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LEUKEMIA, THE PARADIGM MIRACLE
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THE SEARCHLIGHT MESSENGER

LEUKEMIA, THE PARADIGM MIRACLE

 
 
Another year has gone by, and in two short weeks, we celebrate National Cancer Survivor’s Day. When this day arrives, I am always taken back and remember those who never had a chance to celebrate this day.
 
Having practiced medicine for more than three decades, as a physician I was firmly involved with the care of little children. As a Family Doctor, Internist, and Hospitalist, I saw my fair share of childhood diseases. One could truly say, I was allowed to save many lives with help from others on the medical teams I was proud to work with, and of course the cutting edge technologies afforded those of us who are privileged to practice medicine in the United States.

It is interesting, the things in life which will push a man toward a life of education, and prepare him for the profession of medicine. One of those things was an event in my childhood in the early 1960s.
 
When I was a boy, I had many friends in school and outside of school alike. Growing up on a ranch in Nebraska, it was not unusual to have many friends who lived in small towns come to visit. One of my friends outside of school lived in a nearby town, but came over often. David and I were both eight years old. I remember fondly of playing “army” with David in the yard, and board-games indoors when he would come over. I liked him. He was friendly and got along with my sister and little brother too. We became fast friends, and I would always get excited when David came over or we went to his family's house. We were both Cub Scouts but in different troops. You would always hear about how much David loved Scouting.
 
Soon though, the visits became fewer and fewer. David seemed to look frail and discolored to me as time went by. The color thing really bothered me. I know this sounds awful, but in addition to his color, he had an odd smell around him that seemed to worsen every time I saw him. What's worse, is it seemed that I was the only person that thought he smelled funny.

I asked  Mom, “What’s wrong with David?” Mom said, “He’s sick, honey. He has cancer of the blood. It’s called leukemia”. As you can imagine, this was a little difficult for an eight year old to take in, but as time went by, I learned more and more.

David’s parents were good friends of my parents, so we saw each other as families often. After he became ill, we saw less and less of them. Very rarely did I get to see my friend. David had an ever advancing condition of weight loss, bruising, sore joints, infections, was easily brought to tears, and after a while, his hair even looked funny. How does an eight year old process this inevitable plunge? As children; David, his sister, my brother, my sister and I, we were not emotionally mature enough to process this whole thing.
 
At home we would get the occasional phone call that he was back in the hospital. My parents were great. When we would get these calls, Mom and Dad would sit with us and try their best to explain this thing called leukemia. Understand, this was 1961, and leukemia was known as an unrelenting killer of children. There were no cures. Not even a good treatment. The medical community was desperate for a foothold.
 
One night we received a phone call from David’s father. David had passed away at the young age of eight.  I remember, it was really the first time I heard those words, “passed away”. It was also the first funeral of someone that caused me to take pause, and realize we are mortal. I know, I was just a child. I had seen two grandfathers buried, but I was very quiet and overcome by this intense event. All of these grownups I knew as strong, would breakdown and start to cry. I never the less watched in a surreal world of sadness, my parents’ good friends bury my buddy, David…. And that image which is still so clear…. My friend, asleep in his Cub Scout uniform.
 
All the while I was there, I remember thinking David might come running out from behind that marble stone, but he never did.

Why had this happened? I seemed to feel a pull even then, “The Calling”, so many of us drawn to “Medicine” and trained as healers, will occasionally and quietly talk about.
 
Time went by, but I often thought of David and how unfair it had been for him and his family. The early 1960s saw almost all children die who had leukemia. The five year survival rates of children then, were only one in ten. All any family could do, was wait and watch while their babies died in agony. He never had a chance, I often reflected. A sweet kid, taken from his family at such a young age. He never got the chance to do anything after he became sick. Never got to be an Eagle Scout, play baseball, be cool at school, or fall in love. How scared he must have been. I come to tears just writing about this.
 
Time marched on and while in high school, I would hear of small advances in the fight against cancer and leukemia. Then, in the early 1970s, when I was in college studying chemistry, we began hearing about new therapies.

Although the drug, Methotrexate, had been used with some promise through the 1950s and 1960s, the survival rates continued to be low, and drug resistance was always a glaring problem. It killed leukemia cancer cells by attacking their ability to process folic acid for DNA synthesis.

But the 1970s and 1980s brought Bone Marrow Transplantation and Craniospinal Irradiation. Huge game changers which produced not just remission, but cures.
 
I had grown up with kids who had polio, but now, it was gone. Diphtheria was gone. Small pox was all but vanquished (completely eradicated by 1982). Psychiatric hospitals were giving way to more advanced neuroleptic drugs, allowing former patients to re-enter society and become productive citizens. They had just invented the CAT Scanner. They had started to use lasers in ophthalmology.  And, I thought, even William DeBakey is transplanting hearts with Denton Cooley down in Texas of all places! Things were really happening in Medicine, and I wanted to be on the inside not the outside.
I had an epiphany. Already a man of science, I realized then, that I was going to be a doctor.
 
As time went by, more of these anti-metabolite drugs became available and we started to see a real dent in childhood mortality from leukemia. Soon after, in the late 1970s, when I was a biochemist and starting my medical career, a drug from a flower called, “The Rosy Periwinkle”, which only grows in the rain-forests of Madagascar(go figure), gave us a new drug called Vincristine. A drug that could only be brewed in mother nature’s kitchen. We were now seeing high cure rates and remissions. Lives were now being saved in this war.
 
My friend David had what we call one of the “acute leukemias”. There are many types of leukemia, but there are two well known leukemias that prey on children. They are Acute Lymphoblastic Leukemia, ALL, the one David had, which generally seeks out kids two to ten years of age, and Acute Myelogenous Leukemia, AML, which generally hunts down our babies under one year of age.

The acute leukemias are proliferating bone marrow tumors of cancerous precursor white cells still in the immature blast cell phase. The cells do not work like healthy white cells to combat infection. They multiply wildly, creating havoc in the body, literally consuming the patient to death, a condition we call, "cachexia". Patients have intense bone pain, anemia, infections, swollen lymph nodes, enlarged spleens and livers, and, for some, meningitis, strokes, heart attacks, and kidney failure. Without treatment, they are dead in a few weeks to a few months.
 
We still do not have a full grasp on their cause. Most are caused by oncogenes, which are mutated cancer inducing genetic codes for programming carcinogenisis and disrupting programmed cell death we call “apoptosis”. What causes this, is the head scratcher. Many of us feel it is radiation exposure, or certain viruses. Perhaps environmental toxins, or even cosmic radioactive bursts. And of course, man-made toxins are obvious suspects.
 
By the early 1990s we were seeing cure rates in both ALL and AML of fifty percent and remission rates in the eighty percent range. What a leap. In just 3 decades we saw a paradigm shift in the treatment and outcomes of our children with leukemia, moreover, a shift in therapies which utilized a team approach to protect our children from the acute depression and other collateral illness which accompany these diseases. Newer drugs like Daunorubicin have accelerated this to even better outcomes. Although this drug is very effective, it is extremely cardiotoxic and not generally used in children. However, it should be noted that we are now seeing ninety five percent remission rates and sixty percent cure rates in our children with ALL, and AML, a true shift in mortality that could only be dreamed about just thirtyfive years ago.
 
Drugs like Methotrexate are still at the heart of leukemia therapy, and are used in combination with other drugs, along with bone marrow transplants and radiation treatments. Unfortunately, these drugs are very expensive, which creates an obvious ethical dilemma.
 
But now, what treatments are on the horizon for leukemia? There is a new drug. This drug arrived on the cancer chemotherapy shelves about fifteen years ago, but shows outstanding promise even outside of cancer therapy. Used mainly for Chronic Myelogenous Leukemia, CML, a leukemia seen mostly in older adults, it is highly effective. Rendering oncogenetic codes for cancer cell induction dead in their tracks. It is a target drug aimed at a specific chromosome translocation defect which exists in more than 90% of CML patients, called the Philadelphia Chromosome. The drug, Imatinib, was built from a rational drug design based on biochemical research already in place regarding the specific allele the Philadelphia Chromosome codes from, and shuts down the production of a protein called tyrosine kinase which induces cancerous breakdown of normally functioning white cells.
 
Imatinib has been used as therapy for other leukemias including refractory ALL and myeloproliferative disorders (bone marrow cancers) with outstanding success. But what is also very interesting is its experimental applications which are currently being investigated.
 
Imatinib has been touted as a treatment for pulmonary hypertension, a rapidly fatal form of high blood pressure in the lungs. It has been shown to reduce outcropping we call smooth muscle hypertrophy and hyperplasia of the pulmonary vascular tree. In systemic sclerosis, the drug has been tested for potential use in slowing down pulmonary fibrosis. In addition, current laboratory investigations show promise in stopping the progression of atherosclerotic vascular disease. Yes, a treatment for coronary artery disease.
 
At Emory University in Atlanta, there are promising studies suggesting that Imatinib could be used as an antiviral against smallpox. Why is this important? Although this disease has been wiped off the face of the earth with the remarkable efforts of the World Health Organization, and no case has been identified in over thirty-five years, We continue to believe a weaponized form of small pox launched from a rogue nation is possible.
 
Studies also suggest that a modified version of imatinib can bind to the protein which increases the production and accumulation of amyloid plaques in Alzheimer’s disease, rendering it inert. Yes, a treatment for Alzheimer’s Disease.
 
But with all of this in our doctor bags, there is still a dark and ominous specter. Although great strides have been made, and I was privileged to meet and take care of children with leukemia, and even watch them overcome the illness and move on with their lives, one patient stands out.
 
I was working the Emergency Department one night in 1995. It had been relatively quiet that evening, when at approximately two in the morning a man walked in carrying his teenage son. We acted quickly and helped him get his son to a gurney in an open bay.

The staff and I immediately recognized the man’s son as Eric, a well known high school football star. The father said he found his son crawling on the floor trying to get to the kitchen to get a drink of water. Eric looked awful. There was that damn color again. Eric was delirious with fever, weak, and poor to respond. We went to work on him immediately. His dad said that he was fine just a month ago, but had developed a sore throat at about that time, and was seeing one of our local doctors who just kept giving him antibiotics.

We managed to get young Eric stabilized. Just as we were settling him in and making his father comfortable, I received a call from the laboratory. The lab tech asked me to come down to the lab. I ran to the laboratory. When I got there the tech was shaking her head as if to say, “this is really bad”. I looked at the blood count machine’s screen. “my God”, I said to the tech. “His white count is seventy thousand”. I looked in the microscope. “Blast cells”. I knew right away we were looking at an acute type of leukemia, but couldn’t recognize it with just light microscopy. We needed more tests.
 
When I dashed back to the Emergency Department, Eric was coming around a little. I spoke with him and reassured him. But the look on my face when I turned to his dad? He knew I didn’t have good news. We talked at length, then, I called in Eric’s regular doctor.

They talked while the team and I continued to work on Eric. I called in the helicopter, spoke with the Hematology Fellows at the university, returned to Eric and his dad, made sure they knew what we were doing, and flew them both to University Hospital. All eyes turned to the Hematology Oncology Service with hope that they could help young Eric.
 
One week later, while seeing patients in my office, the Hematology service at the university telephoned me to say that Eric had “passed away”. You sit by yourself and reach for introspection when these things sting you as a healer. When we lose children, most of us as doctors weep in quiet seclusion and solitude (We all have PTSD).

I wondered. How does a robust young athlete get sick with leukemia, fail in health so quickly, and die in one month? As it turned out, Eric contracted a type of AML, called Promyelocytic Leukemia, one of the most deadly forms of AML, one which preys on teen-aged children, and takes them away from us with stealth and quickness.

So you see, our job is not done. I am reminded as to why we call it a “practice”.
Our knowledge of the genome, stem cell technology, oncogenetics, and nanotechnology races onward. Our ability for rational drug design is extraordinary, and the technical savvy to produce these great magic potions has been nothing short of miraculous.

In just over four decades, we have all but squashed the disease that took my friend, David. But as you can see with Eric, we are not finished. I still think of David fifty-five years later, and how his death stirred in a young boy, "The Calling". If I was educated only to save but one human being, it was all worth it.
 
We already have at our fingertips two technologies that must be placed into motion. Stem cell research has already given us the ability to crush this killer, and should never be interrupted. And, the science to manipulate the oncogenes so responsible for the fuel that drives these diseases.

My hope is that with our new technologies, in the near future, we will not need any drugs for leukemia. We will simply turn off the genetic machinery of bone marrow cancer, and not allow leukemia even to exist, and therefore, never threaten our children again.
 
Dr. Counce
 
 



MIGRAINES IN CHILDREN

Many of you have read my article on migraines entitled
Is My Headache a Migraine. Recently I have been approached with questions from my college campus students regarding their children and the brittle headaches their kids endure. Two students in particular stated that their child’s doctor had diagnosed them as having migraines, prescribed the medicine, periactin as needed, but did not explain to them what migraines in children are really all about.

This is a little disturbing to me, as I feel the more educated my patients are, the better they are able to manage their headaches and lead normal healthy lives. This falls on the treating doctor, and unfortunately, it seems this new era of doctors is in such a hurry, it has forgotten how to teach. Osler would role in his grave!

This part of treatment is obviously more important than the "periactin". And both should be part of an overall plan. "Written down and easy to follow", by both the parents and the little one.

So, I thought this would be a good time to again discuss this very debilitating disorder. No one ever wants to see a child suffer through these. I recommend reviewing the above article in addition to this one.

When you think about someone having a headache, you probably think of an adult. But many kids have headaches too, and for many of the very same reasons that adults have them.

Children and teens can experience muscle tension or migraine headaches. Among school age children ages 5 to 17 in the United States, 20% are prone to headaches. Approximately 15% of these kids experience muscle tension headaches and 5% are dealing with migraines.

Chronic or frequent headaches can be tough to handle, and are even harder to understand when you are young, especially if you do not know anyone else who has them.
By the time they reach high school, most young people have experienced some type of headache. Fortunately, less than 5% of headaches are the result of serious disease, such as a tumor, abscess, infectious disease, or head trauma.

Most headaches are muscle tension type, the result of good and bad stress, sleep issues, or in a few instances, environmental or food triggers. About 5% of recurrent headaches will be diagnosed as migraine.

Episodic headaches are those that occur a few times a month at most. Chronic headaches occur with much more frequency, even several times in a week. If a child who has only had an occasional headache (once or twice a month) starts experiencing them more frequently (two, or three times a week), then these should be considered chronic and medical attention should be sought as soon as possible.

One of the most frustrating aspects of chronic headaches is the stress factor. Avoiding a known trigger is usually easier than avoiding stress. Young people want to do well on tests and in school, and they want to attend important events, but anticipating a math quiz or musical recital, or eagerly looking forward to a party or being in the school play, can result in anxiety or excitement. And, for some kids, this leads to a headache.

Up to 4% of children have their first headache before they reach elementary school, and they may not yet know how to describe the pain. If a young child has been crying or not eating, or has been restless or irritable, consult with your doctor about finding the source of discomfort or pain. Remember, the child has no idea what is happening and this can be very frightening.

The more knowledge (and easy to understand guide lines) school health officials, as well as parents have about children and chronic migraines, such as common triggers, symptoms, prevention, and treatments, the easier it will be to identify the child who is suffering through these headaches.

The best evidence based approach to treatment, interestingly, is the more holistic approach to little patients. It entails two things: 'chronic therapy', which addresses decreasing the frequency and intensity of the headaches, and 'acute therapy', which gives the patient and parents weapons to stave off an evolving attack.

As I have discussed in other articles, in adults, a migraine's throbbing head pain usually occurs on one side of the head, but in children it can affect both sides. The migraine is often accompanied by nausea, vomiting, dizziness, blurred vision, sensitivity to light and sound, and changes in temperament and personality. A headache's duration varies from individual to individual. But, generally, unlike adult migraine, which can continue up to four days, a child's migraine might be as short as one hour or may last for a day or so. Children also improve more rapidly to sleep. So, the best treatment for children is a nap in a quiet, and dark room.

About 15% of kids experience a migraine headache with an Aura. A typical aura is seeing colored or flashing lights, blind spots, or wavy lines or feeling a tingling in the face or an arm or leg. An aura alerts a migraine sufferer to the onset of a headache, warning the child several minutes before the pain starts. A small percentage of migraine sufferers also encounter temporary motor weakness, as they may lose their sense of coordination, stumble, or have trouble expressing themselves.

The stratified visual aura experienced by many migraineurs.Young children with migraine may not have head pain at all but rather experience recurrent stomach problems or dizziness. These types of migraine are called migraine variants (Migraine Variants will be addressed in a future article). Children who have migraine also are more prone to motion sickness.

What causes a migraine? This is treated at length in my original article.
For most kids, migraine is inherited from a parent. Migraine occurs because of alterations in a person’s genetic makeup.  An individual migraine attack is often triggered by a particular environmental or emotional event. In some cases, triggers can be identified. Among the most commonly recognized ones are stress (good or bad), a change in routine, a change in sleep pattern, bright lights or loud noises, or certain foods and beverages. Let’s look at these for moment.

One of the things I first have patients, especially children do regarding brittle migraines, is keep a diary of foods, sleep patterns, and other possible triggers. The best way to do this is to get the whole
family involved, and use a big wall calender with plenty of space for everyone to write down what they observe, as one person may notice something another didn't.

There are many triggers in childhood migraines that should be weeded out. Foods are huge, but other things as mentioned above, like stress level, even positive stressors like more money, new teacher, family gatherings, etc. can be big. Sleep can be a major player. I can't stress enough, the value of regular sleep patterns and at least 9 hours of sleep every day for kids.

Food is probably the biggest player, so you have to read labels closely. Here are the biggest triggers I've seen in practice:
(1), Caffeine in any form, even in medicines. Keep in mind that caffeine is also used to treat headaches, but can be a two edged sword, and, induce “rebound phenomena”. (2), Mint, it's in everything, start tossing it out. (3), Red food dyes. (4), Yellow food dyes. (5), Hard aged cheeses, like Parmesan, and cheddars, remember also, that cheeses are not naturally yellow ( they have yellow dye in them). (6), Pizza. (7), Lunch meats. (8), Hot dogs and sausages. (9), Bacon, use "fresh-side", or "sugar cured".

The above meats have nitrates in them which induce migraines.
MSG (10), chocolate in any form. (11), yogurt. (12), Chinese food (oriental).
(13), The additive, Mono-Sodium Glutamate (MSG) is a monster and must be avoided, it is in everything from snack foods, frozen foods, bullion, and ramen, to canned soups. (14), All citrus products. And watch out for sugar binges. Remember to write down every little detail that appears significant on that calendar, and let your doctor know how it's going.

After a formal diagnosis, a doctor's goal is to help reduce or eliminate the symptoms of a migraine and prevent future attacks.


In regard to treatment, sometimes children, especially young children, do not need any medication to treat a headache. Often there are non-medicinal treatments that can provide primary, or added benefit.

During a migraine attack, a child should be allowed to rest, and even sleep, in a quiet, dark and cool room. Raising the child’s head up on a pillow and providing a cool compress for the eyes or forehead can help them feel more comfortable. When at school, a child should be allowed to go to the nurse’s office and rest. Sometimes a quick nap is all it takes and they can return to the rest of the school day.

Trigger avoidance and a regular schedule are huge preventive measures that can be taken to avoid the frequency of attacks. Relaxation and stress management techniques can be helpful during an attack and to help alleviate stress before it becomes a full blown an attack. Daily physical activity is also very important in headache management and stress reduction. Two methods that have been well documented to help children with migraine include meditation and biofeedback. There is also much research that suggests hyper-hydration with plain water may prevent frequency in migraine attack.

Once a migraine has begun, several types of medication can alleviate the symptoms. Analgesics, such as acetaminophen or ibuprofen, are first-line pain relievers for treatment of headaches in children and adolescents. The Triptans can be helpful in those children who don’t find simple analgesics helpful. There are several different triptans available and two (almotriptan [Axert®] and rizatriptan [Maxalt®]) are FDA-approved for children. In addition, your doctor may also prescribe anti-emetics to stop the nausea and vomiting or a sedative to help a child rest.

Aspirin is not generally recommended for kids, as there is now, well documented evidence linking aspirin to the development of Reye's Syndrome, a rare disorder that children and teenagers can get while they are recovering from childhood infections, such as chicken pox, flu, and other viral infections. Reye's symptoms include nausea, severe vomiting, fever, lethargy, stupor, restlessness, and even delirium.

Children and adolescents who experience migraine attacks more than twice a week and which interfere with school or social activities, may be prescribed a daily medicine to try to prevent headaches. There are no medications that have been specifically designed for migraine so they all come from other categories including anti-seizure, blood pressure and anti-depressant drug classes. Common preventive medicines include beta blockers, tricyclic antidepressants, topiramate, and valproate. Please note: none of these medications are approved for migraine treatment in children. However, research in this area continues with excellent progress and doctors will utilize these medications as "off label" prescriptions.

Frequent headaches, especially those that occur more than once a week, deserve treatment, with both medication and non-medicinal options.  Headaches are not good for the brain and headaches often lead to more headaches. With the right treatment regimen your child can get his or her headaches under control and prevent further progression.

Further questions can be directed below, and look for continued articles on headaches in future posts on The Searchlight Messenger.

BatmanDr. Counce

Doc's Apple Pie

The Holidays are upon us, and many have been asking for this apple pie recipe.
Yep! It's one you should write down.

I love to bake. I remember my first effort was of all things, Pineapple Upside Down Cake. I was eleven. That I didn't kill anyone in the family, and they actually really liked it (Betty Crocker), I was hooked immediately.

Been a self trained chef ever since. But I had good teachers. My mother, my grandmothers, my sister, and a woman named Ingrid. All revered kitcheneers, they taught me everything. I think I have almost every possible gadget one would need in a kitchen. I have to say, I am at one of my favorite happy places when unleashed in a kitchen.

This is the ninth year I have published this recipe. So here we go again. I am asked every year to bake this pie for the holidays. What's really cool about it for me, is it has become a tradition I am proud to say continues my grandmother's legendary pie-making of 5 decades. So yeah, the family "pie making" torch was passed to Chuck. Really by chance, when you stop and realize how many chefs we have in the family.

To carry on this tradition, is a great pleasure, and totally cool that I get to do it!

This pie is one of the best pies you will ever eat! I mean, who doesn't like pie anyway? And when you get your hands on a "from scratch" killer gourmet pie, gloves are off, man!

Many ask for this recipe. A recipe that I kept secret when I first started playing around with it, but realized, this is not a recipe to be kept a secret, and should be shared with everyone. It's too much fun to make, let alone eat. So here it is. This by no means is an easy undertaking, but the result is to die for!

Two things about apple pie. The serious apple pie chef will use a variety of tart and sweet apples in his or her pies. This creates a blend of flavors and textures everyone looks for in a fine fruit pastry. Color is cool too, but those stunningly beautiful and expensive apples you pick out tend to look the same after they are peeled, cored, and cooked.

Apples I recommend for this pie, are the best grown in North America. They are all in season this time of year. You'll need Greening; Idared; Macoun; Cortland; Winesap; Braeburn; Jonamac; Good ol Granny Smith; and Northern Spy, in combination. If there are others you would recommend, please leave a comment for me below.

Most of the better varieties are grown in Washington and Oregon. Just like the climate of Northwest America by its nature is perfect for fine wines we love from The Napa Valley northward to Washington, it’s even better for apples. They've been growing there for 300 years. Much longer than our grapes.

In the twenty-first century, it isn't difficult to get produce from anywhere. Just ask your grocer to order what you want. Any combination is fine, but mix at least 4 different types, depending on what your farmers market or grocer has. Since my “pie days” are a big thing, I use as many as possible, because I’ll make 2 pies in one “pie day”. Yeah, it’s a long day, but a fun day.


The second thing? The crust. Crusts should be the signature on your pastries and pies. A crust will make or break a pie. You cut, peel, and core apples, then cook them, but your crust is like fine china, and must be respected at every turn when making gourmet pies.

After blending the ingredients in your crust, handle it as little as possible. That means "make it, roll it, and leave it alone". The crust in my apple pie uses no shortening. Instead, I use cream cheese. A little trick I learned from Greg Pettit. Oh yeah, Baby! You know there's butter in there too! Yeah, I know! The gloves are off! We aim to be decadent here. Hey! How are YOU, Evil DarthFatter? Oh! And Your Lowness, Lord Sucrose. Have a seat. We're just gettin' started. Would you like a little coffee in that cream? I thought so.

"Anyhow", My apple pie is a long process, as are most “from scratch” pies. This pie, when you include the shopping, is a two day but very fun baking adventure.

Shopping for these special ingredients is very fun. Take someone with you. They’ll love it! Finding and selecting the apples, fresh spices, and all of the accoutrements is a blast! Shopping for food, especially on special occasions, and with a good friend, is one of those "little things" we all live for.

On baking day, let’s just say, no one wants to leave the house. Your house will be filled with the smells of warm cinnamon, bread, and apples. Everything we savor about cooking and baking in the Winter. Yeah, I know!

Everyone in your house will keep hangin' around. They won't leave. It's just fun watching this piece of Kitchen Art come to literal fruition.

The aromas and flavors from the different apples waft from the kitchen throughout the whole house while rendering this dish. The crust is special, and while baking, smells awesome! And when you eat it, your palate is teased, tortured, and tantalized as the flavors and textures melt all over you. The apples, and cream cheese crust are a perfect combination for anyone’s palate. You will lose yourself in this pie, and even better, everyone will want more, so make at least two pies.

You can pair this dish with a white wine. I recommend a Sauvignon Blanc, preferably from The Duckhorn Vineyards of The Napa Valley. Yes, they are known for their “Reds”, particularly their Merlots, but their “Whites” are usually special efforts, and are genuinely robust, with the tastes of fruits, including banana, peach, melon, and of course, apples on the "Finish".
 

Here it is. Have fun, then enjoy your good work. Keep in mind that the recipe below, is for one pie.





Ingredients:


 Pastry

1. 1 and 1/4 cups all-purpose flour, plus more for rolling

2. 1/3 cup cake flour (Softasilk® is the only brand available in Colorado Springs)

3. 2 tablespoons sugar

4. 1/4 teaspoon salt

5. 4 ounces cream cheese, chilled, the real stuff, not the low fat stuff

6. 1 stick (4 ounces) unsalted butter, That’s UNSALTED, cut into 1/2-inch pieces

7. 1 tablespoon ice water

8. 1 large egg yolk

9. 1 teaspoon cider vinegar


Filling

1. 4 pounds large apples (about 8)—peeled, cored and cut into eighths

2. Finely grated zest and juice of 1 lemon

3. 3/4 cup sugar, plus more for sprinkling

4. 3/4 teaspoon cinnamon

5. 1/4 teaspoon salt

6. Pinch of ground mace. Sometimes hard to find, mace is actually the ground seeds of nutmeg.

7. 1 stick (4 ounces) unsalted butter

8. 1/2 cup apple cider


Directions:


1. MAKE THE PASTRY. In a large bowl, stir the all-purpose flour with the cake flour, sugar and salt. Add the cream cheese and use your fingertips to break up the cheese into the mixture until it resembles coarse meal. Cut in the butter with a pastry blender until pea-size clumps form.


2. In a small bowl, mix the ice water with the yolk and cider vinegar. Gradually add the ice water mixture, stirring with a fork. Turn the pastry out onto a lightly floured surface and press it into a 10–inch log.

Starting at the far end of the log, use the heel of your hand to quickly smear the pastry away from you, a little bit at a time. Use a pastry scraper to gather up the pastry and repeat the smearing process one more time.

Gather the pastry together. Cut off 1/3 of the pastry and pat each piece into a disk. I said pat it. Don’t roll it yet. Wrap each disk in wax paper or plastic, and refrigerate for at least 30 minutes or up to 2 days.


3. MEANWHILE, MAKE THE FILLING. In a large bowl, toss the apples with the lemon juice and zest, 3/4 cup sugar, cinnamon, salt and mace. In 2 large skillets, melt the butter. Add the apples and any accumulated juices and spread them in each skillet in a single layer.

Cook the apples over moderate heat for 5 minutes, stirring occasionally, until lightly browned in spots. Add 1/4 cup of the apple cider to each skillet, cover and cook, shaking the pans occasionally, until the apples are tender, about 5 minutes. Remove the lids and let the apples cool. If the juices are not thick and syrupy, simmer uncovered for 2 to 3 minutes longer. Let cool completely.


4. On a lightly floured surface, roll out the large pastry disk to a 12-inch round. Ease the pastry into a 9-inch glass pie plate. Trim the overhang to 1/2 inch and refrigerate.

Roll out the smaller pastry disk to a rough 12-by-8-inch rectangle; trim the edges. Using a pastry or pizza cutter and a ruler as a guide, cut eight 12-by-1-inch strips. Line a baking sheet with parchment or wax paper. Weave the strips into a lattice on the baking sheet and brush the lattice with water. Sprinkle with sugar and freeze just until firm, about 10 minutes.


5. PREHEAT THE OVEN TO 375°. Fill the pie shell with the cooled apples and their juices then flatten them slightly with a spatula.

This is where people get impatient. Make sure those apples are cool, and don’t try to speed it along in the refrigerator. Let them cool naturally, and at room temperature.

Brush the rim of the pie shell with water and slide the lattice on top. Press the edges together to seal. Trim any overhanging lattice. Fold the rim over onto itself and crimp decoratively. I use my Grandmother’s “thumb and two fingers pinch”.

Bake the pie for about 1 hour, until the crust is golden all over and the filling is bubbling. Cover the rim with strips of foil if they become too brown. Transfer the pie to a rack and let cool completely.


Make Ahead


The pie can be made one day ahead and kept at room temperature. You can re-warm before serving, but this pie is also good, fresh out of the refrigerator.


My pleasure. Enjoy....


Dr. Counce








Colorado's Bold New Healthcare Initiative


Frustrated with the suppressing effects of the Patient Protection and Affordable Care Act and the continued sky rocketing costs of health care, this Fall, Colorado will vote on Amendment 69, a petition induced amendment to the Constitution of the State of Colorado.

If passed, this single payer health insurance program will go into effect over an 18 month period. It's goal? To eliminate insurance premiums (about $8,000 to $12,000 per family annually), "un-affordable deductibles" (as much as $7,000 per family), and any out of pocket expenses like co-pays.

Understand, the only way to move away from the Affordable Care Act is for states to make a better and more affordable but fiscally solvent plan on their own. So again, Colorado spearheads a change in the law of the land, thumbing their noses at the Federal Government's inadequacies, and taking on the task themselves to protect Colorado's citizens.

It will start with a thirty-eight billion dollar budget through a state income tax increase of ten percent, and provide universal health coverage, choking off the profit seeking behaviors of national private insurers, and will save Colorado six billion dollars a year.

If passed, the first year of the plan will be directed by a 15 member interim Board of Trustees chosen by state legislative leadership and the Governor. This will be followed by an election of professionals and community members to the Board of Trustees to over-see and manage all "ColoradoCare" operations, with elections held annually thereafter. Amendment 69 outlines the length of the terms of the elected trustees, term limits, and procedures for filling vacancies. ColoradoCare Trustees are not subject to recall elections, but may be removed by a majority vote of the board.

Essentially, the State of Colorado will be carved into seven districts, with each district electing three board members each (total of 21). in the last year, It has been well known in professional medical and academic circles that VENTURE XVII supports this amendment. The B.E.A.M. Foundation will be funding the campaigns of two of it's members to run for ColoradoCare Board of Trustees positions. Yes, VENTURE XVII is actively involved, as three of the B.E.A.M. Foundation's positions are to alleviate poverty, create economic empowerment, and promote accessible healthcare to all. In addition, the B.E.A.M. Foundation supports Senator Bernie Sander's initiatives to make healthcare "a right of our citizens".

Unfortunately, the United States is the only first world economy where you can still be bankrupted by a medical condition. This is considered unconscionable by many, and Colorado feels compelled to act instead of talk (which has been going on now for over thirty years). Did you know that over sixty percent of bankruptcies are induced by medical expenses? Did you know that over forty percent of foreclosures are induced by medical problems?

The insurance companies keep getting richer, and our premiums and out of pocket costs keep going up and are crushing our citizens. When I see a patient for 15 minutes, I spend an hour on paperwork and coding or the insurance company will not compensate me for the visit, even if it's only for a Medicaid copay. Enough is enough! Colorado is fed up. Colorado not only has the resources, but the means to carry this through, and maintain it indefinitely.

Isn't it interesting that all of the media advertising opposing the amendment is backed by Blue Cross Blue Shield, United Health Care, Kaiser Permanente, The Travelers, other small cap insurance entities and those invested in the insurance industry. Why, you ask? Because if this passes, they will no longer write insurance in Colorado, and will lose market share of almost nine million insured lives. Do the math. 

Gaining health insurance is an important step in ensuring access to healthcare. Without insurance coverage, many patients would not be able to pay for the medical services they receive. But so far, no policy attempted in the United States, not even the Affordable Care Act, has been able to bring coverage to everyone or reign in costs. ColoradoCare attempts to solve that situation.

ColoradoCare would automatically cover everyone whose primary residence is in Colorado. The system would include people who currently can’t afford insurance, don’t want it, or don’t qualify for existing programs because they are immigrants who lack documentation.

Supporters say universal, publicly financed coverage would save money and time that is currently spent on insurance bureaucracy and paperwork, and allow patients to see any provider who agrees to contract with ColoradoCare.

Opponents (the insurance companies) argue the opposite, saying the proposed system would limit Coloradans’ choices about their health plans, restrain market competition and leave too many important details to be decided in the future. Typical corporate rhetoric.

The issue here is typical of all politics. There will be a tax increase. Everybody gets itchy when we talk about tax increases. But this initiative has a silver lining of beneficence: State of the Art Healthcare, but at no cost to the citizens of Colorado.

Here's an example of its impact on a family of four paying $1000 in state income tax per year. Now their income tax is $1100, but they didn't have to pay $12,000 in premiums in addition to if a family member was hospitalized, the $7,000 deductible they would most likely have to borrow.

Keep your eyes on Colorado. If this works well over the next three years, you will see other states take notice and use our system as a template for their own.

I understand when you read this, you can see that it is slanted to the "Yes Vote". But it's also about doing the right thing. We have the resources (remember all that money we're making from Weed?), We have some of the best medical and business minds in the nation right here. We can make a difference.

For an independent analysis, please go to: http://colorado69.org/



Keep reading, and Stay healthy.


Dr. Counce

















Venetoclax Shows Promise in Acute Myelogenous Leukemia

Venetoclax monotherapy appears to improve outcomes in some patients with acute myelogenous leukemia (AML), according to a phase 2, single-arm study.

"This study included patients that were in categories that are difficult to treat - relapsed, refractory, and/or elderly and deemed medically unfit to receive induction therapy," Dr. Anthony Letai from Dana-Farber Cancer Institute in Boston told Reuters Health by email.

"The fact that some of these patients had leukemias that were relapsed or refractory to very tough regimens, including regimens that require multi-week inpatient hospital stays, but nonetheless responded to an oral outpatient therapy taken once a day was a very interesting result," he said.

Venetoclax, a highly selective, oral small-molecule B-cell leukemia/lymphoma-2 (BCL2) inhibitor, received FDA approval for chronic lymphocytic leukemia (CLL) earlier this year.

Dr. Letai and colleagues investigated the efficacy and biological correlates of response in the first clinical study of venetoclax monotherapy in 32 patients with relapsed/refractory AML or untreated AML unfit for intensive therapy.

The objective response rate was 19% (six of 32), with two patients achieving a complete response and four achieving a complete response with incomplete blood count recovery. All objective responses were achieved by the week-4 assessment.

An additional 19% had antileukemic activity demonstrated by partial bone marrow response and incomplete hematologic recovery.



The six-month leukemia-free survival rate was 10% (median leukemia-free survival, 2.3 months), and the six-month overall survival estimate was 36% (median overall survival, 4.7 months), the researchers report in Cancer Discovery, online August 12.
At the time of this report, all patients had discontinued venetoclax: 29 due to progressive disease, one due to adverse event, one withdrew consent, and one proceeded to allogeneic hematopoietic stem cell transplant after achieving stable disease.

"Our data provide evidence that AML with IDH1/2 mutations exhibits BCL2 dependence and validates preclinical data that suggest suppression of cytochrome c oxidase activity in IDH1/2 mutant AML lowers the mitochondrial threshold to trigger apoptosis upon BCL2 inhibition," the researchers note. "However, activity observed in patients with wild-type IDH1/2 suggests targeting BCL2 with venetoclax should not be restricted to patients with mutations in IDH1/2."

Venetoclax monotherapy was generally well tolerated, although treatment-emergent adverse events were reported for all patients. Nausea, diarrhea, hypokalemia, vomiting, and headache were the most commonly reported adverse events.
"This study was the first report of venetoclax in AML, and as such was a single-agent study," Dr. Letai said. "However, I do not think single-agent use will be common in AML for this drug. I think that venetoclax will be incorporated into combinations with many other agents active in AML."


"Right now, in the elderly setting, it is being combined with either hypomethylating agents (vidaza or decitabine) or low-dose cytarabine, both commonly used in the elderly in AML," he said. "The response rates have been fantastic, around 70%, as reported in abstracts at ASH and ASCO. There will likely be clinical testing of combinations including venetoclax at all stages of AML therapy, including induction, consolidation, salvage. Indeed, some of these trials are already starting. Who knows, perhaps even maintenance? It is well tolerated, so lends itself to combination."

"Genomics and genetics are often equated with personalized medicine, the job of which is to match the right patient with the right drugs," Dr. Letai added. "Venetoclax has so far demonstrated activity in CLL, mantle cell lymphoma, AML. There are no genetic abnormalities related to BCL-2 that would indicate activity in these cancers. If we relied on genetics alone, these would have missed."

"Instead, we and others took a functional approach to identifying BCL-2 dependence in cancers, and thus identifying good targets for venetoclax," he said. "I think that these functional precision-medicine approaches are going to be vital to taking advantage of all the new drugs that are appearing in cancer. If we rely on genomics alone, we will probably miss most of our therapeutic opportunities."

Dr. Fernando Ramos from the University of Leon in Spain, who recently reviewed AML in older adults, told Reuters Health by email, "Venetoclax may be an interesting option for rescue therapy in this patient subset."

"Precision medicine has come a long way," added Dr. Ramos, who was not involved in the study. "Venetoclax may be an interesting partner to azanucleosides in unfit AML patients."

Currently, venetoclax is in phase 2 testing for AML, diffuse large B-cell lymphoma, and non-Hodgkin lymphoma and in phase 3 testing for multiple myeloma.

AbbVie and Genentech funded the study, employed 13 of the 22 authors, and had various relationships with four other authors, including Dr. Letai.