HARBINGERS OF SPRING Ann Moran of Sound Beach recently discovered these snowdrops popping up in her front yard. She writes, ‘Some of my plants in the yard are telling me that spring is not far away. I’ll believe it when I see it!‘
Fun fact: Snowdrops were named after earrings not drops of snow. In the 15th, 16th and 17th centuries women often wore dangly, white drop-shaped earrings known as ‘eardrops.’ Some other common names of snowdrops are Candlemas bells, white ladies, Little Sister of the Snows, snow piercers, dingle-dangle and flower of hope.
Grama grass (Bouteloua gracilis ‘Blonde ambition’) is a welcome presence through winter. Photo by Kyrnan Harvey
By Kyrnan Harvey
At the High Line, the exemplary greenway planted over the abandoned elevated railroad on the west side of Manhattan, the professional horticulturists wait until March for the “cutback” of herbaceous perennials. The dry foliage and stalks gone to seed offer shelter, food and perching possibilities to birds. Leaving them uncut through winter also protects the dormant crowns of plants from winter cold and wind.
But there is a third reason practitioners of the New Perennialist movement delay until March — along with the ecological and the horticultural, there is also the aesthetic. The art of close observation has rewarded us with appreciation of the browns of winter: the lines, the textures and the patterns, especially with the white counterpoint of snow underneath and fresh snow draping the skeletal remains.
The 19th-century Irishman William Robinson was the progenitor of the movement that steered away from formal, geometrical, Victorian bedding-out schemes and garish patterns of hothouse flowers. Through his illustrated books, “The Wild Garden” and “The English Flower Garden” (readily available in reprints); his journal, The Garden; his famous garden Gravetye Manor in Sussex; and through his friendship and collaboration with his contemporary Gertrude Jekyll, he introduced many gardening traditions that today are synonymous with “the English garden” — herbaceous borders, mixed borders (small trees, shrubs, vines, perennials, biennials and annuals grown together in informal drifts), ground covers and rock gardens.
Robinson rejected the artificial, statuary, topiary, fountains and carpet bedding and extolled the naturalistic, the wild and the untidy. His inspiration was not Italian grandeur but rather the simple cottage garden: hardy plants from around the world naturalized to blend into their surroundings. “The best kind of garden grows out of the situation, as the primrose grows out of a cool bank,” he writes in “The English Garden.”
It is an aesthetic that discovers and appreciates the subtle beauties of the natural world in all its diversity near and far. Karl Foerster (1874-1970) was a German nurseryman and writer who discovered a great many perennials, not least grasses, and elevated their status within gardening cognoscenti.
Many of these are North American natives — asters, coneflowers, goldenrods, and most importantly, grasses — but it was European plantsmen, nurserymens and philosopher-gardeners (Ernst Pagels, Mien Ruys, Rob Leopold, Henk Gerritsen, James van Sweden, Wolfgang Oehme) who in the mid-to-late 20th century introduced and popularized many dozens of plants — and the naturalistic aesthetic — that today we take for granted and that is now known as the New Perennialist movement.
And it is a Dutchman, Piet Oudolf, who today is the most acclaimed and influential plantsman and garden designer. The planting at the High Line is the embodiment of his celebrated aesthetic, and is merely one of his many public gardens revealed in a documentary that premiered last November titled “Five Seasons: The Gardens of Piet Oudolf.” He has written numerous books but my favorite is “Oudolf Hummelo,” co-written with Noel Kingsbury. (Hummelo is his family garden in Holland started in 1982.) It is in his beautiful books (or his Instagram) that you will quickly appreciate the merits of delaying until March the cutback of perennials.
As winter drags on, I only just started to cut back the grasses to expose the pushing daffodils. I know of a gardener who uses a mower at its maximum cutting height, but I have Narcissus, Camassia, Allium and Eremurus visible already, so I use my gas-powered hedge trimmer, which makes really quick work of cutting down even the most beastly Miscanthus, and I can be careful not to step on the precocious perennials.
Nor am I in any rush to get to work on the late-winter pruning and cutback of summer-blooming shrubs like Buddleia, Caryopteris, Hydrangea paniculata and roses. I prefer to wait until late March, when any threat of arctic blast is past.
Kyrnan Harvey is a horticulturist and garden designer residing in East Setauket. For more information, visit www.boskygarden.com
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.
The following dialogue was inspired by an actual conversation. No friendships ended as a result of this interaction.
Joe: That’s interesting.
Aaron: What made it interesting?
Joe: It held my interest.
Aaron: That’s tautological.
Joe: What does tautological mean?
Aaron: It’s a kind of circular argument, like something is interesting because it held your interest. So, what’s interesting about what I said?
Joe: No, you see, it’s not what you said, so much as the way you said it and, of course, the fact that it was, indeed, you who said it. Like, remember that time you said that our boss was having an affair with the man she kept insulting at work and then, lo and behold, she was?
Aaron: Yes, I remember that was because she was having an affair with you.
Joe: Oh, right. Good times.
Aaron: Can you tell me how what I said interested you?
Joe: But, first, did you read the latest thing about Donald Trump?
Aaron: Which one?
Joe: The one where he’s mad at the media and the media is reporting about stuff he says isn’t true.
Aaron: You’re going to have to be more specific than that.
Joe: You want specifics? How about Russia?
Aaron: What about it? It’s a country.
Joe: You’re funny.
Aaron: Stop calling me funny and tell me what Trump and the media are disagreeing about.
Joe: Are you angry?
Aaron: I’m trying to have a conversation.
Joe: Conversation. That’s interesting.
Aaron: What’s interesting?
Joe: It’s like the way you’re looking at me right now. You know what I mean?
Aaron: Nope.
Joe: You have your eyes open and your eyebrows are up, like you’re expecting me to say something interesting, when, you know, you’re the one who always says interesting things. I read interesting things. This
morning, I read something compelling about Trump and the media.
Aaron: OK, let’s go with that. What was compelling about it?
Joe: It was just, you know, well, maybe you wouldn’t think it’s compelling and maybe you knew it already, which means I probably don’t have to tell you.
Aaron: I want to talk about something.
Joe: We are talking about something. We’re talking about me and you and this weather. You know what I’m saying?
Aaron: Not really.
Joe: The weather is all around us, right? And, it’s all around everyone else. Except that, when people are somewhere else, the weather around them isn’t the same as it is here. So, to experience weather, you really have to be here.
Aaron: Right, uh huh. Go on.
Joe: Now you’re looking at me differently. You’re frowning. You need to laugh more often. That’s your problem.
Aaron: I don’t have a problem. I’m trying to have a conversation.
Joe: About what?
Aaron: Well, a few minutes ago, you said what I said was interesting and I’ve been waiting patiently to find out what you thought was interesting about it.
Joe: Oh. Let me think. I’m going to replay the entire conversation in my head and then I’ll let you know.
Aaron: Right, sure.
Joe: No, really. Was it before or after the conversation about the weather?
Aaron: Before.
Joe: See, I was listening. I remembered that we talked about the weather.
Aaron: You weren’t listening to me. You were listening to you. You brought up the weather.
Joe: Right, OK, I have a confession to make. I wasn’t listening to what you said all that closely, but I know it was interesting.
Aaron: What part? Do you remember any of the conversation?
Joe: Not really. I have to go. It’s been nice chatting with you.
Aman at a March 14 PTA meeting in a high school in Rocky Point, New York, confronts a student in the aisle and holds a knife over his head. The pocket knife is closed and the man is trying to make a point about the need for security on behalf of the students in the school, including his two daughters. It is a heart-stopping moment, and the video was provided to TBR News Media by a senior student named Jo Herman.
We ran the video, along with the story of the meeting, on our website, Facebook page and YouTube. Such is the world we live in and the concern of parents around the nation that, to date, the Facebook video post has been seen by more than 11.3 million viewers. The total reach for all our Facebook posts last week was in excess of 17 million. That’s 17 MILLION plus, about the same as the entire population of the Netherlands. In addition, there have been many thousands of shares and comments on our Facebook page and our website. These numbers were supplied to us by Facebook Insights, the dashboard of Facebook and the most authentic source.
If ever we needed evidence of this world we are living in today, and the heartfelt concern of parents
throughout the United States, here it is. Could there be any parents who feel untouched by the concern for the safety of their children in the schools? Children have become the latest targets of an assassin’s gun.
These are not jihadists doing the killing. These are not ideologues carrying out the murders. These are our own citizens, in many cases children themselves, who are able to procure weapons and turn them on their teachers and classmates. Those 11 million viewers and all the rest of the parents, grandparents, siblings, relatives and friends of children who haven’t seen this video are no less terrified at the tragedies that have already been perpetrated and the violence that may yet come.
What is to be done? There are many reactions. Our children have realized their political clout and called for action with their walkouts and 17 moments of silence. Politicians in various states have proposed legislation, even passed legislation in one state, Florida, to try to gain control of this madness. The state is being sued for doing so, and the president offers words.
Consider this. A puppy dies on an airplane and within 48 hours, there is legislation passed to attempt to prevent such an unhappy event from happening again. How many more youngsters and adults must die before we can get our arms around this horror?
Social media can be great. It can be a miracle thread that connects us, informs us, unites us. It can also be a misery, as governments around the world are realizing. Facebook has been corrupted by its inability to prevent personal information from being stolen by nefarious thieves. But it has delivered a loud and clear message with the frenzy of response to a single incident in a small town on Long Island: The population is frightened, more frightened than by any attacks made against us by foreign nations or religious fanatics in the past. This threat is inside our defenses and until now seemingly unstoppable.
Yes, we need gun control. Yes, we need mental health services. Yes, we need greater vigilance. Yes, we need protection. We need all of that and more. Most of all, we need leadership, not contention, because this is a
moment that is shaking our republic in its heart.
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.
•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].
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.
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.
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.
Prev
