Arts & Entertainment

From left, Jason Sheltzer, Nicole Sayles (who is a former lab technician and a co-author of an earlier MELK paper) and SBU undergraduates Chris Giuliano and Ann Lin. Photo by Constance Brukin

By Daniel Dunaief

If eating macaroni and cheese made Joe sick, he might conclude he was allergic to dairy. But he could just as easily have been allergic to the gluten in the macaroni, rendering the dairy-free diet unnecessary.

Scientists try to connect two events, linking the presence of a protein, the appearance of a mutation or the change in the metabolic activity of a cell with a disease. That research often leads to targeted efforts to block or prevent that protein. Sometimes, however, that protein may not play as prominent a role as originally suspected. That is what happened with a gene called MELK, which is present in many types of cancer cells. Researchers concluded that the high level of MELK contributed to cancer.

Jason Sheltzer, a fellow at Cold Spring Harbor Laboratory, and Ann Lin and Christopher Giuliano, undergraduates at Stony Brook University who work in Sheltzer’s lab, proved that wasn’t the case. By rendering MELK nonfunctional, Sheltzer and his team expected to block cancer. When they knocked out MELK, however, they didn’t change anything about the cancer, despite the damage to the gene. But, Sheltzer wondered, might there be some link between MELK and cancer that he was missing? After all, scientists had found a drug called OTS167 that was believed to block MELK function.

To test this drug’s importance for MELK and cancer, Sheltzer used this drug on cancer cells that didn’t have a functioning MELK gene or protein. Even without MELK, the drug “killed cancer cells,” regardless of the disappearance of a gene that researchers believed was important for cancer’s survival, he said.

“We showed for the first time that [the drug] was killing cells that didn’t express MELK,” Sheltzer said. The drug had to have another, unknown target.

Sheltzer suggested that this is the first time someone had used CRISPR, a gene-editing technique, to take a “deep dive” into what a drug is targeting. This drug, he said, has a different mechanism of action from the one most people believed.

Sheltzer, whose work was published in early February in eLife, expanded the research from a petri dish, where researchers grow and study cells, to mouse models, which are often more similar to the kinds of conditions in human cancers. In those experiments, he found no difference between the tumors that grew with a MELK gene and those that didn’t have the MELK protein, continuing to confirm the original conclusion. “The tumors that formed in cells that had MELK and the tumors that formed in cells that didn’t have MELK were the same size,” he said.

Originally, Sheltzer believed the MELK protein might be involved in chemotherapy resistance. His lab found, however, that no matter what they did to MELK in these cells, the cancer appeared indifferent. Other researchers suggested that Sheltzer’s work would be instructive in a broader way for scientists.

Sheltzer’s research on MELK “will motivate a new set of standards for target discovery and validation in the field going forward,” Christopher Vakoc, an associate professor at CSHL, explained in an email. Sheltzer “brings a rigorous approach to cancer research and an impressive courage to challenge prevailing paradigms.” Sheltzer’s work highlights the challenge of understanding the mechanism of action of new medicines, Vakoc added.

Sheltzer plans to explore several other genes in which a high concentration of a specific protein coded by that gene correlates with a poor prognosis.

Using CRISPR, Sheltzer believes his lab can get precise information about drug targets and their effect on cancer. He’s also tracing a number of other types of cancer drugs that he thinks might have compelling properties and will use CRISPR to study the action of these drugs. “We want to know not just that a drug kills cancer cells: We want to know how and why,” he said.

By figuring out what a drug targets, he might be able to identify the patients who are most likely to respond to a particular drug. So far, the finding that a drug doesn’t work by interfering with a specific gene, in this case MELK, has been easier than finding the gene that is the effective target, he explained.

One of Sheltzer’s goals is to search for a cancer cell that is resistant to the drug, so that he can compare the genes of the vulnerable one with those of the cell that’s harder to treat. Detecting the difference in the resistant cell can enable him to localize the region critical for a drug’s success.

Sheltzer said finding that MELK was not involved in a cancer’s effectiveness was initially “depressing” because researchers believed they had found a cancer target. “We hope that by publishing these techniques and walking through the experiments in the paper that other labs can learn from this and can use some of the approaches we used to improve their drug discovery pipelines,” he said.

Sheltzer is pleased that Lin and Giuliano made such important contributions to this paper. CRISPR has made it possible for these undergraduates to “make these really important discoveries,” he said. Lin, who has worked in Sheltzer’s lab for two and a half years, was pleased. “It is very exciting to share my knowledge of MELK in regards to its role in cancer biology,” she wrote in an email. “Authoring a paper requires a great deal of work and I am super thrilled” to see it published.

Sheltzer, who lives with his partner Joan Smith, who is a software engineer at Google, said he was interested in science during his formative years growing up in Wayne, Pennsylvania, which is just outside of Philadelphia, and appreciates the position he has at Cold Spring Harbor Laboratory. Soon after earning his doctorate at MIT, Sheltzer set up his own lab, rather than conducting research for several years as a postdoctoral researcher. “I was really fortunate to be given that opportunity,” he said.

As for his work with MELK, Sheltzer hopes he’s saved other labs from pursuing clinical dead ends.

By Heidi Sutton

With quirky worlds and peculiar creatures, some familiar and some not, Dr. Seuss’ enchanting stories have entertained children and adults for generations. Now the Smithtown Center for the Performing Arts brings some of those most memorable tales to the theater’s stage with a Kids Performing for Kids production of “Seussical Jr.” The show opened on St. Patrick’s Day and runs through the end of April.

Kieran Brown as Jojo and Luke Ferrari as the Cat in the Hat in a scene from ‘Seussical Jr.’

With book, music and lyrics by Lynn Ahrens and Michael Flaherty, the show combines “Horton Hears a Who,” “Horton Hatches the Egg” and “Miss Gertrude McFuzz” with all their wonderful characters into a two-hour fantasmical musical adventure; in essence, creating the perfect respite on a chilly March afternoon.

Andrew Murano (“Shakespeare in Love”) directs an incredibly talented young cast of 23 actors, ranging from the age of 8 to 18, in bringing the magical world of Dr. Seuss to life in perfect rhyme, and oh, how magical it is!

From the moment the Cat in the Hat (Luke Ferrari) pops out of a trap door on the stage and belts out “Oh the Thinks You Can Think (When You Think About Seuss),” the show takes off and never loses momentum. Ferrari’s feline character serves as narrator and transports the audience from the Jungle of Nool with Horton the elephant and Gertrude the girl-bird, to the microscopic city of Who-ville with Jojo to, in the second act, the Circus McGurkus, with singing, dancing and uplifting messages.

While the entire cast does a great job, the main characters are simply outstanding. Michael Loccisano shines as Horton and his recurring solo, “Horton Hears a Who,” where a person’s a person no matter how small, is heartfelt. Kieran Brown is a natural as Jojo and his incredible talent is unveiled in “It’s Possible.” Other standouts include Brooke Miranda (Gertrude,) Lorelai Mucciolo (Sour Kangaroo) and Leah Kelly as Mayzie. Their futures as actors look promising indeed.

A nice touch is how the cast utilizes the aisles and even the balcony to convey the story. Designed by Ronald Green III, the costumes are lively and colorful and the set, constructed by Tim Golebiewski, look as if they’ve jumped right off the pages of one of Seuss’ books. The “Green Eggs and Ham” finale is just the cherry on top.

The Smithtown Center for the Performing Arts, 2 East Main St., Smithtown will present “Seussical Jr.” through April 29 with special Spring Break Days from April 2 to 6 at 1 p.m. Booster seats are available and there is a 15-minute intermission. Meet the Cat in the Hat, Horton, Gertrude and Jojo in the lobby for photos after the show. Children’s theater continues with “Willy Wonka Jr.” from May 19 to June 17 and “Mary Poppins Jr.” from Sept. 15 to Oct. 28. All seats are $15. To order, call 631-724-3700 or visit www.smithtownpac.org.

All photos by Danielle Nigro

Stock photo

By Bob Lipinski

Bob Lipinski

Adding grated cheese to a dish of pasta is something we do automatically, sometimes without regard to the type of cheese we’re using or which is suggested in the recipe. Not all grated cheeses are alike. These hard-grating cheeses belong to a group known as grana (in Italian), which means they have a flaky, grainy or granular texture; sharp, well-aged and hard to very hard. These cheeses are suitable for grating when they begin to get old.

Grana cheeses can be made from cow, sheep or even goat’s milk. Although most are made in Italy, some are produced in Greece, Switzerland, Argentina and the United States.

Parmigiano-Reggiano is one of the most popular grana cheeses, but keep in mind, “all Parmigiano-Reggiano cheeses are grana, but not all grana cheeses are Parmigiano-Reggiano.” Italian hard cheeses were once referred to as “cacio duro.” The word “Grana” is legally protected by Grana Padano Protected Designation of Origin, such that only Grana Padano can use the term to sell its produce in EU countries.

Some examples of grana cheeses are Asiago, Bagozzo, Crotonese, Grana Padano, Granone Lodigiano, Parmigiano-Reggiano, pecorino, Piave, Vacchino Romano (Italy), Kefalotyri (Greece), Sapsago and Sbrinz (Switzerland), Reggianito (Argentina) and dry Jack (U.S.).

Grana cheeses will keep for several months if wrapped in damp cheesecloth and then enclosed in aluminum foil and refrigerated. You can purchase grana cheese either previously grated or in chunk form.

If purchasing already grated, plan on using it within 60 days since it will begin to dry out. When using chunks, grate only the cheese you need at one time and refrigerate the unused portion. Hard cheeses may be frozen for up to eight weeks but should then be used for grating, shredding or cooking.

In addition to sprinkling on pasta or popcorn, many grana cheeses are great enjoyed by the chunk with a piece of crusty bread and glass of wine (red or white) or even whiskey. Let the cheese come to room temperature for optimum enjoyment.

My wine recommendations are:

•2016 Standing Stone Riesling (Finger Lakes, NY)

•2016 Gundlach-Bundschu “dry” Gewürztraminer (Sonoma, CA)

•2016 Four Graces “Pinot Gris” (Willamette, OR)

•2016 Shooting Star “Chardonnay” (Lake County, CA)

•2013 Podere Ruggeri Corsini “Barbera Armujan” (Piedmont, Italy)

•2011 La Spinona “Barolo Sorì Gepin” (Piedmont, Italy)

•2015 Poggio al Sole “Chianti Classico” (Tuscany, Italy)

My whiskey recommendations are:

•Wild Turkey Rare Breed Straight Kentucky Bourbon Whiskey Barrel Proof

•Jim Beam Black Label Straight Kentucky Bourbon Whiskey

Bob Lipinski, a local author, has written 10 books, including “101: Everything You Need to Know About Gin, Vodka, Rum & Tequila” and “Italian Wine & Cheese Made Simple” (available on Amazon.com). He conducts training seminars on wine, spirits and food and is available for speaking engagements. He can be reached at www.boblipinski.com OR [email protected].

Mose Allison
Evening will honor the music of longtime Smithtown resident

By Kevin Redding

Mose Allison. Photo by Michael Wilson

A reporter once asked the late jazz and blues pianist and singer Mose Allison — regarded among musicians like Bonnie Raitt, Leon Russell, Pete Townshend and Van Morrison as “one of the finest songwriters in 20th century blues” — why he wasn’t more famous.

“Mose, you were a social critic before Bob Dylan, satirical long before Randy Newman and rude before Mick Jagger,” the reporter said. “How come you’re not a big star?” Allison, who was born in Mississippi and moved from New York City to Smithtown in the mid-1960s to raise a family and spent much of his time walking in the local woods and swimming in the Long Island Sound, responded: “Just lucky, I guess.”

On Saturday, March 24, The Long Island Museum, in partnership with WUSB-FM’s Sunday Street Concert Series and the Greater Port Jefferson-Northern Brookhaven Arts Council, will give the 2006 Long Island Music Hall of Fame inductee his proper due with The Word From Mose: A Celebration of the Music of Mose Allison, a tribute concert in the Carriage Museum’s Gillespie Room at 7 p.m.

Jack Licitra

The concert, following the tradition of other Sunday Street Series shows organized by Charlie Backfish, Stony Brook University history lecturer and host of the university’s weekly radio program “Sunday Street,” will feature local and outside musicians, who will strum and sing through decades of Allison’s breakthrough material, including his more well-known tracks “Your Mind Is on Vacation,” “Everybody’s Crying Mercy” and “I Don’t Worry About a Thing.”

Allison, who died Nov. 15, 2016, just four days before turning 89, was a four-time Grammy nominee and frequent collaborator with jazz greats Zoot Sims and Stan Getz whose songs spanned more than 30 albums — The Rolling Stones, Diana Krall, The Who, The Pixies and Elvis Costello are among those who have recorded Allison’s songs.

Pete Kennedy

The lineup includes “Sunday Street” regular and New York-based singer-songwriter Pete Kennedy; Pat Wictor, electric and slide guitarist of the group Brother Sun; Jack Licitra, a Sayville-based keyboardist and guitarist as well as the founder of the music-teaching studio South Bay Arts in Bayport; and Abbie Gardner, an acclaimed Dobro player who has toured for many years as part of the trio Red Molly. Some members of Allison’s family, including his daughter and singer-songwriter Amy Allison, will also be in attendance.

The evening will also include a screening of a short BBC documentary on Allison called “Ever Since the World Ended,” featuring interviews with Costello, Morrison, Raitt and Loudon Wainwright III and footage of Allison performing.

“Not only is he such an important artist, Mose Allison was someone who lived in this area for many decades and we thought it was time to do something like this for him,” Backfish said of the decision to honor the musician. “When he wasn’t on tour, which was quite often, he would be back in the area and playing shows at the Staller Center at Stony Brook University or jazz clubs in Port Jefferson.”

Pat Wictor. Photo by John Mazlish

Backfish said he also had the opportunity to interview Allison on his radio program many years ago. “He had such an incredibly rich catalog in so many ways and these artists are going to get together and play both well-known songs of his and the deep tracks,” he said. “I would hope that if people aren’t aware of Mose, they’ll suddenly find someone they will check out and listen to, and for those who know him, this will be a great way to celebrate his music and listen to artists reinterpret his songs.”

Wictor, a longtime Allison fan who, with his band, recorded a version of “Everybody’s Crying Mercy,” said Backfish approached him to participate in the concert for his “affinity” for the man’s work. “I love Mose partly because he cannot be categorized easily,” Wictor said. “He sort of mixed jazz and blues, and social commentary, in a way that nobody else did. And I like his sense of humor in his lyrics, which were always a little sardonic and mischievous. He comes across as a person that doesn’t suffer fools gladly and that’s always enjoyable to me. The songs themselves are very musically interesting, too — blues-based but they always have a unique musical and lyrical quality unlike anything else.”

Abbie Gardner

Kennedy said Allison was unusual among jazz musicians in his time because he wrote a lot of songs with lyrics, while others primarily stuck to instrumental compositions. “Allison actually wrote songs that he sang and that’s what we’re focusing on during the concert,” said Kennedy, who noted that he’s had a lot of fun examining Allison’s songs more closely and learning them in anticipation of the show. “His songs sound totally modern to me now, even the old ones from the 1950s and ’60s. The writing is really clever, really humorous and had a little bit of social commentary to it, but not in a negative way.”

Licitra, too, expressed his excitement over his involvement, calling Allison’s music “the thinking man’s blues.” “I’m really looking forward to giving people a taste of his style of intellectualism and humor,” he said. “And for me, this is all about the group of performers on the bill. I’m a big fan of all of them and so I’m excited about playing with them and seeing how they each interpret Mose’s [work].”

The jazz legend’s son John Allison, who grew up in Smithtown, said while his father was a true “musician’s musician” and beloved in many artist’s circles, he was as low profile as could be at home. “There he was, living in Smithtown, so unassuming that even our neighbors, for 15 years, didn’t know what he did until they saw him on TV with Bonnie Raitt for a PBS concert at Wolf Trap,” John Allison said, laughing. “He just wanted to do his thing. He read books and played music. I’d come home from high school and he’d be listening to some weird Chinese, classical music and just laughing and loving it … [and] sometimes he did tai chi in the living room.”

The Long Island Museum is located at 1200 Route 25A, Stony Brook. Advance tickets to the tribute show are $25 through Friday, March 23 at www.sundaystreet.org with tickets at the door for $30 (cash only). Beer, wine and cider will be available for purchase. For more information, please call 631-751-0066.

Snowy. Photo courtesy of Kent Animal Shelter

MEET SNOWY!

This week’s shelter pet is Snowy, a 7-year-old, white domestic long-haired cat waiting for a new home at Kent Animal Shelter. His owners were allergic and couldn’t keep him anymore. Snowy is active, playful, affectionate and friendly to everyone he meets. Won’t you open your heart to this handsome guy? He comes neutered, microchipped and up to date on all his vaccines.

Kent Animal Shelter is located at 2259 River Road in Calverton. The adoption center is open from 10 a.m. to 4 p.m. every day. For more information on Snowy and other adoptable pets at Kent, visit www.kentanimalshelter.com or call 631-727-5731.

Update: Snowy has been adopted!

Roasted Asparagus with Balsamic Glaze

By Barbara Beltrami

Spring is here, or is it? As I sit here writing this a week before publication and approximately two weeks before the holidays, the third snowstorm in two weeks is swirling outside my window. The calendar says spring started on March 20, but right now it’s hard to take that seriously. Anyway, think positively with me and read on.

This year, as so often happens, Easter and Passover fall at the same time. No matter which holiday we observe, it is a signal to officially welcome spring. Out with the old dried up winter floral arrangements, in with pussy willows and daffodils. Out with hearty stews and soups and root veggies; in with asparagus, tender young greens and tiny new potatoes.

And while each holiday has its own religious and traditional observations, many dishes prepared for the feasts have a lot in common. For Passover, eggs are used in abundance to replace the forbidden leavening; for Easter, eggs from the eponymous bunny find their way into many creative dishes. Clear broths served with matzo balls, thin noodles or tortellini usher in the holiday meal, and light fluffy cakes made with flour or matzo meal and egg whites offer a grand finale.

So set your table with daffodils, roast a leg of lamb or a ham and those tiny new potatoes, prepare a bunch of asparagus and perhaps a baby arugula and mache salad and whip up a feather-light spring-y (pun intended) cake. (Next week I’ll give you a recipe or two for those cakes.)

Roasted Asparagus with Balsamic Glaze

Roasted Asparagus with Balsamic Glaze

YIELD: Makes 6 servings

INGREDIENTS:

2 pounds asparagus, trimmed and washed

½ cup balsamic vinegar

¼ cup extra virgin olive oil

2 tablespoons soy sauce

2 tablespoons brown sugar

Coarse salt and freshly ground black pepper, to taste

DIRECTIONS: Preheat oven to 375 F. Grease a 9- by 13-inch baking pan and lay asparagus in it. In a small bowl, mix together the balsamic vinegar, olive oil, soy sauce and brown sugar. Being sure to coat all the spears, gently toss the asparagus with the balsamic mixture. Bake, gently tossing again once or twice, for 10 to 20 minutes, until asparagus are tender. Remove to platter, sprinkle with salt and pepper and serve hot, warm or at room temperature with roasted meat or fowl and potatoes.

Roasted Baby Potatoes and Carrots with Shallots

YIELD: Makes 6 to 8 servings

INGREDIENTS:

2 pounds baby potatoes, scrubbed but not peeled

1 pound baby carrots, washed and trimmed, if necessary

2 shallot bulbs, peeled and separated into cloves

3 tablespoons extra virgin olive oil

One handful fresh flat-leaf parsley, de-stemmed and finely chopped

Coarse salt and ground pepper, to taste

DIRECTIONS: Preheat oven to 400 F. In a large bowl toss all the ingredients together, then place in a large shallow baking dish and put in oven. Turning occasionally with a spatula, roast 30 to 45 minutes until carrots are tender and potatoes are crisp on the outside. Serve immediately with roasted meat or fowl.

Baby Arugula, Mache and Green Grape Salad with Citrus Vinaigrette

YIELD: Makes 4 to 6 servings

INGREDIENTS:

3 cups baby arugula, washed and patted dry

3 cups mache, washed and patted dry

1½ cups green seedless grapes, washed and patted dry, then halved lengthwise

½ cup extra virgin olive oil

2 to 3 tablespoons champagne vinegar or white wine vinegar

1½ tablespoons freshly squeezed lemon juice

1 tablespoon orange juice

1 teaspoon honey

½ teaspoon prepared mustard

1 garlic clove, bruised

Salt and freshly ground black pepper, to taste

DIRECTIONS: In a large salad bowl, toss arugula, mache and grapes together. If using within an hour, do not refrigerate; otherwise cover and refrigerate until one hour before use. In a small bowl, whisk together the oil, vinegar, lemon juice, orange juice, honey, mustard, garlic, salt and pepper. Remove garlic clove before dressing salad. When ready to serve and not before, toss the mixture with the greens and grapes and serve immediately with roasted meat or fowl or as an appetizer.

 

 

Children can discover the wonder of plants the Brookhaven Ecology Center next month. Photo from Town of Brookhaven

Spring Pee Wee Gardening

The Town of Brookhaven Highway Department offers Spring Pee Wee Gardening classes for ages 3 to 5 at the Wildlife Education & Ecology Center, 249 Buckley Road, Holtsville on Thursdays, April 12, 19 and 26, May 3, 10 and 17 or Fridays, April 13, 20 and 27, May 4, 11 and 18 at either 10 to 11 a.m. or 1 to 2 p.m. The children will learn about the environment, animals and plants through crafts and stories. $50 for six-week session. For more information, please call 631-758-9664, ext. 10.

Adult Horticulture Classes

The Town of Brookhaven’s Department of Highways will present Adult Horticulture Classes at the Holtsville Ecology Site, 249 Buckley Road, Holtsville on Wednesdays, April 11, 18 and 25 and May 2, 9 and 16. Participants will learn about starting plants through propagation, growing vegetables from seeds, spring gardening techniques and unique gardening crafts. Fee is $50 for six-week session. Deadline to register is March 29. For more info, call 631-758-9664, ext. 10.

Einstein the screech owl. Photo by Kevin Redding

TIME TO CLEAN OUT THOSE CLOSETS

Let’s help Einstein and his friends at Sweetbriar! The nature center, located at 62 Eckernkamp Drive, Smithtown seeks donations for its annual spring yard sale and fundraiser on April 28 and 29 including antiques, collectibles, memorabilia and other “cool” stuff. Please NO clothes, books, baby supplies, electronics or anything that weighs over 40 pounds unless it fits the above guidelines. Proceeds will go toward the center’s mission of providing nature education and wildlife rehabilitation. To make a donation, please call Eric at 631-979-6344 or Joe at 631-901-5911.

A plant-based diet involving lots of vegetables, fruits and some grains may have a similar effect as steroids in reducing inflammation. Stock photo
Steroids reduce inflammation, but it comes at a cost

By David Dunaief, M.D.

Dr. David Dunaief

Steroid use as a performance-enhancing drug was a significant factor in the recent Olympics, with the Russian team banned for their illegal use. However, if we look beyond the flashy headlines to rudimentary use, we see that corticosteroids, or steroids, play an important role in medicine.

This is a commonly prescribed class of medications. In fact, our bodies make corticosteroids, the indigenous form of steroids, in the cortex of the adrenals, glands that sit on top of the kidneys. Here, we are going to concentrate on the exogenous form, meaning from the outside as medication.

Use or benefit

Steroids have an anti-inflammatory effect. This is critical since many acute and chronic diseases are based at least partially on inflammation. Chronic diseases that benefit include allergic, inflammatory and immunological diseases (1). These types of diseases touch on almost every area of the body from osteoarthritis and autoimmune diseases — rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, lupus, psoriasis and eczema — to asthma, COPD (emphysema and chronic bronchitis) and eye disorders. This type of medication is pervasive.

Delivery

Steroids are delivered orally, topically as creams, lotions and eye drops, or via injections, intravenous solutions and inhaled formulations. The most commonly known medication is prednisone, but there is a plethora of others, including prednisolone, methylprednisolone, cortisone, hydrocortisone and dexamethasone. Their benefits can be tremendous, improving functionality and reducing pain or improving breathing. You could say they are lifesaving in some instances, and with rescue inhalers they may just be that.

The bad

However, there is a very big caveat: they come at a price. Steroids have lots of adverse events associated with them. This is where the bad part comes in and keeps on coming. Steroids cause weight gain, increased glucose (sugars), high blood pressure, cardiovascular events, osteoporosis, change in mood (psychoses), cataracts, glaucoma, infection, peptic ulcers, Cushing’s syndrome and the list goes on. Ironically, steroids help with breathing; however, as I’ve seen in my clinical experience, they can cause shortness of breath when weaned from a longer-use high dose too quickly.

The upshot

The good news is that a plant-based diet may have similar beneficial effects in chronic diseases as steroids without all the downsides. Let’s look at the evidence.

The role in pneumonia

Pneumonia is among the top-10 leading causes of death in the world (2). It can be a most painful and debilitating disease. I know, for I experienced it personally while I was in my medical training. Every time I coughed, it felt like there was a fire in my chest.

In a meta-analysis (a group of nine studies), there was no overall effect of corticosteroids in reducing the risk of mortality in community-acquired pneumonia (3). However, don’t fret; when the data was broken into subsets, the findings were different. In subset data of those who had severe pneumonia, there was a statistically significant 74 percent reduction in mortality. And when duration was the main focus in subgroup analysis, those who received prolonged use of steroids reduced their risk of mortality by half.

Unfortunately, with the benefit comes an increased risk of adverse events, and this meta-analysis was no exception. There was a greater than two-times increased risk of abnormally high glucose levels with prolonged use. Thus, when giving steroids, especially for a prolonged use, it may be wise to check glucose levels.

In a more recent randomized controlled trial (RCT), the gold standard of studies, the results reinforced the beneficial effects of steroids on pneumonia. They showed that in those with both severe pneumonia and high inflammation, there was a two-thirds reduction in treatment failures when corticosteroids were added to the regimen (4). There were 120 patients involved in the study. They received antibiotics plus either methylprednisolone or placebo for five days.

Osteoarthritis: surprising results

As we know, osteoarthritis specifically of the knee is very common, especially as the population continues to age. Intra-articular (in the joint) injections directly into the knee are becoming routine treatment. A recent study compared injectable hyaluronic acid to injectable corticosteroid (5). The results showed that over three months, the corticosteroid was superior to hyaluronic acid in terms of reducing pain, 66 percent versus 43.8 percent, respectively. Interestingly, over the longer term, 12 months, hyaluronic acid reduced the pain and maintained its effect significantly longer than the steroid, 33 percent versus a meager 8.2 percent, respectively.

Study groups received five injections of either steroid or of hyaluronic acid directly to the knee over a five-week period. Thus, steroids may not always be the most effective choice when it comes to pain reduction. Hyaluronic acid may have caused this beneficial effect by reducing inflammation, protecting cartilage and preventing cell death, according to the authors.

COPD: length may not matter

It is not unusual to treat COPD patients with oral steroids. But what is the proper duration? The treatment paradigm has been two weeks with 40 mg of corticosteroids daily. However, results in an RCT showed that five days with 40 mg of corticosteroid was noninferior (equivalent) to 14 days of the same dosage and frequency (6). About one-third of patients in each group experienced a COPD exacerbation within the six-month duration of the trial. The hope is that the shorter use of steroids will mean fewer side effects. There were over 600 patients in this trial. We have come a long way; prior to 1999, eight weeks of steroids was a more commonplace approach to treating acute COPD exacerbations.

Topical steroid risk

Even topical creams and lotions are not immune to risk. For example, potent topical creams and lotions placed around the orbit of the eye with prolonged use may negatively affect vision (7). However, the evidence is based mostly on case reporting, which is a low level of evidence.

Dietary effect

One of the great things about steroids is that they reduce inflammation, and we know that the basis of greater than 80 percent of chronic disease is inflammation. A plant-based diet involving lots of vegetables, fruits and some grains may have a similar effect as steroids. The effect of diet on chronic disease may be to modify the immune system and reduce inflammation (8).

The bioactive substances from plants thought to be involved in this process are predominantly the carotenoids and the flavonoids. Thus, those patients who respond even minimally to steroids are likely to respond to a plant-based diet in much the same beneficial way without the downsides of a significant number of side effects. Diet, unlike steroids, can be used for a long duration and a high intake, with a direct relationship to improving disease outcomes.

In conclusion, it is always better to treat with the lowest effective dose for the shortest effective period when it comes to steroids. The complications of these drugs are enumerable and must always be weighed against the benefits. Sometimes, other drugs may have more beneficial effects over the long term, such as hyaluronic acid injections for knee osteoarthritis. A plant-based diet, with anti-inflammatory properties similar to steroids, may be a useful alternative for chronic disease or may be used alongside these drugs, possibly reducing their dosage and duration.

References: (1) uptodate.com.(2) N Engl J Med. 1995;333(24):1618-24. (3) PLoS One. 2012;7(10):e47926. (4) JAMA. 2015;313(7):677-686. (5) Open Access Rheum 2015;7:9-18. (6) JAMA. 2013;309(21):2223-31. (7) Australas J Dermatol. Mar 5, 2015. (8) Int J Vitam Nutr Res. 2008 Dec;78(6):293-8.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.

Medicare and Medicaid are both invaluable programs that can be used to cover various medical and custodial expenses.

By Nancy Burner, ESQ.

Nancy Burner, Esq.

This is a question we receive often. Navigating the maze of healthcare coverage can be confusing.nFor starters, a brief overview of the programs will help to demystify and clear some of the confusion. Medicare is a federal government program first implemented in 1965 as part of the Social Security program to provide health coverage to persons 65 or older and in some cases younger so long as they can show a qualifying disability.

Coverage through Medicare is broken down into sections, Part A is considered hospital insurance and covers inpatient hospital care, rehabilitation in a skilled nursing facility, hospice services, lab tests surgery and home health care. There is no premium for Part A provided you or your spouse have worked at least forty quarters and paid into the program.

It is important to note that the coverage for skilled nursing is limited to the first twenty days in full and then there will be a co-pay of $167.50 per day for days twenty-one through one hundred. A person must continue to qualify based on their skilled need throughout the hundred-day period for Medicare to continue cover. There is no guarantee that a person will receive all hundred days of coverage. Custodial care and extended stays will not be covered by Medicare.

Part B covers doctors and other health care providers’ services and outpatient care. The monthly premium for Part B is typically $134.00 but can vary depending on the person’s income. Part D provides cover with respect to prescription drugs. This is a stand-alone drug plan that can assist in reducing prescription drug costs. Finally, Medicare Part C, is also known as the Medicare Advantage which are optional plans offered by Medicare-approved private companies which replace Medicare Part A and B.

Unlike Medicare, Medicaid is a means tested program and is state specific. Medicaid can provide coverage for a personal care aide at home through the Community Medicaid program or can also cover an extended custodial stay at a skilled nursing facility through the Chronic Medicaid program. In order to be financially eligible to receive services at home, an applicant for Community Medicaid cannot have liquid non-retirement assets in excess of $15,150.00.

Also exempt is an irrevocable pre-paid burial, retirement assets in an unlimited amount so long as the applicant is receiving monthly distributions and the primary residence. With respect to income, an applicant for Medicaid is permitted to keep $837.00 per month in income plus a $20.00 disregard. However, where the applicant has income which exceeds $862.00 threshold, a Pooled Income Trust can be established to preserve the applicant’s excess income.

Even though there is a resource limit of $15,150.00, there is no “look back” for Community Medicaid. In other words, both the income and asset requirements can be met with a minimal waiting period allowing families to mitigate the cost of caring for their loved ones at home.

With respect to coverage in a nursing facility, Chronic Medicaid can cover an extended custodial stay at a nursing facility. In New York, an applicant applying for Chronic Medicaid will be required to provide a sixty-month lookback with respect to all financial records, including bank statements and tax returns. Unlike Community Medicaid, an applicant for Chronic Medicaid will be penalized for any monies transferred out of the applicant’s name during the sixty-month lookback except for transfers to exempt individuals, including to but not limited to spouse or disabled child. If your loved one requires long term nursing home placement, it is imperative to consult and Elder Law attorney in your area to discuss how to preserve the maximum amount of assets.

Medicare and Medicaid are both invaluable programs that can be used to cover various medical and custodial expenses. Understanding the difference and what each program covers will allow you to be an advocate for yourself or a loved one.

Nancy Burner, Esq. practices elder law and estate planning from her East Setauket office.