughter can only be shared by those who are of like mind. –A Voice From the Attic

Don’t be surprised if you find that nobody wants you except in your professional capacity. – One-half of Robertson Davies

Food poisoning: it's not the mayonnaise!

by James Channing Shaw, MD

One July, years ago, a neighbor at our summer cottage came over to borrow some mayonnaise.

"Of course," my mother said. "Help yourself." She retrieved a jar of mayonnaise from a cupboard (the refrigerator back then was too small to hold everything).

The neighbor, noticing the jar hadn’t been refrigerated and was half used, asked, "How long has this been at room temperature?"

"All summer.”

Blank stare from the neighbor.

"It never goes bad. The lemon juice is a preservative," my mother explained. She had been storing mayonnaise at room temperature every summer at the cottage for ten years. No one had ever become sick.

The neighbor couldn’t handle it. She left, dismayed, without the mayo.

So here are the questions: Would you eat mayonnaise from a jar left out all night? How about two weeks? If you got food poisoning after the company picnic, would you blame the mayo? Popular thinking says that you'd definitely blame the mayonnaise in the potato or chicken salad, and would throw out the mayo if left out overnight.

But popular thinking is often wrong. Here are some answers: Although mayonnaise gets much of the perceived blame these days for food poisoning, by far the most common culprit in food borne illness in North America is Staphylococcus aureus, a type of bacteria that comes from food handlers. Up to 50% of healthy adults are carriers of Staph. aureus. (it hides unnoticed in nasal passages and throat). There are other causes of food borne illnesses, like E. coli in poorly processed meat, but Staph. aureus ranks first. Once introduced to the food, the Staph bacteria multiply and produce a toxin that causes the illness we know and hate. The important issue is NOT the mayo; it is human contamination. Prevention comes from proper food prep, i.e. hand washing and keeping hands away from the face. Refrigeration only becomes an issue after the food is prepared. If it is contaminated, refrigeration certainly retards the bacterial growth and toxin production.

Surprisingly, mayonnaise is self-preserving. The acids from vinegar and lemon juice kill most bacteria. Studies have proven that chicken salad is preserved longer by adding mayonnaise, and (get ready for this), store-bought mayo is safe at room temperature indefinitely, even after opening.

Homemade mayo is a special case. Rarely, raw egg yolks (essential to mayonnaise) contain Salmonella, and the only way to assure the killing of Salmonella is through pasteurization. Fortunately, store-bought mayo is pasteurized, so it is not a problem. Instructions for home pasteurization can be found on the internet and in cookbooks. In essence, you heat the egg yolk/vinegar mixture to about 72º Celsius, enough to kill the bacteria but not cook the yolks.

So give mayonnaise a break. It has been unfairly misunderstood for years.

See also: PRACTICING SAFE CHICKEN, a new posting. here's the link:
http://james-channing-shaw.blogspot.ca/2013/03/normal-0-false-false-false-en-us-ja-x.html.

Easy Escargots

Easy Escargots (snails) Prep time: 15 minutes
Cook time: 15 minutes
Serves: 4 as a starter


Escargots, a big red Burgundy, an electrical storm, and very loud Beethoven at 3:30 in the afternoon. That was the setting in which I first made this dish. Sometimes a new recipe must first be tried in private (I had the place to myself for two days). The inspiration, of course, came from France. It was so successful that I simply had to include it in this collection.


Don't get me wrong. I realize that escargots are not everyone’s cup of tea. Eating snails is simply a non-starter for most of the population of North America. So this recipe is for two groups of people: 1) those of you who have loved eating escargots in French restaurants and would like to prepare them in a simple successful method; and 2) those adventurous souls who recognize the example of the French and would like to advance their palates into scrumptious new territory.


You don’t need special serving equipment. Don’t bother with the shells. They're only for show anyway unless you are actually cooking live snails. Instead, this recipe calls for a small baking dish.


MUSIC: Beethoven changed symphonic music forever with his 3rd Symphony, that’s what I was told, so I was trying to learn about that when I put it on. Consider listening to the killer first movement. Or try the 9th symphony which also blew humanity out of the water. In a different vein, Coltrane changed jazz, James Brown changed R&B, Jaco Pastorius changed bass playing, the list goes on and on, so find a musical visionary and play that music. Play it loudly.*


HERE’S ALL YOU NEED:


1. Snails, one can of 24 to 36
2. Ceramic baking dish or Ramekin: medium size
3. Butter, unsalted, ½ stick (¼ Cup)
4. Garlic, 1 clove
5. Parsley (Italian), a handful, chopped (¼ Cup approximately)
6. Red wine, a small dollop or two (2 tablespoons maximum)
7. Kosher salt, one medium pinch (less than ¼ teaspoon)


HERE’S WHAT TO DO:


· Pre-heat oven to 450º to 500º.
· Melt butter in the ceramic dish (microwave or oven).
· Rinse, drain escargots and add to melted butter.
· Chop garlic and add to dish
· Finely chop parsley and add to dish
· Add salt and red wine
· Stir gently to mix
· Heat in oven until bubbling and sizzling nicely, about 10 minutes usually. Use extreme caution removing from oven.


CADENZA: Escargots are best served with French baguette. Any bread will suffice however. I prefer slices, partially toasted, crunchy on the outside, soft and warm in the middle.


WINE: This dish is based on the Burgundian recipe, so a Burgundy style pinot noir is best, and red goes very well with the big flavors of the garlic, butter, and parsley. A white Burgundy would always be fine as well (or Chablis, Chardonnay).


About escargots. Snails come in a can unless you buy fresh at an outdoor market. I prefer the smaller size snails, 36 to a can, but the larger (24 to a can) are fine too.


About parsley: Italian (flat leaf) is best. The crinkly parsley would work in a pinch but try for Italian.


*About loud music. Not everyone enjoys music so loud you must shout to have a conversation. In my ‘old days’, shouting over Miles or Coltrane was just fine during a meal. But on the subject of loud music, I can't help being reminded of the landlord I once had in Boston who lived on the top floor of an old house and rented out the flats on the first and second floors. He was large, had a tetra-syllabic Italian name, taught Italian 'litrature', and smoked big cigars. Evenings, he would blast Italian opera through the floor to our apartment. My girlfriend and I had little knowledge of opera at the time, but on more than one occasion, the music provided ample accompaniment for what we were doing on the sofa, and we learned to like it. Loud has its place.

Skim milk for cappuccino?

James Channing Shaw

So. I'm waiting in line at Starbucks and the young woman ahead of me asks for a grande-chai-latte-soy-non-sweetened-caramel-extra-hot-no-water-no-foam, and the order guy rattles it off to the espresso-maker guy as if he gets 50 similar orders every day! When it is ready, the espresso-maker guy (oh, excuse me…the barristo) calls it out again, every word, for the customer, with just as much ease. Only in America.

When it comes to coffee, North America has made great strides since the 1970s when the likes of Maxwell House and Folgers were the only games in town. Young people don't have a clue about how good they have it now. Back then, the entire East coast was awash in coffee that tasted like dirty dishwater. Back then, even in nice restaurants, coffee was percolated in huge vats, and for those who didn’t travel to the Mediterranean, espresso was an abstraction known only to a few Bohemian types in hidden subterranean clubs or the cognoscenti of high-class Italian restaurants. Fortunately, espresso is now a household term, along with French press, Turkish, cappuccino, caffé latté, etc. More and more, Americans appreciate and expect coffee with rich, robust flavor.

The American way, however, is to transform everything to its own liking. The Starbucksification of America has taken what for years has been a stable industry in Italy (we could probably include Spain, France, Turkey), and turned it completely upside down. Customers now ask for everything under the sun and they actually receive what they order. With no backtalk!

In Italy, it is unheard of to order a cappuccino after about 11:00 a.m. without receiving some form of snub (in Italian of course) by the waiter like "You dunce, cappuccino is a breakfast drink!" After mid-day, to any self-respecting Italian, espresso is the thing, or possibly macchiato. In America, though, the customer is always right, and you might as well close down your shop if you don't offer thousands of variations and flavors, any time, day or night.

I'm actually OK with that. Where America has gone seriously awry is with skim milk in cappuccinos and lattés. Cappuccinos made with non-fat milk are an American abomination of the worst kind. Steamed milk is supposed to be made from full-bodied, smooth, rich milk. The silky white froth should slip into your mouth blissfully, luxuriant and warm. It is not supposed to be stiff, standing at attention on top of a cup of coffee, or adhering like chunks of Styrofoam to the sides of the cup.

Simply put, excellence in foam can not be had with non-fat milk. Oh, you can make bubbles with non-fat milk, to be sure—the milk protein bubbles up nicely—and even the manuals for home espresso units in North America tell you that foam is easiest to make with non-fat milk. But easiest is the operative word, not best. They are not concerned about flavor. The bubbles are too big, and the foam too stiff, too dry. It requires some fat to keep the bubbles small, smooth and rich. Skim milk foam, like costume jewelry, is a cheap imitation of the real thing.

That being said, I fully realize it is politically incorrect to be disparaging about another person's taste. Apparently, any form of bad taste is acceptable these days. But are there no limits? Are we not allowed to ridicule those, for example, who actually eat food sold in convenience stores? Are we not allowed to criticize those who like their steaks well-done? Can you imagine the chef at a Michelin two-star acquiescing to a diner's request for a well-done steak, or for the Caesar dressing be put on the side, and hold the anchovies? The same goes for skim milk for cappuccino. People, stay home! Eat your frozen pizza and watch reality TV!

In the 50s and 60s, Americans were notorious for their bad taste when it came to food (Velveeta and overcooked zucchini come quickly to mind). That reputation has improved to an impressive degree with the help of visionaries like Alice Waters (Chez Panisse) and Thomas Keller (The French Laundry) who revolutionized American cuisine in the 1970s and 1980s, and T.V. chefs like Anthony Bourdain who have recently taken food nearly to cult status. I wonder what Bourdain thinks of decaf cappuccino, made with skim milk, served at nine o'clock at night.

But maybe there is hope in America: not too long ago I had lunch at a little Italian restaurant in New York City, and printed on the menu were these words: "No de-caffeinated coffee. No skim milk. We only use the best ingredients." It was so refreshing, and they were still in business!

What Starbucks needs to do now is send all its barristos to Rome for a week to learn how to make espressos and cappuccinos. Learn the culture. But that is merely my wishful thinking. Maybe the truth is that Italians are coming to Seattle to learn how to say 'grande-chai-latte-soy-non-sweetened-caramel-extra-hot-no-water-no-foam', in Italian.

Slamming toilet seats

Slamming toilet seats
by James Channing Shaw

My office is across the hallway from a public bathroom (washroom in Canada). The English term 'water closet' is more accurate for this particular washroom since it's a one person, close-the-door-and-lock-it bathroom. All day long I am constantly jarred by the 'whack!' of the heavy plastic seat falling onto the porcelain rim. Someone goes in, closes the door, throws the dead bolt, and bang! down goes the seat. I can forget about ever having a five minute power nap after lunch.

Do people slam toilet seats at home? I suspect not. What happens to them when they leave the house? Do they leave all respect for public property at their front doorstep every morning? It's as if toilet seat bangers have no perception of anyone other than themselves. I know people like that. I'm related to people like that. Is this Nature or Nurture? Were the parents of toilet seat bangers so permissive that they grew up thinking that anything they wanted to do was OK, regardless of consequences to others? I would love to know the answer to these questions.

Actually I think I understand two reasons why people slam toilet seats. First, we think we can be disrespectful of property when it’s not our own. We don’t care if the thing breaks as long as we didn’t have to buy it in the first place, and don’t have to pay for the new one. Sadly, it's human nature. Second, there must be some phobia about germs that makes people afraid to touch the toilet seat and let it down gently. They must be using their foot or a stick or something to hit the toilet seat down, into submission, as it were, before they completely wrap it with toilet paper so they can finally sit on it.

What degree of separation from kin is necessary to view toilet seats as prime vectors for disease? Spouses and children?—they're cool. Slobbering Labrador Retrievers?—generally not a problem. Aunts and Uncles?—they're usually OK if not too old and don't smell bad. Neighbors?—could get a little sketchy. The cleaning lady?—now we're getting warm. Colleagues from the office?—you get the picture. So it is about strangers, and those in a socioeconomic class lower than the one you currently occupy. It's the thought of the buttocks of the riff-raff having just sat where you are about to put your buttocks, that makes people squeamish so they approach the toilet seat as if it were radioactive. The broken toilet seats I've seen in my life!

But I do have some suggestions. Concerning respect for the next guy or public property, I can't do much about that other than to say: Parents, teach your kids to do the right thing. It just might stick. Concerning germ phobia there are some points to make. First, bacteria don't bore holes into normal skin; nor do they typically fly around the room. If you happen to get bacteria or viruses on your hands now and then, like every time you bite your nails, scratch your head, rub your eyes, or touch the spout on the office water cooler, you can always wash your hands. It washes off!

Second, if you just can't handle the thought of putting the toilet seat down gently with bare hands, use a paper towel or piece of tissue for protection. Germs don't jump through paper in a nano-second.

Finally, men, guys, this is really about you: after you pee and wash your hands, use the paper towel with which you dried your hands to lower the seat for the next customer. She could be your future wife, if that's not too old-fashioned. Alternatively, try sitting down to pee; you'll likely have to do that eventually anyway, when your prostate gland gets too big. Just a thought.

Layering for warmth. Or not!

I am surprised every autumn when, as soon as it starts getting cold, the media start to preach about 'layers' and the importance of 'layering for warmth', as if the ruling came from stone tablets. They make no distinctions among fabrics.

In fairness, I suppose that anybody who wears enough layers of any material can probably stay reasonably warm, but the truth is, in severe cold, IT’S NOT THE LAYERS that determine warmth and functionality in clothing, IT’S THE GARMENT ITSELF. The irony is that layering is most valuable when you're too warm and need to shed clothes. Sound crazy? It's actually simple.

Two main principles are essential for staying warm in cold weather: 1) create pockets of warmed trapped air close to the skin, and 2) prevent the wind from blowing them away. Ask any mountaineer or polar expeditioneur: the crucial items for warmth are goose down parkas and pants, plus wind resistant outer fabrics (Gore-tex being the prototypical best 'outer' fabric). And for nights, the bulkiest down sleeping bag is the warmest way to a good night’s sleep.

'Loft' is the important concept here. Loft is the property of a garment that allows trapping of little pockets of air. Usually the thicker the fabric, the greater the loft, but the downy feathers of geese or Eider ducks (eiderdown) are by far the loftiest materials known to humankind. Down feathers trap air, maintain their shape indefinitely, bounce back after being crushed, and so far, in the history of keeping warm against the elements, down is irrefutably the warmest insulator for its weight. Eiderdown has been used in bedding and garments since the Stone Age, and goose down clothing, popularized in the 1930s by Eddie Bauer, continues as the gold standard. There is one 'downside': if down clothing gets wet, it becomes worthless for warmth and takes a long time to dry. Also, down is expensive.

What about loft in other materials?

Fur: highly effective in a Neanderthal sort of way, but very heavy, and politically sketchy these days.

Synthetics: great invention of the 1980s. Fleece and polypropylene are light in weight and relatively inexpensive, perfect alternatives to down in all but the severest cold, where down is still best.

Wool, that time-honored gift to humanity: wool has considerable loft, from sheepskin coats to cashmere sweaters, to felt liners, and unlike down, wool keeps some loft even when wet.

Cotton: worthless for warmth. Very little loft

Woven silk: strong, but no loft, no warmth.

Bulk silk: this is the long-fiber silk used in duvets. Time-honored and reasonably good in moderate cold.

Linen: take a wild guess. Strictly a summer fabric.

Another misperception is the concept of tight versus loose clothing. Not too long ago, I came across the Cornell University website on how to survive cold winters as a student in upstate New York. It emphasized loose clothing because tight clothes 'don't help to keep you warm' (the website also emphasized layering). This was surprisingly bad information from an institution of higher learning. It is true, tight cotton pants provide little protection against cold, but loose cotton pants are no better! It's the material, not the fit that is important. Wool or fleece will always be warmer than cotton or nylon. And for those of you who think loose is warmer than tight, I suggest you compare a tight cotton t-shirt with a blousy cotton shirt on a hot summer day in Atlanta. Against-the-skin is always warmer than loose and flowing. Have you ever heard of loosely fitting long underwear?

For those frigid walks to class in upstate New York, layers are fine if you don't have anything better. If you can afford it, buy a down coat and forget about the layers. If you don't have the money for down, wear long underwear, wool pants, a wool or fleece sweater and wool coat and you should be able to keep hypothermia at bay for at least an hour or two.

So when is layering important? It's about cooling off, not staying warm. Let's say you are cross-country skiing in minus 5º Celsius (23º Fahrenheit), and working up a sweat. You need to take some clothes off. Going directly from down-filled parka to sweaty t-shirt is not the smartest solution. Layering allows you to remove what you need and not risk hypothermia. The best fabrics for layering are medium loft with wicking properties: Merino wool, polypropylene, or fleece. Even better for cooling off are zipper vents, found in most high-end outerwear, but removing a layer or two works splendidly.

Voila. Layering definitely has its place. Understand the concept; reject the slogan. You'll be more comfortable for it.