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THE SEARCHLIGHT MESSENGER

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 (Better Homes), 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 tenth 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 Irish butter in there too! 

"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 Irish 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 Irish 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.


Alberta, Canada, Home of Venture 17, is on Fire


Send your thoughts this way please, while we fight this monster.

The staff of VENTURE XVII, based in Calgary, is currently volunteering with evacuation of Northern Alberta, Canada. This is getting out of control. In 2012 We were fighting the Waldo Canyon and Lake George Fires in Colorado. A year later, We were fighting the Black Forest Fire North of Colorado Springs.

The infamous Hayman Fire, rolled on us fourteen years ago, virtually killing some of the most beautiful and pristine wilderness on the backside of The Rampart Range of Colorado. Yeah, 140,000 acres of it. Then the Montana Fires of 2007. Half a million acres wiped out in two months!

But this thing. He's a killer! in just 3 days, he's already consumed over 350 square miles. Been really hard to reign him in. Fires are always our worst fear up here in the Rockies. Whether in the Yukon up North or the San Juans in the South, it's all Alpine Forest with interlacing meadows and tributaries of grasslands.

When I worked with my friends, The Chippewa Cree in Montana, they would tell me that the elders would always point out that the fires were "A Cleansing", and to respect them. They consider fires a natural part of the wilderness and as natural as the Sun rising every morning. I can't help but agree with this, but times have changed, and as Man moves deeper into our forests, more of us depend on our forests and grasslands for our survival.

The teachings of our Native American Fathers should be respected at every turn, but we are no longer nomadic people, and can't just pick up and move when a cleansing comes calling. Whole cities, transportation infrastructure, farmland, livestock, and our sources of water and food can go up in smoke overnight, turning our world upside down.

This one's going to rock our world for a while. The best professional fire fighters in the world are on it! "Film at eleven"!




My Advice to Medical Students

It’s been many long years since I graduated from my medical residency. I made Chief Resident so spent an extra year learning how to teach and manage doctors who are full of themselves.

I've seen it all. From the totally clueless senior medical student, to Hospital Chief of Staff. A long time to glean some perspective, and time for introspection. My generation of doctors, was the last to go to college, medical school, and train without computers or smartphones. We didn't even have the internet.

We didn't carry pocket ultrasounds, smartphones, or ophthalmoscopes. All we brought to the bedside was our own brains, a stethoscope, and a compassionate bedside manner. Times have changed. And although we are armed with all kinds of technology, doctors are still doctors, and there aren't very many of us. Moreover, it is predicted that by 2020, the United States will lose half of its physician workforce as doctors make there exodus from an industry that has forgotten about how important we are. Not just anyone can do this. If they could, we would just toss you a human "cookbook" and say "here you go! Fix it yourself!"

I get calls from colleagues everyday, asking how I was able to move into the Education Industry, they want out so badly. The three decades of training in a profession obligated to bring the tip of the sword in science, is a tough enough burden, let alone Corporate America and Ad Hoc Committees telling us how to practice (and they don't even have a License to practice). Throw in "CLIA, OSHA, Semiannual Blood-borne pathogens training, The internet, HIPAA, Managed Care, The doctor crushing Affordable Care Act, and "the straw", ICD-10 ( All of which were thrust upon us in a twenty year span), and you have an already hugely stressful occupation filled with PTSD ready to throw in the towel and say, "Try doing it without us!"

It is still a bold, proud, and academic profession, however, and continues to call to those men and women who can bring not only scientific knowledge, but an understanding ear that listens, holistic care, intelligence, integrity, and a steadfast compassion for mankind.

I continue to train young doctors. These students, interns, and residents are smart, they already know what hard work is, they are all "A" students, hugely ambitious and talented. Many of my conversations with them turn into advice. So this is what they hear.

1. People die; it’s not a personal failure on your part. Our weapons against disease cannot outlast the inevitable. Our interventions and therapies can make disease more manageable and prolong life, but death will always be the ultimate and natural conclusion of our efforts.

2. Your choice of specialty will not determine your ultimate life happiness. You are not doomed to misery should you chose not to sub-specialize nor are you guaranteed happiness if you do. Choose something you enjoy, Choose a specialty that provides a lifestyle congruent with your values. But don’t confuse intellectual intrigue with life happiness; there is so much more to the latter that has nothing to do with medicine.

3. Remember what it means to be a normal person. To retain a sense of awe in what you now get to do on a regular basis. To be able to explain things in non-medical terms the way you learned them before being indoctrinated. To feel sadness, joy, grief, loss, elation. To remember the viewpoint of suffering.

4. Keep friends outside of medicine. You’ll be more human. And more interesting.

5. Guidelines are helpful, but they are not strict rules. Don’t try to meet every guideline while losing site of the big picture. You wouldn’t want your 95-year-old grandma on a high dose statin to prevent a heart attack, metformin for the elevated fasting glucose only apparent within the past year and three blood pressure pills that make her feel dizzy all the time to achieve some magic number that no one agrees on anyway. Don’t subject someone else’s grandma to that either.

6. Retain your humility. When family members say, “Something’s not right with Grandpa,” listen to them. They are usually right. Ask questions when you don’t know the answer. It can be especially humbling to do so in front of your colleagues, but your pride is no longer your priority. Your priority is your patient, without exception.

7. Be kind in your comments about the “outside community doctor.” There is a high likelihood you will be that person at some point in your career. They usually aren’t as dense as you might think; they are just struggling to provide the same perfect care you are in a very imperfect system.

8. Burnout is inevitable. Plan for it. Write down what drew you to medicine in the first place. Use it to keep yourself motivated. Learn to unplug. Turn that thing you call "a phone" off. Don't overlook your own health. Mental or physical.

9. Other services are not your enemy. Be kind when someone calls you with a “dumb consult”; you have likely called one yourself.

10. Avoid perpetuating the cycle of abuse. The profession of Medicine has been built on a "train by intimidation" approach since Osler. We are well known to "pimp" each other in an effort to show academic prowess. Just because you were demeaned and humiliated as a student or resident does not mean you are entitled to do the same to your younger colleagues. They are no more “unmotivated,” “lazy,” or “arrogant” then you were. We are all a bunch of prima donnas. Turn it down a notch!

11. Think about how your orders affect your patients Holistically. How the orders may actually contribute to their suffering and discomfort. Nurses have been asking for us to do this for years.

12. Be mindful of the habits you cultivate. How you speak to patients, families, nurses. How you treat your family when you are stressed. Your eating habits, your spending habits, your sleep habits. These will follow you past residency, for better or for worse. Make sure they have been chosen with intention.

13. Medical training is expensive. Most of us have debt. Just because you have a big salary out of residency, doesn’t mean that you are wealthy. Do the math and avoid the temptation to increase your debt further immediately on graduation with a huge new house, car or other toys. A few years of frugal living will pay dividends later on.

14. It doesn’t automatically get better after residency. Hate to break it to you, but it’s the truth. But it can be great if you prioritize what’s really important. Just pick those priorities carefully.

15. Don't forget that the word "Doctor" means "Teacher", doctor.

Lastly, the advice I give to every young doctor I mentor: You must remember that the medical profession is like a jealous lover. It requires all of your time, and all of your energy. It will tolerate nothing less. The people who seek us, need us, and need to trust us. This trust can never be betrayed.

Always stand with a smile, never be impatient, and always give your patient hope. Be as passionate in your craft as you are gentle in friendship, and make everyone who crosses your path, glad they met with you today."
 
 
Dr. Counce