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Long-term proton pump inhibitor use may have serious side effects

By David Dunaief, M.D.

Dr. David Dunaief

Reflux (GERD) disease, sometimes referred to as heartburn, though this is more of a symptom, is one of the most commonly treated diseases. In line with this, proton pump inhibitors (PPIs) have become one of the top-10 drug classes prescribed or taken in the United States.

The class of drugs called PPIs includes Prevacid (lansoprazole), Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). Several of these medications are now available over-the-counter, rather than by prescription. When they were first approved, they were touted as having one of the cleanest side-effect profiles. This may still be true, if we use them correctly. They are intended to be used only for the short term. This can range from 7 to 14 days for over-the-counter PPIs to 4 to 8 weeks for prescription PPIs.

Dangers of long-term use

While PPI pre-approval trials were short-term, not longer than a year, many physicians put patients on these medications for decades. And the longer people are on them, the more complications arise. Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

Though PPIs may increase the risk of a number of complications, keep in mind that none of the data are from randomized controlled trials (RCTs), which are the gold standard of studies, but mostly observational studies that suggest an association, not a link.

Chronic kidney disease

In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (1). All of the patients started the study with normal kidney function based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a modest 17 percent increased risk. 

The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease. But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (2).

Dementia

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A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (3). These patients were at least age 75. The authors surmise that PPIs may cross the coveted blood-brain barrier and potentially increase beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent.

The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk. Researchers also did not take into account family history of dementia, high blood pressure or excessive alcohol use, all of which have effects on dementia occurrence.

Bone fractures

In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (4). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year.

They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption through the gut. PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (5).

Need for magnesium

PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (6). Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.

Another study confirmed these results. In this second study, which was a meta-analysis of nine studies, PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (7). The authors note that a significant reduction in magnesium could lead to cardiovascular events.

The bottom line is that it’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as H2 blockers (Zantac, Pepcid). Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (8).

If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration: 7 to 14 days, according to the FDA, without a doctor’s consult, and 4 to 8 weeks with one (9).

References:

(1) JAMA Intern Med. 2016;176(2). (2) JAMA Intern Med. 2016;176(2):172-174. (3) JAMA Neurol. online Feb 15, 2016. (4) Osteoporos Int. online Oct 13, 2015. (5) Am J Med. 118:778-781. (6) PLoS Med. 2014;11(9):e1001736. (7) Ren Fail. 2015;37(7):1237-1241. (8) Am J Gastroenterol 2015; 110:393–400. (9) fda.gov.

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

Photo by Julianne Mosher

This week, Suffolk County Executive Steve Bellone (D) officially signed a new law stating that drivers must give bicyclists a 3-foot distance on the road.

Photo by Julianne Mosher

We think it’s great, and know how important it is to share the road. No one wants to hurt someone who’s riding for leisure or exercise.

But what concerns us the most are the riders who might feel entitled, who don’t follow their own rules of the road. 

Yes, vehicle drivers — especially on Long Island — can be awfully aggressive and distracted at times. But to play devil’s advocate, it isn’t just the car drivers. We have seen some aggressive bike riders, too. 

There are times that sharing the road on a busy street like Route 25A or Nesconset Highway is near to impossible. The driver of the vehicle slows down traffic to abstain from the biker, who is weaving in and out of their bike lane. 

Not all bike riders are bad, and again we think it’s great they are staying fit and not thrusting carbon dioxide fumes into the air. But, just as there are bad apples to everything, we are begging those riders to not take this new law in vain.

While car drivers are now more responsible for keeping a safe distance from a bicyclist, we are asking the rider to do the same. 

Please don’t ride your bike in traffic, and please pay attention, yourself. Please don’t be a nuisance to the people trying to get to work during rush hour, and please, please, please stop at stop signs, too. 

If we all abide by the rules of the road, all of us will be safe and laws like this won’t even have to be considered down the road. 

Use common sense. Be kind. Stay safe. 

Siobhan

MEET SIOBHAN!

This week’s shelter pet is the regal Siobhan, a 1-year-old domestic shorthair up for adoption at the Smithtown Animal Shelter. This grey beauty was found as a stray and covered in ticks. She was crying out for attention, and still does if no one is giving her the love she craves. Siobhan would be a lovely addition to any family. She is spayed, microchipped and is up to date on her vaccines. 

If you are interested in meeting Siobhan, please call ahead to schedule an hour to properly interact with her in a domestic setting, which includes a Meet and Greet Room.

The Smithtown Animal & Adoption Shelter is located at 410 Middle Country Road, Smithtown. Shelter operating hours are currently Monday to Saturday 10 a.m. to 3 p.m. (Sundays and Wednesday evenings by appointment only). Call 631-360-7575 or visit www.smithtownanimalshelter.com.

Photo by Elisa Hendrey

SHADES OF BLUE

Elisa Hendrey of Sound Beach took this photo on April 17 at the new fishing pier at Cedar Beach in Mt. Sinai. She writes, ‘This is one of my favorite places to walk and take photographs. I was attracted by the intense color of the water and the beautiful sky as well as the long parallel lines of the pier and the rock jetty.

Send your Photo of the Week to [email protected]

 

Above, a humpback whale breaks the surface of the water. Photo from Eleanor Heywood/National Marine Fisheries Service permit no. 21889

By Daniel Dunaief

The waters off the South Shore of Long Island have become a magnet, attracting everything from shipping vessels, recreational boaters, fishermen and women, potential future wind farms, and humpback whales.

While the commercial component of that activity can contribute to the local economy, the whale traffic has drawn the attention of scientists and conservationists. Whales don’t abide by the nautical rules that guide ships through channels and direct traffic along the New York Bight, a region from the southern shore of New Jersey to the east end of Long Island.

Left, Julia Stepanuk with a drone controller. Photo by Kim Lato

Julia Stepanuk, a PhD student at Stony Brook University in the laboratory of Lesley Thorne, Assistant Professor in the School of Marine and Atmospheric Sciences, is focusing her research efforts on monitoring the humpback whale’s use of this habitat.

“This can help us understand how we focus our energy for monitoring and conservation,” she explained in an email. If the whales are traveling, it helps to know where to minimize human impact.

Ultimately, the work Stepanuk, who also earned her Master’s degree at Stony Brook in 2017, does provides ecological context for how whales use the waters around New York and how old the whales are that are feeding in this area.

In her dissertation, Stepanuk is “looking at the biological and ecological drivers, the motivators of where the whales are, when they’re there, specifically, from the lens of how human activity might be putting whales at risk of injury or mortality.”

Each summer, whales typically arrive in the area around May and stay through the end of October.

When she ventures out on the water, Stepanuk uses drones to gather information about a whale’s length and width, which indicates the approximate age and health of each individual. Since 2018, she has been gathering information to monitor activity in the area to track it over time.

With the research and data collected, she hopes to help understand the ecology of these whales, which will inform future policy decisions to manage risk.

Stepanuk’s humpback whale work is part of a 10-year monitoring study funded by the New York State Department of Environmental Conservation, which includes four principal investigators at the School of Marine and Atmospheric Sciences. The study looks at carbonate chemistry, physical oceanography, fish distribution, and top predator abundance, distribution and body condition, Thorne explained.

“My lab is leading the seabird and marine mammal aspect of this project,” said Thorne.

The grid over the whale demonstrates how members of Thorne’s lab measure the size of the whale from drone images. Photo by Julia Stepanuk

By documenting the ecological ranges of whales of different ages, Stepanuk may provide insight into the age groups that are most at risk. Many of the humpback whales that travel closer to shore are juveniles, measuring below about 38 feet.

Stepanuk has seen many of these whales, either directly or from the drones she flies overhead. She has also gathered information from events in which whales die after boats hit them.

Mortality events off the east coast have been increasing since 2016 as numerous whales have washed up along the coast. About half of the humpbacks in these mortality events have evidence of human interaction, either ship strike or entanglement, Stepanuk said.

“There have been many more strandings than usual of humpback whales along the east coast” in the last five years, Thorne explained.

Humpback whales likely have appeared in larger numbers in New York waterways due both to the return of menhaden in nearshore waters, which comes from changes in the management of this fish stock and from environmental management more broadly, and from an overall increase in the humpback whale population after 40 years of protection, Thorne suggested.

Ultimately, Stepanuk said she hopes to use the scientific inquiry she pursued during her PhD to help “bridge the gap between academic, policymakers, conservationists, interested parties and the public.” 

A part of Stony Brook’s STRIDE program, for science training and research to inform decisions, Stepanuk received training in science communication, how to present data in a visual and accessible way, and how to provide science-based information to policymakers.

For Thorne, this study and the analysis of the vessel strikes on humpback whales could be helpful for understanding similar dynamics with other cetaceans.

Julia Stepanuk and Matt Fuirst, a previous master’s student in Lesley Thorne’s lab, release a drone. Photo by Rachel Herman

“Understanding links between large whales and vessel traffic could provide important information for other studies, and could provide methods that would be useful for studies of other species,” said Thorne.

Stepanuk offers some basic advice for people on a boat in the New York Bight and elsewhere. She suggests driving more slowly if visibility is limited, as people would in a car in foggy weather. She also urges people to pay close attention to the water. Ripples near the surface could indicate a school of fish, which might attract whales.

“Slow down if you see dolphins, big fish schools and ripples,” she said. “There’s always a chance there could be a whale.”

If people see a whale, they shouldn’t turn off their engines: they should keep the engine in neutral and not approach the whale head on or cut them off. For most species, people can’t get closer than 300 feet. For North Atlantic right whales, which are critically endangered, the distance is 1,500 feet.

She suggests people “know the cues” and remember that whales are eagerly feeding.

Stepanuk has been close enough to these marine mammals to smell their pungent, oily fish breath and, when they exhale, to receive a residue of oil around her camera lens or sunglasses. She can “loosely get an idea of what they’re feeding on in terms of how bad their breath is.”

When she was younger, Stepanuk, who saw her first whale at the age of eight, worked on a whale watching boat for six years in the Gulf of Maine. An adult female would sometimes leave her calf near the whale watching boat while she went off to hunt for food. The calf stayed near the boat for about 45 minutes. When the mother returned, she’d slap the water and the calf would race to her side.

“Experiences like that stuck with me and keep me excited about the work we do,” Stepanuk said.

Video: Humpback whale lunge feeding off the south shore of Long Island

 

Photo from Christine Pendergast

By Fr. Francis Pizzarelli

Father Frank Pizzarelli

Spring is supposed to be a time for new beginnings. Our spring has been marred by senseless shootings across the country, further inflamed by hateful rhetoric on both sides of the aisle that does not address the real heart of our social mayhem.

The vaccine which is supposed to be used as an instrument of healing in some circles is being used as a weapon. We have elected leaders that don’t lead but rather fuel the discontent and polarization that has become so infectious across our country.

It is springtime. Let’s talk about new beginnings, renewal and another way to talk with each other that is life-giving. Words matter. They can heal and help or hurt and destroy.

We need to challenge those with hurtful and despicable rhetoric to express their strong feelings in words that are respectful — words that don’t incite but rather encourage a deeper and more productive conversation about the things that really matter and have a profound impact on our community.

At the beginning of April, a young 16-year-old female Native American and African-American sophomore in high school wrote an op-ed piece in Newsday entitled “Why I sat for the Pledge of Allegiance.” Social media ripped her apart and she was threatened and harassed.

After reading her opinion piece, I decided to have my college and graduate students take a look at her article and discuss it. I saw for the first time what our future leadership could do. 

These students had a real in-depth conversation on a very delicate topic. It was impressive to see them exercise their well-developed critical thinking skills. They were genuinely sociologically mindful. They looked at every aspect of that student’s opinion. Not all agreed with her choice to be seated but they all agreed with her right to self-expression without harassment. They all condemned the despicable ad hominem attacks and rhetoric directed at her.

Ultimately, every class focused on the injustices she raised which led to a lively conversation of where do we go from here? How do we address these inequalities and hold people more accountable? It was refreshing to listen to the next generation of leaders speak passionately about human rights, social justice and express the desire to be a part of the solution, not part of the problem.

On October 14, 2020, Dr. Christopher Pendergast, a dynamic teacher, motivational speaker and founder of the A.L.S. Ride for Life, died quietly at his home in Miller Place surrounded by his family. He was 71.

On April 28, Dr. Pendergast would have celebrated his 72nd birthday. Although he is no longer with us physically, his spirit lives on with Ride for Life’s mission and his endless acts of kindness and love that he did for so many while he walked among us.

Before he died he and his wife wrote a very powerful book entitled “Blink Spoken Here.” The last words of this exceptional story say “speech is freedom. Communication is the connection to the outside world. We all have a right to speak and to be heard … even if it’s only one blink at a time … Never be afraid to speak up. Your opinions matter.” Amen!

Father Francis Pizzarelli, SMM, LCSW-R, ACSW, DCSW, is the director of Hope House Ministries in Port Jefferson.

Photo by Pixabay

By Daniel Dunaief

Daniel Dunaief

I have two friends whose sons are contemplating important choices. The first son, Matt, is trying to decide where to attend college.

He has gained admission to two elite schools. He can’t go wrong, as his parents have told him repeatedly, with either choice. Making this decision in a normal year would be hard. In a pandemic year, it’s almost impossible.

Matt can’t stay over at each school for a weekend or even attend a few classes. He can’t get much of a feeling for the “vibe” of the school because he can’t go into most of the buildings, even with a mask and with his letter of admission.

He can compare the national rankings from U.S. News and World Report, check college guides, talk with his guidance counselor, chat with graduates from his high school who attend each school and stroll around each campus. 

He can’t, however, fully try on the school, the way he might a tailored suit. Masks cover the faces of most of the people at each school, which makes it impossible to search for smiles on the faces of his potential future classmates.

He recently found himself leaning toward school A. The same day, his father spoke with a friend of his whose daughter was attending school B.

His father showed a picture of his friend’s daughter to Matt. The friend’s attractive daughter caused Matt to rethink his tentative decision.

That brings me to my other friend’s son, Eric. In his mid-20s, Eric has been caught in the same social world that has limited the options for everyone else.

Eric has been dating a woman for over two years and is considering the future of the relationship. He is not sure whether it’s the appropriate time to consider living together or getting married.

Eric is incredibly attached to his girlfriend, who has been one of the few people he sees regularly in real life during the pandemic.

Eric is not sure how long this altered reality, in which he works from home, speaks with family and friends virtually most of the time, and sees his girlfriend during his limited social hours, will last. In the meantime, he’d like something in his life to move forward.

Matt and Eric are weighing their options. For Matt, the choice of college may well come down to the last picture of another student he sees before he pushes a button.

Choosing a college can, and likely should, involve more significant factors. Then again, both of the colleges line up so well that he is likely to have a similar experience, albeit with different people around him, at each school.

Eric’s decision, however, isn’t so interchangeable. It involves a leap of faith that those of us who are married have made that relies on our own criteria. We can consult family, friends, and counselors as we weigh the pros and cons, but, ultimately, the responsibility and opportunity rest with us.

Coming up with his own questions and his own scale to evaluate the relationship is challenging, particularly when everything seems somewhere between good and great right now. He can’t possibly know what life will look like in two, five, 10 or 20 years from now.

I don’t envy either Matt or Eric as they contemplate these decisions. I do, however, agree with Matt’s parents: he can’t go wrong. For Eric, the decision has more significant longer-term ramifications and likely reflects variables that are difficult to imagine, particularly amid the uncertainty of the present.

METRO photo
Leah Dunaief

By Leah S. Dunaief

Would you like to be different? Would you like to change your personality? Perhaps you would like to be more extroverted. Or more open to new experiences. Or even just more organized. Well, thanks to the pandemic, here is your chance. 

People can and do successfully change their personalities even as adults. Now we are about to emerge from the isolation of lockdown and quarantine and rejoin the larger world. The stage is set for a new you. But this transformation will take work. To start, one could embrace the “As If Principle,” proposed by Richard Wiseman, a psychology professor at the University of Hertfordshire in England. This would require one to behave as if one were already that different person, and after a time, the new behavior and the person would sync. Famously, that is the story the debonair Cary Grant told of his early life, which started on the Bristol docks as Archie Leach and wound up at the pinnacle in Hollywood. “I pretended to be somebody I wanted to be until finally I became that person. Or he became me,” Grant said, according to the British newspaper, The Guardian.

An article in the April 11 issue of The New York Times took up this subject. Headlined, “You Can Be a New You After the Pandemic,” written by Olga Khazan, the story states the following. “Researchers have found that adults can change the five traits that make up personality — extroversion, openness to experience, emotional stability, agreeableness and conscientiousness — within just a few months.” 

Another psychology professor, this one at Columbia University, asserts a similar theme. Geraldine Downey, who studies social rejection, has found that “socially excluded people who want to become part of a group are better off if they assume that other people will like them. They should behave as if they are the popular kid. Getting into social interactions expecting the worst, as many socially anxious people do, tends to be a self-fulfilling prophecy.” In another example of change, “people were able to become more extroverted or conscientious in four months just by listing the ways they’d like to change and what steps they would take to get there,” according to the NYT article. If one wants to be more outgoing, one can make a list of upcoming events in which to interact or persons to call for lunches, and after enough such efforts, the act becomes natural.

It can help in this transformation to see a therapist, research recommends. One such example described a person with neuroticism, “a trait responsible for anxiety and rumination.” After a short burst of therapy, in which the “warm, comforting presence” of a therapist encouraged the idea that the client is a valued person, neuroticism receded, and the studies showed the effect lasted for at least a year.

But not everyone can afford a therapist. Mirjam Stieger, a postdoctoral researcher at Brandeis University, and her colleagues developed an app that “reminded people to perform small tasks to help tweak their personalities, like “talk to a stranger when you go grocery shopping,” to prompt extroversion. The app then asks them if they had done that. According to the study, after three months, the change had stuck.

Agreeableness, by the way, involves “greater empathy and concern for others.” And so, being agreeable after this pandemic could mean being gentler toward one another. We now know, for example, how much essential workers sacrificed during the pandemic, many even their lives. That would suggest greater kindness and patience toward someone who, during the pre-pandemic, might just have been dismissed as annoying. We don’t know what exactly has been that person’s recent experience. At least that can be a conscious thought to modify behavior in what otherwise might have been a contentious situation.

For those who wish to change or live differently, as the NYT article says, “your personality is more like a sand dune than a stone.”

Lemon Chicken

By Barbara Beltrami

Mrs. Betty Haynes who lived next door to us when I was a kid, was a nice lady and a terrific cook. Short and rather rotund, she would shuffle about her kitchen in slippers into the rocking chair in the corner and fan herself. “Honey, I ain’t no spring chicken,” she’d exclaim after she’d  put a chicken into the oven or pot or frying pan. It seemed that all she ever cooked was chicken (In fact, much to our parents’ consternation, we kids used to secretly refer to her as Mrs. Chicken). Eventually, she moved to Florida, and when we visited her, she would regale us with her chicken as she always had, but it had taken on new twists…twists of lemon and orange and lime from the trees in her tiny backyard. Here are my takes on her citrus-y chicken dishes, perfect for spring taste buds. 

Lemon Chicken

YIELD: Makes 4 servings

INGREDIENTS:

1/4 cup extra virgin olive oil

4 garlic cloves chopped

1/3 cup dry white wine

Freshly grated zest of 1 large lemon

3 tablespoons freshly squeezed lemon juice

1 tablespoon chopped fresh marjoram leaves

1 teaspoon fresh thyme leaves

Coarse salt and freshly ground pepper to taste

4 boneless half-pound chicken breasts with skin, washed and patted dry

1 lemon cut into 8 wedges

1/4 cup chopped fresh flat leaf parsley

DIRECTIONS:

Preheat oven to 400 F. In a small saucepan heat two tablespoons oil over medium-low heat. Add garlic and cook briefly, about one minute; remove pan from heat before garlic turns brown. Next add wine, lemon zest and juice, marjoram, thyme and a little salt; pour mixture into ovenproof baking dish. Place chicken breasts, skin side up, in baking dish; drizzle with remaining olive oil and season with salt and pepper; tuck lemon wedges among chicken pieces. Bake 30 to 45 minutes until skin is light golden and chicken is done. Remove from oven, cover tightly with aluminum foil and let sit for 10 minutes. Slice and serve with fresh asparagus and new potatoes.

Lime Chicken

YIELD: Makes 6 to 8 servings

INGREDIENTS:

8 large chicken thighs with bone and skin, washed and patted dry

Salt and freshly ground black pepper to taste

1 teaspoon cayenne pepper

Pinch ground nutmeg

3 tablespoons extra virgin olive oil

1 cup dry white wine

2 cups chicken stock or broth

Freshly squeezed juice of two limes

4 garlic cloves, chopped

Chopped leaves from 1 bunch of cilantro

DIRECTIONS:

Preheat oven to 350 F. In a small bowl, thoroughly mix the salt, pepper, cayenne and nutmeg. Rub thighs on both sides with spice mixture (be sure to smear it under the skin as well). In a large cast iron skillet, warm oil over medium-high heat. Brown thighs, turning once, until golden, about 8 to 10 minutes per side; remove from skillet and set aside. Stirring with back of wooden spoon, deglaze pan with white wine, reduce liquid to half the volume, then add broth.Bring to a simmer and add lime juice and garlic. Return chicken to pan, bring to strong simmer, and add cilantro; simmer 5 minutes. Cover pan, transfer to oven and bake until cooked through, about 40 to 45 minutes; remove from oven and let sit 5 minutes or so. Serve hot with couscous or pilaf.

Orange Chicken

YIELD: Makes 4 to 6 servings

INGREDIENTS:

1 large orange

3 tablespoons extra virgin olive oil

1 teaspoon paprika

1 tablespoon chopped fresh rosemary leaves

Salt and freshly ground black pepper to taste

6 chicken thighs

DIRECTIONS:

Preheat oven to 350 F. Grate zest of orange; remove pith and cut orange into 6 wedges. In a small bowl combine the zest, one tablespoon of the oil, the paprika, rosemary and salt and pepper. Rub chicken (including under the skin) with mixture, transfer to shallow nonreactive baking dish and tuck orange wedges among chicken pieces. Roast until an instant-read thermometer inserted in thickest part of thigh registers 165 F, about 30 to 35 minutes. Remove from oven, let sit 5 minutes and serve with broccoli or coleslaw.