Almond: Heart Guard – High-Fat Weight Control

Almond—a spice? You bet!

Though we think of almond as a nut, it’s really a seed from the fruit of the almond tree. And, by definition, a dried seed is a spice. Its spicy nature is why almond imparts so much flavor to an array of sweet and savory dishes. It’s also why almond has such a storied history as a traditional medicine. So let’s rescue almond from the nuthouse (so to speak) and bring it home to the spice cabinet, where it belongs.

As a spice, almond is unique in several ways. Where most spices are virtually calorie-free, almonds are calorie-crowded—one ounce (about 20 almonds) contains 150 to 200 calories. And 78 percent of those calories are from fat. But never fear—most of that fat is in the form of “good” monounsaturated fatty acids, which (as you’ll see in a moment) research links to a healthier heart. (And even to weight control.)

Almonds also contain other heart-helping nutritional factors. Just one ounce of almonds supply 50 percent of the Daily Value (DV) for vitamin E, a nutrient long touted for aiding circulation. The same ounce provides 25 percent of the DV for magnesium, a heart-calming mineral. The spice is also rich in folate (a B-vitamin linked to lower levels of heart disease), in plant sterols (natural compounds that have a similar composition to cholesterol, helping block its absorption), and in fiber (also linked to lower cholesterol).

Let’s look more closely at why almond is one of your heart’s best friends . . .

Be a Mono-Maniac—About the Health of Your Heart

Want to eat a meal that contains the top six nutritional heart protectors? Dine on a serving of fish flavored with garlic and topped with slivered almonds. Don’t forget a side or two of vegetables. Drink a glass of red wine with the meal. And for dessert, munch on an apple and a small piece of dark chocolate. Yes, say British researchers (who used statistical evidence from the scientific literature on heart disease to dish up this heart-protecting meal), eating these foods every day would reduce the worldwide rate of “cardiovascular events” such as angina, heart attacks, and stroke by 76 percent and extend life by an average of 6.6 years.

“We selected these foods because each possesses a substance that benefits the heart in a special way,” said lead researcher Oscar H. Franco, MD, of the University Medical Center Rotterdam in the Netherlands.

Almond was chosen because two ounces supply the day’s requirement of heart-protecting monounsaturated fatty acids (MUFA). Statistically, almond accounted for about 12 percent of the total calculated reduction in heart disease and increase in longevity.

Other findings about almonds and the heart:

Lower cholesterol. A team of world-class nutritional researchers at the University of Toronto tested almonds to see if they could help the hearts of 27 people with high cholesterol. After one month of eating one ounce of almonds a day (about a handful), heart-clogging LDL cholesterol fell by 4.4 percent. Eating 2.5 ounces a day lowered LDL by 9.4 percent. The ratio of “bad” LDL to “good” HDL cholesterol also improved. And almonds decreased the oxidation of LDL, one of the first steps in turning dietary cholesterol into artery-clogging blockages.

What accounted for the improvement in the cholesterol profile? The high levels of MUFA, said the researchers. They point out that years of studies show MUFA can increase artery-clearing HDL, improve LDL/HDL ratios, and lower LDL—thereby significantly decreasing the risk of heart disease. And when you’re consuming more MUFA from almonds, said the researchers, you’re also consuming less saturated fat from meat and dairy—and saturated fat is a known risk factor for heart disease.

“Almonds . . . reduce lipid [blood fat] risk factors for coronary heart disease,” conclude the researchers in Circulation, a journal of the American Heart Association. They recommend them for “inclusion in lipid-lowering diets.”

Lower C-reactive protein. C-reactive protein is a biomarker of chronic, low-grade inflammation—and the most up-to-date thinking points to artery-damaging inflammation as the process behind the epidemic of heart disease (and many other chronic diseases). The University of Toronto researchers teamed almonds up with several other nutritional components in an approach they call a “Dietary Portfolio” (an analogy to an intelligently varied investment portfolio). The foods—almonds, plant sterols from a heart-healthy brand of margarine, soy protein from soy foods such as tofu, soluble fiber such as that found in oatmeal—lowered high levels of C-reactive protein by 23.8 percent. That was more than a statin drug, which research shows can also lower the inflammatory biomarker.

Lower blood pressure. In a similar study of the Dietary Portfolio—this time on 50 people with high blood pressure—eating almonds and the other foods for one year lowered systolic blood pressure (the upper measurement in the blood pressure reading) by 4.2 points and diastolic blood pressure (the lower measurement) by 2.3 points. The researchers then analyzed the diets of the study participants to find out which of the Portfolio foods they actually ate and didn’t eat over the course of the year—and discovered that “only compliance with almond intake . . . related to blood pressure reduction.” In other words, it was the almonds that made the difference, not the plant sterols, the soy, or the soluble fiber. The study was reported in the European Journal of Clinical Nutrition.

EATING ALMONDS CAN LOWER HIGH BLOOD PRESSURE.

Almonds lower high blood pressure and increase HDL. And high blood pressure and low HDL are two factors in a condition called the “metabolic syndrome”—which also includes high blood sugar, excess stomach fat, and high triglycerides (a blood fat). Having all or most of these risk factors increases your risk of death from a heart attack or stroke by 74 percent. And metabolic syndrome also is a setup for type 2 diabetes—which itself increases the risk of heart disease six- to seven-fold! Almonds to the rescue . . .

Mastering the Metabolic Syndrome

Researchers at the City of Hope National Medical Center in California conducted a study on weight loss that also measured the parameters of the metabolic syndrome. Sixty-five overweight people were put on a low-calorie diet formula and about 2.5 ounces a day of almonds. Another group used the formula and ate foods equal to the almonds in calories and protein. After six months, those on the almonds lost 62 percent more total weight, lost 50 percent more belly fat, had 56 percent less body fat, and had an 11 point drop in systolic blood pressure (compared to no change in the no-almond group). The almond group also had an increase in HDL (again, no change in the no-almonds). Of those in the study who already had diagnosed diabetes, 96 percent of those eating almonds reduced their diabetes medications, compared to 50 percent of the no-almonds. Both the almond and no-almond group had positive changes in levels of blood sugar, insulin (the hormone that controls blood sugar), total cholesterol, triglycerides, LDL, and LDL/HDL ratio.

“An almond-enriched low-calorie diet improves a preponderance of the abnormalities associated with the metabolic syndrome,” concluded the researchers in the International Journal of Obesity and Related Metabolic Disorders.

High-Fat Weight Control

Almonds aren’t shy about calories. A handful supplies 150 to 200. Snack on a handful of almonds twice a day, and you’re taking in 400 calories—maybe 20 percent of your total intake! But here’s the big surprise in the little almond: studies show that people who eat more almonds are much less likely to gain weight!

Researchers in Spain analyzed two years of health data in nearly 9,000 people and found that those who ate almonds at least twice a week were 31 percent less likely to gain weight than those who didn’t.

Scottish researchers found that adding almonds to the diet for 10 weeks didn’t cause weight gain—because people started to eat less of other foods. You can eat heart-healthy almonds without risk of putting on the pounds, they concluded.

Scientists in the Department of Foods and Nutrition at Purdue University in Indiana took a close look at the effect of eating almonds, asking a group of 13 healthy volunteers to chew a mouthful of about 10 almonds either 10, 25, or 45 times. Chowing down on the almonds “acutely suppressed” hunger, the researchers note in the American Journal of Clinical Nutrition. It also “elevated fullness”—the feeling of satisfaction after eating. The ideal amount of chewing for those benefits: 25 times per mouthful (10 was too few, and 45 was too much).

In addition to controlling your weight, eating almonds will simply make you healthier. In a study reported in the British Journal of Nutrition, researchers followed the eating patterns of 81 people. After six months, they were told to keep eating as usual—but add two ounces of almonds a day, an additional 220 calories and 16 grams of fat.

The outcome? Well, they ate the almonds, but they ended up eating less calories and less fat than they were eating before adding almonds. They also ate less sodium, less dietary cholesterol, less trans fats, and less sugar.

Getting to Know Almond

Washington D.C. is famous for apple blossoms—and Majorca for almond blossoms. From January through early March, Spain’s largest island is covered in a carpet of geranium-pink flowers from four million almond trees.

Almond is not native to Spain, however, but to western Asia and North Africa. Ancient Egyptians believed the almond had medicinal powers, and they used it to treat everything from colds to cancer. India’s traditional Ayurvedic physicians used almond to treat digestive, skin, and dental problems. They also ground it into a paste and mixed it with porridge to help patients pass kidney stones.

The lush, beautiful
almond tree grows in
warm, temperate climates.

Almond may help prevent and/or treat:

Cholesterol problems (high total cholesterol, high “bad” LDL cholesterol, low “good” HDL cholesterol)

Diabetes, type 2

Heart disease

High blood pressure (hypertension)

Insulin resistance (prediabetes)

Metabolic syndrome

Overweight

Stroke

Triglycerides, high

Today, Majorca is reputed to produce the world’s tastiest almonds—and Spanish cuisine has the world’s largest collection of almond recipes, ranging from the savory (including soups and sauces) to the sweet (including confections, biscuits, and a variety of desserts). Almond is the basis for Catalonia’s famous romescu sauce, a puree that also includes tomatoes, garlic, and red chiles.

The Germans make lavish use of almond. Lübock in the north is world famous for its marzipan, a sugary almond paste that is an ingredient in many cake fillings and confections.

Italians use almond in their universally popular liqueur amaretto. In France, there’s the almond syrup orgeat, an emulsion of almond, sugar, and water that is used to flavor a mai tai and other cocktails.

In the US, almonds are most popular for making sweets, including butter pastries, cakes, and pralines.

In India, almonds are popular in savory dishes, accenting rice dishes, curries, and vegetable dishes.

In the Middle East, chefs grind almonds into flour, which they use as a thickener for stews, soups, and gravies.

How to Buy Almond

The almond tree—a lush, beautiful weather-sensitive tree that grows only in warm, temperate climates, such as Spain, Italy, and California—produces the familiar almond: a shell-covered oval seed with off-white flesh covered by thin, brown, leathery skin. Once picked, you can buy almonds in a variety of ways—in the shell, shelled and whole, natural, blanched, with or without their skins, dry roasted, sliced, slivered, diced, and as a paste, powder, butter, oil, or extract.

The freshest almonds are still in the shell. Look for unshelled almonds that aren’t split, moldy, or stained. If you buy shelled almonds, get them in sealed bags rather than from open bins, which expose them to air and humidity, dissipating freshness. If buying from bins, look for almonds that are plump and uniform in color. And smell them: they should smell sweet and nutty. If the smell is bitter and sharp, they’re rancid—the fat in the almond has spoiled.

When purchasing dry roasted almonds, opt for those with no additives or preservatives.

The more intact the almond, the longer the shelf life. Almonds in the shell stay fresh longer than shelled almonds in the skin, which stay fresh longer than skinned almonds, which stay fresh longer than skinned and slivered . . .

As with all spices, keep almond in an airtight container away from excessive heat and direct light. (The cooler the temperature, the longer they’ll keep.) You can refrigerate almonds, where they’ll stay fresh for several months. They keep in the freezer for about a year.

You can find almonds in all their forms in most markets, specialty stores, Indian and Asian stores, and online. The best almonds come from Spain (Majorca), Italy, and California.

You’ll find purveyors of almonds by place of origin in the “Buyer’s Guide”.

Almonds come in two varieties: sweet and bitter. Bitter almonds aren’t for sale because they’re poisonous. (They’re loaded with cyanide, among other toxic compounds.) However, bitter almonds are used to make almond oil, with the poisonous compounds extracted in the oil-making process.

Almond pairs well with these spices:

Ajowan

Allspice

Anise

Chile

Cinnamon

Cocoa

Coconut

Garlic

Mint

Nutmeg

Sun-dried

tomato

Vanilla

Wasabi

and complements recipes featuring:

Casseroles

Chicken

Cookies

Curries

Green beans

Lamb

Pudding

Salads

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Other recipes containing almond:

Black Pepper Rice with Almonds

Garbanzo Beans with Mushrooms and Toasted Almonds

Los Banos Low-Fat Brownies

Sage Sausage and

Apricot Stuffing

Wasabi Orange Chicken with Toasted Almonds

In the Kitchen with Almond

Almond’s sweet, buttery taste makes it a natural for almost any sweet or savory dish. Almonds are easy to grind in a spice mill. Give the grinder a few quick pulses until you get the size of crushed nuts desired. (If you let the grinder run, you’ll end up with almond butter.)

Raw almonds should be blanched or roasted before using.

You can remove almond skins by blanching the almonds in boiling water until you see that the skins are starting to swell. Rinse under cold water. The skins should come off easily when you pinch the flesh.

Prawns with Almond Hot Pepper Sauce

This seafood dish is made with romescu sauce, a signature dish from Spain’s Catalonia region. It is traditionally served with grilled seafood. If you have leftover sauce, serve it warmed over penne.

To prepare the shrimp:

2 pounds jumbo shrimp, shelled and deveined

3 tablespoons olive oil

2 tablespoons fresh ground black pepper

1 teaspoon coarsely ground sea salt

To make the sauce:

cup blanched, slivered almonds

1 large ripe tomato, seeded

3 cloves garlic, smashed

2 dried red chiles, seeded

½ teaspoon ground red chile (cayenne)

¼ cup red wine vinegar

1 cup extra-virgin olive oil

Salt and freshly ground black pepper to taste

1. Combine the shrimp, the 3 tablespoons of olive oil, pepper, and salt in one layer in a baking dish and set aside while making the sauce.

2. Preheat the oven to 350°F. Line a baking sheet with aluminum foil. Place the almonds in one layer on the foil and bake for 10 minutes or until the almonds color lightly. Cool. Pulverize the almonds in a spice grinder with a few quick turns.

3. Put the tomato, garlic, red chiles, and vinegar in a food processor and process until smooth. Add the almonds and blend with a few quick turns. With the processor running slowly add the 1 cup of olive oil through the feed tube.

4. Increase the oven temperature to 400°F. Put the shrimp in the oven and roast for 10 minutes or until they turn pink and are firm.

5. Serve the shrimp on a bed of hot rice and spoon the sauce, room temperature, over the shrimp. You can also lightly heat the sauce and serve it tepid. Just continually stir the sauce as it heats so it does not separate. You can also serve the sauce chilled in place of traditional cocktail sauce to go with cold, peeled shrimp.

Serves 8 as a first course or 4 as an entree.

To roast almonds, put them on a baking sheet in a 350°F oven for about 15 minutes. Slivered and sliced almonds should be baked about half that time.

To put more almonds in your diet, eat a handful at least five times a week as a snack. Here are other ways to increase almond intake:

• Churn almonds into butter by putting almonds in a spice grinder and letting it run. Eat it with a sliced apple.

• Spread almond nut butter instead of peanut butter or cream cheese on your morning bagel.

• Add a new twist to your kids’ PB&J by substituting almond for peanut butter. (They may not even notice the difference.)

• Add slivered or sliced toasted almonds to cereal, yogurt, salads, and sandwiches.

• Make almonds into a cocktail snack by mixing 1 cup of unblanched almonds with 2 teaspoons extra-virgin olive oil, 3 teaspoons of dried thyme, 1 teaspoon of salt, and an egg white. Toast in a 400°F oven for 10 minutes. Sprinkle with fresh thyme.

• Add sliced almonds to chicken or tuna salad.

• Add a drop of almond extract to sweets containing almond.

• Add a few drops of almond extract to whipped cream.

Ovarian Hyperstimulation Syndrome – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Iatrogenic physiologic complication of controlled ovarian hyperstimulation (most often related to treatment for infertility)Results in ovarian enlargement, increased vascular permeability with resulting 3rd-space loss and intravascular fluid depletion, electrolyte imbalance, hemoconcentration, and ascitesClassification of OHSS is based on clinical symptoms and ultrasound findings. Mild: Abdominal distension and discomfortModerate: Abdominal distension, enlarged ovaries (8–10 cm3) and ascites on ultrasound (largest pocket <3 cm)Severe: Clinical evidence of ascites and/or hydrothorax, hemoconcentration >45%Critical: hemoconcentration >55%, creatinine clearance <50 mL/min, renal failure, thromboembolism, ARDSSymptoms of OHSS may occur early (within 10 days of hCG administration) or late (more than 10 days after hCG administration). Late OHSS is usually associated with a pregnancy and may often be more severe.

Epidemiology

Incidence

Predominant age: Women of reproductive ageWith controlled ovarian hyperstimulation (COH) and in vitro fertilization (IVF): Mild OHSS: 20–33% of cyclesModerate OHSS: 3–6% of cyclesSevere OHSS: 0.1–2% of cycles

Risk Factors

Previous history of OHSSYoung ageLow body weightPolycystic ovary syndrome (PCOS) or polycystic ovaries on ultrasoundLarge number of resting follicles (>10 follicles between 2 and 8 mm) per ovaryHigh doses of gonadotropinsLarge number of intermediate-sized folliclesNumber of oocytes retrievedRapidly rising estradiol levelsHigh estradiol levels >3000/4000 pg/mLUse of human chorionic gonadotropin (hCG) for luteal supportAchievement of a pregnancyMultiple pregnancy

General Prevention

Patients who have had OHSS are more at risk for OHSS in the future, and this should be taken into consideration in subsequent treatment cycles. Patients need to inform their health care providers of a history of OHSS when considering further assisted reproductive technology treatment.If a patient is noted to be at high risk of OHSS, the stimulation and monitoring protocol may be modified to reflect this risk. In some circumstances, consideration should be given to canceling the stimulation by withholding the preovulatory injection of hCG, proceeding with a lower dose of hCG, the use of a GnRH agonist to trigger ovulation in GnRH antagonist cycles, “coasting” or withholding stimulatory drugs for several days to allow for estradiol levels to plateau or decrease, avoiding the use of hCG for luteal supporting, or freezing all viable embryos without proceeding with an embryo transfer (1)[B].Recent evidence suggests that the off-label use of dopamine agonists (cabergoline 0.5 mg) after hCG administration may decrease the incidence of OHSS (2)[A].

Pathophysiology

Ovarian hyperstimulation leads to increased capillary permeability and intravascular fluid shifts.Fluid shifts can lead to ascites and pleural effusions.Intravascular volume depletion can lead to hemoconcentration, decreased renal perfusion, and thrombosis.The ovarian renin–angiotensin system, cytokines, and other inflammatory mediators such as vascular endothelial growth factor (VEGF) may play a role in the pathophysiology of OHSS.

Etiology

OHSS is an iatrogenic syndrome that occurs during controlled ovarian hyperstimulation (COH) for infertility treatment.Generally, OHSS is associated with the use of exogenous gonadotropins such as recombinant or purified follicle-stimulating hormone (FSH).OHSS rarely has been associated with types of ovarian stimulation such as clomiphene citrate.

Commonly Associated Conditions

InfertilityPCOSAssisted reproductive technologies

Diagnosis

OHSS is a clinical diagnosis based on history, physical exam, ultrasound findings, and laboratory results.

History

Details of stimulation cycle: Medications usedDate of oocyte retrieval and embryo transferSymptoms of dehydrationAbdominal pain and distensionNausea, vomiting, diarrheaShortness of breathLoss of appetiteWeight changesFluid intakeLethargyRisks factors such as PCOS or previous OHSS

Physical Exam

Vital signs, including O2 saturation if shortness of breathWeight (daily)Monitoring of ins and outs (daily or more often as needed)Chest and cardiovascular examAbdominal circumference measured at the umbilicus (daily)Gentle abdominal exam to detect ascites

Alert

Pelvic and bimanual examinations are contraindicated to avoid ovarian hemorrhage or rupture.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

CBC Hemoconcentration (hematocrit >45% indicates severe disease, >55% indicates critical disease)WBC >15,000 indicates severe diseaseElectrolytes to look for hyponatremia and hyperkalemiaRenal function testsLiver enzymesCoagulation profileß-hCG

Follow-Up & Special Considerations

For patients with mild or moderate OHSS being monitored as an outpatient, CBC and electrolytes should be performed every 1–2 days, until improvement in symptoms.

Imaging

Initial approach

Abdominal/pelvic ultrasound to assess ovarian size, ovarian torsion or rupture, and abdominal ascitesCXR to evaluate pleural effusion in presence of shortness of breath

Follow-Up & Special Considerations

Repeat abdominal/pelvic ultrasound as needed to assess ascites and guide management for paracentesis.

Pathological Findings

Ovarian enlargementDecreased renal perfusionThromboembolismAbdominal ascitesPleural effusionsPericardial effusions

Differential Diagnosis

Hemorrhagic ovarian cystOvarian torsionEctopic pregnancyPelvic infection

Treatment

Medication

Heparin 5,000 units SC every 8–12 hours; all hospitalized patients should be on anticoagulation prophylaxis and graduated compression stockings to prevent thrombotic events (3)[C].Full anticoagulation therapy should be started if there is evidence of a thromboembolic event.

Additional Treatment

General Measures

Mild to moderate OHSS: Generally managed as outpatient Oral fluid intake of at least 1 L daily of a balanced electrolyte solution (sports drinks) (3)[C].Monitor daily weight, abdominal circumference, and urine output (3)[C].Avoid physical exertion or abdominal trauma.Monitor for development of further symptoms.Frequent follow-up is required.For moderate OHSS, frequent assessments every 1–2 days including a physical examination and blood work should occur.Consider hospitalization with worsening signs or symptoms: Severe abdominal painSevere oliguria or anuriaTense ascitesDyspnea or tachypneaHypotension, dizziness, or syncopeSevere electrolyte imbalance: Hyponatremia <135 mEq/L, hyperkalemia >5 mEq/L, hemocrit >45%Severe OHSS: Should be managed as an in-patient. Daily weight and abdominal circumferenceFrequent monitoring of vital signs every 2–8 hoursStrict monitoring of input and output to maintain urine output of 20–30 cc/hourBed rest or reduced activity; the enlarged ovaries are at risk of torsion and ovarian hemorrhage either spontaneously or from injury or trauma.With severe illness, oral fluids should be limited and rehydration provided with IV fluids until evidence of symptom resolution such as spontaneous diuresis.IV fluids should be administered to maintain urine output to 20–30 mL/hour. Normal saline with 5% dextrose is preferred to Ringer’s lactate (3)[C].Once 3rd-space edema reenters the intravascular space, hemoconcentration reverses, and the patient begins to diurese spontaneously.Monitor leukocyte count, hematocrit and hemoglobin, electrolytes, creatinine, and liver enzymes.Thrombosis prophylaxis (3)[C]Intensive monitoring may be required for pulmonary support in cases of acute respiratory distress syndrome, thromboembolic events, or for renal failure.

Issues for Referral

Consultation with a reproductive endocrinology specialist or a gynecologist with experience in the management of OHSS and its complications.

Surgery/Other Procedures

Paracentesis/thoracentesis may be required for symptomatic control and for pulmonary and/or renal compromise. An ultrasound-guided approach for paracentesis is recommended to avoid the enlarged ovaries. Indications for paracentesis include severe discomfort or pain, respiratory compromise, evidence of hydrothorax, or persistent oliguria/anuria despite adequate fluid replacement.Surgery should be avoided whenever possible in these patients.When ovarian hemorrhage is suspected, surgery may be necessary. The goal should be hemostasis, and the ovaries should be conserved when possible.In a situation of ovarian torsion, surgery may be performed to attempt to revascularize the ovary by unwinding the adnexa.

In-Patient Considerations

Inpatients should have a CBC and electrolytes daily. Renal function, liver enzymes, and coagulation profile should be repeated as needed.

Initial Stabilization

Vital signs and O2 saturation

Admission Criteria

Abdominal pain suspicious of torsion or hemorrhageIntolerance of food or liquidsHypotensionSignificant ascites or plural effusionsHemoconcentration: Hematocrit >50%; white blood cell (WBC) count >25,000Hyponatremia (Na <135 mEq/L)Hyperkalemia (K >5.0 mEq/L)

IV Fluids

With severe illness, IV fluid rehydration should be used. After an initial bolus of 500–1,000 mL, fluid administration should continue to maintain a urine output of at least 20–30 mL/hour. D5NS is preferred over Ringer’s lactate because of the risk of hyponatremia.Albumin 25% (50–100 g) should be reserved for situations in which IV fluids are inadequate to maintain hemodynamic stability or urine output.Diuretics should be used cautiously and only after intravascular volume has been restored. Diuretics may aggravate hypovolemia and hemoconcentration.

Discharge Criteria

Tolerating oral liquids and dietResolution of hemoconcentration and electrolyte imbalancesAdequate urine output

Ongoing Care

Follow-Up Recommendations

Patients discharged from the hospital should be followed with frequent health care provider contact until symptom resolution.

Patient Monitoring

Patients who have conceived should have an early ultrasound to confirm pregnancy and rule out multiple gestations and then routine antenatal care as indicated by their pregnancy.

Diet

Consume 1.0–1.5 L daily of a balanced salt solution, such as a sports drink, until resolution of symptoms.

Patient Education

Monitor oral intake and urinary output.Reduce activity to avoid abdominal trauma or impact.www.acog.org

Prognosis

OHSS is a self-limiting disease that will run its course over 10–14 days in the absence of an ensuing pregnancy and may persist for weeks in a pregnant patient. Supportive treatment is initiated to prevent further deterioration of the patient’s condition.

Complications

Ovarian hemorrhageOvarian torsionArterial and venous thrombosisAcute respiratory distress syndromeLiver failureRenal failure

Pregnancy Considerations

Patients who conceive a multiple gestation are at higher risk of OHSS.Studies have shown an increased risk of prematurity, low birth weight, pregnancy-induced hypertension, and gestational diabetes in women who had severe OHSS (4)[B].

References

1. Vloeberghs V, Peeraer K, Pexsters A, et al. Ovarian hyperstimulation syndrome and complications of ART. Best Pract Res Clin Obstet Gynaecol. 2009;23:691–709.

2. Youssef MA, van Wely M, Hassan MA, et al. Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysis.Human reproduction update. 2010

3. Practice Committee of American Society for Reproductive Medicine. Ovarian hyperstimulation syndrome. Fertil Steril. 2008;90:S188–93.

4. Raziel A, Schachter M, Friedler S, et al. Outcome of IVF pregnancies following severe OHSS. Reprod Biomed Online. 2009;19:61–5.

Codes

ICD9

256.1 Other ovarian hyperfunction

Snomed

213201002 hyperstimulation of ovaries (disorder)129635004 ovarian hyperstimulation syndrome (disorder)

Clinical Pearls

Patients who have had OHSS are more at risk for OHSS in the future, and this should be taken into consideration in subsequent treatment cycles.Abdominal and pelvic exams are contraindicated in patients with OHSS to avoid ovarian hemorrhage or rupture.OHSS is a self-limiting disease that will run its course over 10–14 days in the absence of an ensuing pregnancy and may persist for weeks in a pregnant patient. Management is mainly supportive to prevent and identify complications until resolution of symptoms.

Ruptured Ovarian Cyst – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Ovarian cysts are very common in reproductive-age women.Occasionally, once a cyst reaches a certain size or following an episode of strenuous activity or sexual intercourse, a cyst may rupture.A ruptured ovarian cyst may be asymptomatic or may cause extreme pain due to the presence of irritating fluid or blood in the abdominal cavity.A ruptured ovarian cyst may require surgical intervention.

Description

Types of ovarian cysts that may rupture fall into two groups: physiologic and pathologic (1)[C].

Physiologic or functional cysts form as a result of normal hormonal stimulation of the ovary. Most are asymptomatic and spontaneously resolve in 60–90 days. Follicular cysts form when a growing follicle fails to rupture and release an egg. Most common type of functional cystUnilateral and filled with serous fluidCorpus luteum cysts occur when an egg is released and pregnancy does not occur. The residual structure does not regress and may hemorrhage internally (hemorrhagic cysts).Theca-lutein cysts result from excessive stimulation of beta-human chorionic gonadotropin such as in infertility patients, molar pregnancies, or choriocarcinoma.Pathologic cysts are caused by a process other than normal hormonal stimulation. When followed, these cysts remain stable in size or may grow. Endometriomas are cysts or collections of blood clot that form as a result of cycling endometrial tissue on the ovary. Also called “chocolate cysts” due to their appearance.Mature cystic teratoma (dermoid) develop from totipotent germ cells. Most commonly, they contain mucinous material and hair.Up to 14% are bilateral and can grow very large.Less than 1% rupture spontaneously but may lead to shock, hemorrage, and acute peritonitis.Cystadenomas may have solid or mucinous areas and are usually benign but may have borderline malignant areas. They rarely rupture.Other cystic-appearing adnexal structures include paratubal cysts, tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy.

Diagnosis

A ruptured ovarian cyst may be asymptomatic or present as abdominal pain, varying from dull to acute.The broad range of presentations can prove to be a diagnostic dilemma for many physicians.

History

A general past medical and surgical history should be reviewed.Risk factors for gynecologic pain should be elicited: Possibility of pregnancyMenstrual history with attention to symptoms suggestive of endometriosis or history of cystsSexually transmitted disease historyLevonorgestrel-containing intrauterine device (up to 12% of users experience ovarian cysts) (2)[B]Infertility treatmentOther causes of acute abdominal pain should also be considered, including gastrointestinal and urologic etiologies.

Alert

Patients with bleeding diathesis or undergoing anticoagulation therapy may experience significant bleeding from hemorrhagic cysts.

Physical Exam

An uncomplicated ruptured ovarian cyst usually produces dull pain on palpation during the abdominal and pelvic exams. Enlargement of one of the adnexa may be present.A complicated ovarian cyst rupture may have more of an “acute abdomen” presentation due to the presence of blood or fluid in the abdominal cavity.

Diagnostic Tests & Interpretation

Lab

Serum quantitative beta-human chorionic gonadotropin (b-hcg) to rule out pregnancyComplete blood count (CBC) to evaluate for infection and monitor hemodynamic statusCervical cultures if pelvic inflammatory disease is suspectedUrinalysis to evaluate possibility of infection or stonesBlood type and cross matching if the patient is hemodynamically unstable and surgery is planned

Imaging

Transvaginal ultrasound: Most widely used and the gold standard of gynecologic imaging modality due to its cost-effectiveness and availability, and it is well-tolerated (1)[C],(3)[B] The presence of intraperitoneal fluid or blood in the absence of other gynecologic pathology is suggestive of a ruptured cyst.The ovaries may contain cysts, be slightly edematous, contain areas of hemorrhage, or appear normal.An ovarian cyst may be the causative factor in an episode of ovarian torsion. A torsed ovary is diagnosed by no blood flow to the ovary on ultrasound exam.

Alert

A torsed ovary requires immediate surgical intervention.

Follow-Up & Special Considerations

CT scan may be used if the ultrasound is unclear or the diagnosis is uncertain.

Diagnostic Procedures/Surgery

Traditionally, culdocentesis, or aspirating a small amount of peritoneal fluid transvaginally, has been used to diagnose the presence of fluid or hemoperitoneum from a ruptured cyst.Culdocentesis can also be used therapeutically as the removal of irritative blood or fluid from the abdominal cavity may relieve pain.

Differential Diagnosis

Should include all causes of acute abdominal pain, both gynecologic and nongynecologic, such as:

Ectopic pregnancyOvarian torsionPelvic inflammatory diseaseOvarian hyperstimulation syndrome (OHSS)AppendicitisDiverticulitisNephrolitiasisBowel perforation

Treatment

Medication

Pain due to an uncomplicated cyst rupture is usually self-limiting and can be managed on an outpatient basis with pain medication and rest (4)[B].

First Line

NSAID medications are the most effective at relieving pain due to peritoneal irritation.

Second Line

Narcotic pain medications may also be necessary acutely.

Additional Treatment

For patiets with painful, recurrent ovarian cysts, oral contraceptive pills can be prescribed to suppress ovulation. This may help prevent the formation of new cysts but will not impact cysts that have already formed (5)[A].

Issues for Referral

Referral to a gynecologic oncologist should be made in any postmenopausal female with an adnexal mass that has concerning ultrasound findings, an elevated CA-125, ascites, a nodular, fixed pelvic mass and a family history of breast or ovarian cancer. (1)[C],(3)[B]

Surgery/Other Procedures

If pain from a ruptured cyst is severe and persistent, the patient is unstable, or the diagnosis is uncertain, surgical evaluation is recommended (4)[B].

Laparoscopy is the better choice over laparotomy because it is less-invasive, better tolerated by patients, and can usually be done on an outpatient basis. (1)[C],(3)[B]Surgery includes suction-evacuation of any fluid or blood found in the pelvis as well as achieving hemostasis, if needed, at the site of the cyst. If a cyst wall is present, it should be removed.In the vast majority of cases, oophorectomy is not necessary.Laprascopic excision of the cyst and capsule of endometriomas substantially decreases risk of recurrence (6)[A].

Ongoing Care

Follow-Up Recommendations

Most functional cysts resolve spontaneously without treatment and “watchful waiting” with serial transvaginal ultrasounds for 2–3 cycles is appropriate.If cysts fail to resolve or develop concerning ultrasound findings (increasing size or complexity, nodules, septations, excrescences), they may be pathologic and surgical evaluation is recommended (5)[A].Concern for malignancy: The vast majority of ruptured ovarian cysts are a result of functional cysts in reproductive-age women and the risk of malignancy is very low. See “Issues for Referral” section.

Pregnancy Considerations

Ovarian cysts in pregnancy: With the widespread use of ultrasonography during pregnancy, up to 4% of pregnant women are found to have adnexal masses, most of which are follicular cysts which spontaneously resolve by 16 weeks’ gestation.Less than 2% will spontaneously rupture or torse during pregnancy; however, this can lead to preterm labor and delivery, which may cause poor obstetric outcomes.If they are painful, are large (>8 cm), or have ultrasound characteristics that are concerning for malignancy, elective surgical evaluation can be done during the 2nd trimester. (1)[C],(3)[B]

Patient Education

www.acog.org

References

1. Stany MP, Hamilton CA et al. Benign disorders of the ovary. Obstet. Gynecol. Clin. North Am. 2008;35:271–84, ix

2. Mirena [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2009.

3. Management of Adnexal Masses ACOG Practice Bulletin No. 83. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:201–14.

4. Bottomley C, Bourne T et al. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23:711–24.

5. Grimes DA, Jones LB, et al. Oral contraceptives for functional ovarian cysts. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006134. DOI: 10.1002/14651858.CD006134.pub3

6. Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004992. DOI: 10.1002/14651858.CD004992.pub3

Additional Reading

Raziel A, Ron-El R, et al. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol 1993 Jun; 50:77–81.

Møller LM et al. [Complications of gynaecological operations. A one-year analysis of a hospital database] Ugeskr. Laeg. 2005;167:4654–9.

Saunders BA, Podzielinski I, Ware RA, Goodrich S, DeSimone CP, Ueland FR, Seamon L, Ubellacker J, Pavlik EJ, Kryscio RJ, van Nagell JR et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol. Oncol. 2010;118:278–82.

Huchon C, Staraci S, Fauconnier A et al. Adnexal torsion: a predictive score for pre-operative diagnosis. Hum. Reprod. 2010;25:2276–80.

Hoo WL, Yazbek J, Holland T, Mavrelos D, Tong EN, Jurkovic D et al. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?Ultrasound Obstet Gynecol. 2010;36:235–40.

Falcone T. Risk of complications from gynecological surgery is lower with laparoscopy than with laparotomy. Evidence Based Obstetrics and Gynecology 2004;4:185–6.

Codes

ICD9

620.2 Other and unspecified ovarian cyst

Snomed

95598005 ruptured cyst of ovary (disorder)

Clinical Pearls

Functional ovarian cysts are very common in reproductive-age women and usually resolve spontaneously in 60–90 days.If a cyst does rupture, the pain is usually self-limited and can be treated with oral pain medications on an outpatient basis.Surgery may be necessary if pain is extreme or if the patient is unstable. This usually involves laprascopically evacuating irritating fluid and blood from the abdominal cavity, achieving hemostasis, and removing the cyst wall if possible.

Aniseed: The Ultimate Digestif – Relaxation from the Inside Out

Walk into any tavern in any small town along the Mediterranean, and you’ll probably encounter older gentlemen in their daily ritual of sipping pastis (in France), or ouzo (in Greece), or raki (in Turkey).

These drinks are digestifs—after-dinner drinks flavored with the distinctive licorice-like taste of aniseed (also called anise), a spice traditionally used to soothe the stomach and ease digestion.

Scientists have discovered that the gut-calming compound in aniseed is anethole, and that it is yet another factor that makes the Mediterranean diet one of the healthiest in the world.

Relaxation from the Inside Out

Watching the men in their midday ritual, it’s obvious that they’re relaxed and content, enjoying each other’s company. But that relaxation is also taking place inside the body. Research shows that anethole relaxes the parasympathetic nervous system, which controls the muscles of the digestive tract. In fact, when scientists first discovered the body-calming power of aniseed, they declared: “The relaxant effect justifies [the use of aniseed] in folk medicine.”

ANISE FLAVORS DIGESTIFS POPULAR IN TAVERNS ALONG THE MEDITERRANEAN.

It also justifies its use in modern medicine. The use of aniseed for digestive ills has been endorsed by the German Commission E Monographs, which help guide health professionals in that country in the medicinal use of herbs. Commission E reports that aniseed can help alleviate:

• Bad breath

• Colic

• Constipation

• Flatulence

• Indigestion

• Stomach cramps

Aniseed also relaxes the muscles of the respiratory tract, and Commission E reports the seed can ease the bronchial spasms that cause the symptoms of asthma.

In an experiment in the Middle East, scientists found anethole works to reduce digestive spasms in the same way as the prescription drug atropine (Sal-Tropine), which is used to treat stomach and intestinal spasms. Aniseed extract also showed effects similar to the asthma drug theophylline, which relaxes the muscles of the respiratory tract. Writing in the Journal of Ethnopharmacology, the researchers also noted that anethole has anti-inflammatory properties that might help calm asthma.

In another study, scientists in Saudi Arabia found that aniseed extract “completely inhibited ulcer formation” in animals with damaged stomachs. They noted that aniseed stopped the formation of ulcers through at least four different mechanisms, including reducing the acid secretions that can irritate the stomach lining.

In Lebanon, a traditional remedy for constipation is drinking a glass of water in which aniseeds have been soaked—and when scientists there tested the remedy, they found it was effective. The same researchers also found aniseeds helped conserve body fluids during hot weather, preventing dehydration.

Getting to Know Aniseed

The ancient Romans were renowned for gluttony. A typical feast might include camel, giraffe, wild boar, ostrich, lobster, sea scorpions, and songbirds. Afterward, to help digest it all, they would always eat a piece of aniseed-studded cake called mustaceus. Today, Romans (as well as other Europeans) achieve the same effect after far more modest meals by chewing on roasted aniseeds.

Aniseed has been anciently popular both as flavoring and medicine. By the 14th century, it was in such great demand that King Edward I of England saw it as revenue-building opportunity and declared it a taxable drug. He used the money to help pay for the repair and maintenance of London Bridge.

Ounce for ounce, aniseed is 13 times sweeter than sugar, making it a natural for dessert—whether dessert is a handful of roasted seeds, an anise cake, or an after-dinner digestif. And almost every European country seems to have an anise liqueur. In addition to pastis, the French also have anisette and pernod. Italy’s anise-flavored liqueurs are strega and sambucca. In Spain, it is ojen, in Egypt kibib, in Latin America aguardiente, and in the Middle East it’s arrak.

Of course, there are non-alcoholic ways to end your dinner with aniseed. The Portuguese, Germans, and Scandinavians all have specialty cakes and confections made with anise. Anise cookies are a Christmas tradition in Germany and Italy.

Aniseed is popular in Asian cooking, especially Chinese, but it’s used more in savory than in sweet dishes. Scandinavians also favor it in savory dishes, and put it in rye bread and a wide range of processed meats. In India, fennel seed (another licorice-tasting spice) is favored over aniseed.

You might also recognize the taste of anise in cough syrups and lozenges, where—as usual—it’s used both as flavoring and medicine.

How to Buy Aniseed

The majority of aniseeds—oval-shaped, and yellow to green in color—are imported into the US from Turkey. They are sold whole, cracked, or ground. However, the seeds are so small that grinding isn’t necessary—they’re best used whole. In fact, ground aniseed starts to lose its pungency fairly quickly, so if you purchase it ground, use it within a few months. (If you have ground aniseeds that have been sitting around for a long time, throw them away.) The whole seeds will keep in an airtight container in a dark place for about three years.

The anise plant grows in temperate climates.

Aniseed may help prevent and/or treat:

Asthma

Bad breath

Colic

Constipation

Dehydration

Flatulence

Indigestion

Stomachache

Ulcer

________________________________

Aniseed pairs well with these spices:

Allspice

Cinnamon

Clove

Coriander

Cumin

Fennel seed

Nutmeg

Star anise

and complements recipes featuring:

Breads and biscuits

Cookies

Cheese

Chicken

Pasta

Pork

Shellfish stews

Tomato sauces

Vegetable dishes

________________________________

Other recipes containing aniseed:

Chaat Masala

The anise plant—an annual with white flowers—grows almost everywhere the weather is warm, including Greece, North Africa, Spain, Italy, Malta, Central America, and Turkey. (Be careful if you see fresh anise for sale. Quite often, fresh fennel is mislabeled as anise.)

In the Kitchen with Aniseed

Aniseed’s unmistakable licorice flavor is similar to the taste of fennel seed, but it’s more delicate and doesn’t have an aftertaste.

Anise Kisses

Similar to the popular anise drops found in Germany, these little cookies are a pleasant way to freshen your breath and help digestion after a meal.

3 eggs

1 cup sugar

2 cups all-purpose flour

½ teaspoon baking powder

½ teaspoon cream of tartar

1½ tablespoons aniseed, slightly crushed

1. Beat the eggs and sugar with an electric mixer for 15 minutes. The mixture should look almost white and be thick enough to ribbon. Stir in the flour, baking powder, cream of tartar, and 1 tablespoon of the aniseed.

2. Grease two baking sheets or spray them with non-stick spray. Drop heaping teaspoons of the dough on the cookie sheet, separating them by an inch. Sprinkle the remaining aniseed on top. Bake in a preheated 350°F oven for 20 minutes or until the cookies are lightly browned. Remove them to a clean tea towel to cool.

Makes about 80 cookies.

Aniseed is popular in the United States in sweets, but it can also be used in savory dishes. You can roast and sauté it with other spices to enhance roasts, curries, tomato sauces, and stewed vegetables. You can use it to flavor cakes, relishes, marinades, salad dressings, and sausages.

Here are a few other ways to enjoy anise:

• Add a few crushed seeds to help balance rich sauces and gravies.

• When baking, slightly crush the seeds before adding to batter.

• Add a pinch or two of aniseed to vegetable soup, chicken potpie, and shellfish stews.

• Sprinkle the seeds on top of bread batters, sweet rolls, or into pancake batters.

• Put a small bowl of aniseed as a condiment on cheese trays.

AJOWAN Nature’s Pharmacy – Choline, An All-Purpose Healer

Ajowan (pronounced aj’o-wen) is a spice that’s popular in India—where it’s prized not only for its ability to add zest to curries and aroma to breads and biscuits, but also for its power to cure everyday ills. Many Indians are more likely to drink a little omam water—ajowan seeds steeped in warm distilled water—than to take an aspirin for a headache, cough medicine for a cold, an antacid for heartburn, or an antihistamine for allergies. And this folk remedy is now getting its scientific due: researchers have identified more than two dozen medicinally active compounds in the tiny crescent-shaped seeds. One of them is as strong as morphine.

Natural Pain Relief

When you chew on raw ajowan seeds, your mouth fills with a hot, bitter flavor that is so intense it momentarily numbs the tongue a bit. (In the kitchen, ajowan is always cooked, which takes the sting away.) That’s the thymol in ajowan—which can numb pain as well.

In a study by researchers in Iran (where ajowan is a folk remedy for headaches and arthritis), the pain-numbing power of ajowan was compared to morphine in laboratory animals—and ajowan was just as effective! “The present study supports the claims of traditional Iranian medicine showing the Carum copticum [ajowan] extract possesses a clear-cut analgesic [pain-relieving] effect,” write the researchers in the Journal of Ethnopharmacology.

The Secret Ingredient: Choline

Omam water is used as a home remedy for a variety of gastrointestinal ills: easing heartburn, relieving belching and bloating, reducing flatulence, and stopping diarrhea. In one experiment, researchers studied four different omam water solutions (whole seeds soaked in cold water, a warm infusion made with whole seeds, an extract of the powdered seeds soaked in cold water, and roasted seeds steeped in hot water) to find out which worked best and why.

When they gave each of the four preparations to laboratory animals, they discovered that all four helped heal the digestive tract, probably because of the presence of choline, a nutrient that aids the brain in sending healing messages to the body. But the roasted seeds had the greatest effect on GI health. When the scientists analyzed the seeds, they found acetylcholine, a chemical that controls involuntary muscles, like those that line the gut. Other researchers say the presence of acetylcholine may explain why ajowan so successfully soothes an ailing digestive tract.

An All-Purpose Healer

Asthma, high blood pressure, coughing, bacterial infections—ajowan has been used as a folk remedy for all of them. Researchers are supporting its healing reputation with new scientific evidence:

Asthma. Researchers gave a boiled extract of ajowan to people with asthma. Another group of asthmatics received theophylline, a bronchodilator that expands the airways. Every 30 minutes for two hours, the researchers measured lung function. The extract improved breathing ability by up to 32 percent—similar to the drug. Ajowan is comparable to theophylline in opening asthmatic airways, concluded the researchers in the journal Therapie.

High blood pressure. Ajowan had the same effect as the calcium channel blocker verapamil (Calan) in decreasing the blood pressure of laboratory animals. The researchers said that acetylcholine probably played a role in the pressure-lowering effect of the spice.

Cough. Iranian researchers found that ajowan works more effectively than codeine in suppressing a cough in laboratory animals. The probable reason: once again it’s the acetylcholine, calming the contractions that result in coughing.

Bacterial infection. Researchers in India found that ajowan disarmed eight strains of infection-causing bacteria. And in a test of 54 herbs against drug-resistant Salmonella bacteria, ajowan was one of those that could kill the germ.

Getting to Know Ajowan

Ajowan (which also goes by the names carom seeds and ajwain) is a stranger to most American kitchen cabinets but not to American medicine cabinets, where one or more of its active ingredients are used in cough medicines and lozenges. Thymol, its essential oil, is found in toothpaste and mouthwash. And components of the spice are also used to maintain the shelf life of packaged foods and perfumes. Ajowan is a cherished spice not only in the cuisine of India, but also in those of Iran, Pakistan,

AJOWAN IS AN INGREDIENT IN MANY PERFUMES.

Afghanistan, and North Africa. It has a natural affinity for starchy foods, and is used to perk up the flavor in dishes featuring root vegetables and legumes. In India, it’s an essential ingredient in lentil dishes, both for its taste and for its ability to improve digestion and prevent flatulence.

When dining in an Indian restaurant, you might find it in an appetizer fritter called pakora or a filled dumpling called samosa. It’s popular in Indian baked goods, and is found in a wafer-thin Indian flat bread called pappadam and in the puffed, pastry-like fried bread paratha. In Afghanistan, ajowan is used in breads and pastries. It’s also a key ingredient in the Ethiopian spice blend berbere, which is used to flavor vegetable dishes and meat stews.

Ajowan may help prevent and/or treat:

Allergies

Asthma

Cough

Diarrhea

Flatulence

High blood

pressure

(hypertension)

Infection

Pain

___________________________________

Ajowan pairs well with these spices:

Chile

Coriander

Garlic

Ginger

Oregano

Marjoram

Mustard seed

Turmeric

and complements recipes featuring:

Apples

Breads

Fish curries

Legumes

Pancakes

Root vegetables

Savory pastries

Vegetarian entrees

___________________________________

Other recipes containing ajowan:

Chaat Masala

How to Buy Ajowan

Ajowan is inexpensive but somewhat hard to find. It’s available in Indian markets and some specialty spice shops. Use the “Buyer’s Guide” to find it on the Internet.

The small seeds (the size of celery seeds) are always sold whole, as they are rarely used in ground form. Look for seeds that are light brown, uniform in color, and free of extraneous debris. The freshest seeds will have an herbal aroma. If stored in an airtight container away from heat and moisture, they will keep for two years or more.

Ajowan Parathas

Parathas are Indian pan-fried flatbreads that are often served as an accompaniment to a main meal. They are usually eaten with yogurt and pickles.

2 cups whole wheat flour

1 teaspoon salt

3 teaspoons ajowan seeds

1 teaspoon turmeric

½ teaspoon chili powder

Warm water

½ cup ghee or vegetable oil

1. Put the flour, salt, ajowan seeds, turmeric, and chili powder in a large mixing bowl. Combine thoroughly.

2. Make a well in the center of the flour and add a little water, about 2 tablespoons, and start mixing. Keep adding a little warm water until the mixture starts to get lumpy. Add and mix until you get medium-firm dough.

3. Put the dough on a floured surface and knead back and forth, turning, until the dough is nice and smooth, about 10 minutes. As you knead, the ajowan seeds will release their oils and aroma. Set the dough aside, covered with a clean kitchen towel, for 30 minutes.

4. Put a little flour on your hands and start to form the parathas by rolling into balls about the size of a golf ball. Make sure they are smooth with no cracks.

5. Lightly flour a rolling pin and roll out the parathas to the size of a crepe. You can stack them by separating them with a piece of waxed paper until ready to use.

6. Heat a heavy skillet or a griddle over medium-high heat and add enough oil to coat. When the oil is hot, add as many parathas as will easily fit without touching. When the dough starts to bubble, turn the parathas. Heat for about 30 seconds, cover the surface with a little oil, and turn again. Continue this process until both sides are crisp and golden brown. Transfer to a warm oven until you’re finished with the batch.

Makes about 1 dozen.

The small ajowan
plant is similar to parsley.

In the Kitchen with Ajowan

Ajowan has a strong thyme and anise-like flavor—and a little goes a long way. The spice always must be cooked to take away the numbing impact of the raw seeds. The longer it cooks, the mellower it gets. To enhance the flavor, first fry it in a little oil until it deepens in color.

The small seeds are chewable, so they don’t have to be ground. Ajowan lovers generally prefer the crunch that whole seeds add to a dish. But if you’d rather grind the seeds, dry roast them first. The seeds are tender and easily broken with the fingers, so you can get a fine powder using a mortar and pestle.

The spice is best known for the flavor it imparts to breads, savory biscuits, and desserts. It also blends nicely in chutneys, relishes, and pickles. Here are a few ideas for experimenting with ajowan:

• Add it to meat and fish curries, lentil stews, and potato casseroles. Because it mellows with long cooking, feel free to add more than a pinch.

• Dry roast and add it to trail mix or spiced nut blends.

• Add a pinch to homemade bread and pastry doughs. It gives piquancy to the pastry crust of a chicken potpie or other meat pies.

• Sprinkle on top of steamed or stir-fried vegetables.

• Blend roasted seeds into a compound butter for sautéing vegetables.

• Fry it in oil and combine it with garlic, ginger, and turmeric to make a stir-fry.

Amchur: Mango with an Extra Pinch of Health – Filled with Good-for-You Phytochemicals

India’s world-famous Madras Marina Beach, on Bengal Bay’s northern coastal town of Chennai, is one of the largest and most beautiful beaches in the world. It’s a year-round destination, but in late spring it really starts to teem with vacationers, many of whom head as fast as they can to one of the scores of seaside food stalls to snack on the region’s famous delicacy—sliced and spiced green mango.

Green mango is the same tropical fruit that Americans enjoy for breakfast, sliced over cereal or pancakes, or chopped into a salsa to complement a Caribbean fish dinner, but with one difference. Americans eat mangoes when they’re ripe—orange, juicy, and sweet. In India, they eat mangoes when they’re unripe—green and tart.

Most Americans these days are familiar with mango—it’s found in the produce section of supermarkets and is a common ingredient in fusion cuisine. But unless you’ve traveled to India or Asia, or shopped in an Indian or Asian specialty market, it’s unlikely you’ve experienced mango as a spice. The spice—amchur, am meaning mango and chur meaning powder—is a powder made from unripe, green mango. And like the whole fruit, it’s very good for you, delivering a concentrated dose of mango’s many health-giving nutrients.

Filled with Good-for-You Phytochemicals

As its colorful flesh suggests, mango—like oranges, carrots, sweet potatoes, and other orange-colored foods—is filled with healthful phytochemicals, the nutritional compounds that help prevent many chronic diseases, such as heart disease, cancer, and type 2 diabetes. The standout phytochemical in mango is beta-carotene, a powerful antioxidant. But it’s rich in several others.

When researchers from the University of Florida measured the phytochemical content of eight tropical fruits, mango was the winner. “We think mangoes have some unique antioxidants, as well as quantities of antioxidants that might not be found in other fruits and vegetables,” they commented. And one of the most unique—and most powerful—is lupeol.

Anti-cancer. Studies show that lupeol can block the mutation of DNA, one of the main causes of tumor formation—and it does so as an antioxidant, neutering radical oxygen species (ROS), hyperactive molecules that run amok, triggering mutations.

And in an animal study on prostate cancer, lupeol battled back against prostate damage, leading researchers to conclude that “mango and its constituents . . . deserve study as a potential chemopreventive agent against prostate cancer.”

Prostate health. An animal study also shows the lupeol in mango can reduce an enlarged prostate, a condition called benign prostate hypertrophy (BPH) that strikes four out of five men over 50, with urinary symptoms such as urgency, more frequent urination, a weaker stream, straining, and waking up several times a night to urinate. Lupeol, concluded the researchers, “could become an important alternative to treatment of BPH.”

Balancing blood sugar. Studies from researchers in Brazil show mango can help normalize blood sugar (glucose) levels, with glucose level in animals fed mango flour 66 percent lower than in non-mango animals.

Reversing gum disease. In other animal research, researchers found that mangiferin—another antioxidant from mango—can reduce the inflammation of periodontal (gum) disease and slow the rate of bone loss. “Our results have demonstrated promising therapeutic potential of mangiferin both in the prevention and treatment of periodontitis,” they conclude.

Pollution protection. Researchers in India found that mangiferin protected liver cells against the damaging effects of cadmium, a pollutant.

Strengthening the thyroid. In more research from India, animals given extracts of mango had higher output of several thyroid hormones. Some health experts think that hypothyroidism—low thyroid function—is epidemic in the US, accounting for a wide range of problems, including weight gain and fatigue.

 

Amchur is dried, green mango.

Heart disease. Another team of Indian researchers found that mangiferin helped slow the development of heart disease in animals fed a high-fat diet, reporting their findings in Vascular Pharmacology. And a team of Cuban researchers studied a proprietary mangiferin extract called Vimang and concluded that it had “potential” in the treatment of heart disease.

The Indian Mango—Cream of the Crop

There are at least a hundred different varieties of mango, with varying sizes, colors, textures, and tastes. If you thought that a mango you ate today had a different flavor than the mango you ate last week, it’s probably not your imagination—especially if one mango came from India and the other didn’t.

The mangoes of India are different than the mangoes grown anywhere else in the world: larger, less fibrous—and much sweeter. Among mango connoisseurs, the flavor of the Indian mango is considered to be unsurpassed. (And among Indian mangoes, the Alphonso is considered the best brand.)

Late spring marks the beginning of mango season in India, when the branches of the big, burly trees start to sag from the weight of fist-sized fruit. People buy them by the dozens to eat green, sprinkled with cumin, salt, and sometimes soy sauce. Mangoes are enjoyed just as much in the summertime when they’re ripe, but it’s the tart taste of the green mango that is truly prized.

Amchur may help prevent and/or treat:

Benign prostatic

hypertrophy (BPH)

Cancer

Diabetes, type 2

Gum disease

(periodontal disease)

Heart disease

Thyroid problems

___________________________________

Amchur pairs well with these spices:

Ajowan

Almond

Black cumin seed

Black pepper

Chile

Coriander

Cumin

Garlic

Ginger

Fenugreek seed

Mint

Star anise

Tamarind

and complements recipes featuring:

Chickpeas

Chutneys

Curries

Marinades

Meats

Seafood

___________________________________

Other recipes containing amchur:

Chaat Masala

Los Banos Low-Fat Brownies

Like avocados, mangoes only ripen properly off the tree. In fact, mangoes left too long on the tree are inedible, as worms invade the ripening flesh. It’s because they are picked still green that they are ideal for exporting—a big benefit for people in the United States, Europe, and other temperate areas where mangoes don’t grow.

Mangoes grow not only in India, but also in Africa, Southeast Asia, the Caribbean, Latin America, and the Pacific Islands, including Hawaii. But the fruit originated in India, and India is by far the world’s largest grower. During the late 17th century, emperors of India’s Mogul dynasty ordered the planting of 100,000 mango trees to make sure there would be an unlimited supply of the fruit. To this day, Indians know how to put all those mangoes to tasty use. And one such use is amchur.

Getting to Know Amchur

Amchur is little-known outside of India, but it’s a staple in Indian homes. It’s made by drying green mango slices in the sun and then pulverizing the dried fruit into a powder. It has a tart and tangy taste, similar to powdered lime. And, traditionally, it’s used in much the same way Americans use lime (and lemon): as a souring agent. In India, it helps sour chutneys (this is why the mango chutney you can buy bottled in Indian and Asian markets is green, something that often puzzles people unfamiliar with the Indian penchant for the unripe mango). It also sours relishes and pickles (green mango pickles are often highly spiced and extremely hot). And it sours curries, especially vegetable curries. Amchur is also a key ingredient in the spice blend chaat masala, a sour condiment used to complement curry dishes.

Most notably to aficionados of Indian cuisine, amchur is used to tenderize the meat and chicken cooked in famed Indian tandoori ovens. It’s one of the ingredients credited for making tandoori dishes succulent and juicy. (It also lowers the pH level of a sauce, keeping it fresher longer.)

Garbanzo Beans with Mushrooms and Toasted Almonds

Chana means beans in India. This dish is adapted from a popular dish often sold by food vendors in South India. Serve it over basmati rice for a main vegetarian entree. The sambaar masalaadds extra heat.

3 tablespoons canola oil

3 cups sliced mushrooms

½ cup sliced almonds

1 teaspoon black cumin seeds

2 cups chopped onions

10 garlic cloves, minced

1 tablespoon grated fresh ginger

1 tablespoon amchur

1 tablespoon ground fenugreek

1 teaspoon sambaar masalaor 1 tablespoon garam masala

1 teaspoon ground cumin

3 dried red chiles, seeds removed and diced

1½ cups vegetable stock

2 15.5-ounce cans garbanzo beans (chickpeas)

¼ cup cilantro

1. Heat 1 tablespoon of oil in a medium skillet over medium-high heat. Add the mushrooms and fry, stirring constantly, until the mushrooms release their liquid and it evaporates, about three minutes. Add a few tablespoons of vegetable stock if the pan gets too dry. Transfer to a plate and set aside.

2. Wipe out the skillet with a paper towel and add another tablespoon of oil. When the oil gets hot, add the almonds and stir-fry until lightly browned, stirring gently, about three minutes. Transfer to a plate and set aside.

3. Heat the last tablespoon of the oil in a medium-sized Dutch oven over medium-high heat. When hot add the black cumin seeds and sizzle for 30 seconds. Add the onions and fry until golden brown, about five minutes, stirring constantly. Add the garlic and ginger and stir five minutes more, stirring constantly. Add the amchur, fenugreek, sambaar masala, ground cumin, and chiles and cook one minute.

4. Stir in the stock, the garbanzo beans, and the reserved mushrooms. Bring to a simmer, cover, and cook for 25 minutes. When serving, sprinkle with the toasted almonds and cilantro.

Makes 6 servings.

AMCHUR IS USED TO TENDERIZE THE MEAT AND CHICKEN COOKED IN INDIAN TANDOORI OVENS.

Amchur is more popular in northern India. Southern Indians prefer tamarind as a souring agent.

How to Buy Amchur

Amchur is sold as a powder or as dried green mango slices. Your best bet is the powder—the dried slices are tough and hard to grind.

When pulverized, green mango turns gray, but the amchur you’ll find in the market is tan, thanks to a touch of golden-hued turmeric, another popular spice from India. So don’t be put off by a gray color; it has nothing to do with freshness or quality. A grayer amchur only means less (or no) turmeric was added.

Amchur can be purchased at Indian markets or via the Internet. It’s sold under the names amchur, amchoor, or green mango powder. It will keep in a cool, dark place in an airtight container for about a year.

In the Kitchen with Amchur

Think of green mango powder as an exotic (and dry) alternative to citrus. It has a tart flavor but is much milder than a lemon. Use it as you would any souring agent, such as in pickles, chutneys, and relishes.

Amchur is excellent in dry spice blends when you need something tart to add balance. Here are a few other ideas for cooking with the spice:

• Use it in marinades with or instead of citrus juice. It works particularly well in marinades for tough cuts of meat.

• For a tangy taste, sprinkle it on steamed vegetables, as you would lemon.

• Sprinkle a little in melted butter served with steamed shrimp or lobster.

• Sprinkle it on meat and vegetable kebobs before grilling.

• Add it to your favorite fruit chutney recipes.

• Sprinkle it in marinated cucumber and onion salads.

How to Buy and Store the Healing Spices

Imagine an ice cream sundae without vanilla, pesto without basil, salsa without chile, or paella without saffron. You can’t, because the spice defines everything about the dish—its taste, texture, and aroma, how it is made, and how it is remembered. Eating would be just about joyless if it weren’t for spices—and the best cooks know it. Case in point:

Several years ago, researchers from Cornell University examined more than 4,500 recipes from nearly 100 cookbooks. They found that 93 percent included at least one spice, with the ingredient lists averaging four. That average, however, is considered a minimum in the cuisines popular for their unique and intense flavors, such as Indian, Indonesian, and Thai. Compared to those cuisines, the typical American diet is bland.

IN A SURVEY OF COOKBOOKS BY FOOD SCIENTISTS, 93 PERCENT OF RECIPES CONTAINED AT LEAST ONE SPICE; THE AVERAGE WAS FOUR.

It’s not that Americans aren’t fond of exotic food. The proliferation of restaurants featuring these and other ethnic cuisines across the United States attests to the growing American interest in spicy fare. So why aren’t Americans enjoying more spicy food at home?

They’re intimidated! Most of the spices from nations with spicy cuisines are unfamiliar to American palates. Many of them, such as galangal, asafoetida, and black cumin (to name a few), aren’t available in typical supermarkets—in fact, it’s possible you may never have heard of them! Plus, a long list of spices in a recipe makes a dish seem complicated and expensive.

But enjoying spices at home doesn’t have to be intimidating—or complicated, or expensive. The secret to feeling comfortable with spices is understanding them—how to buy them, use them, and combine them in ways that quickly transform a bland recipe into a flavor to savor. This website not only offers hundreds of reasons for spicing up your life to help improve health and avoid illness—it also gives you hundreds of ideas for doing it in a very tasty way.

But first, you need to know the basics.

Spices in Cooking and Eating

Contrary to popular belief, spice is not a synonym for hot. In fact, most spices do not add fiery flavor to food. Rather, spices are aromatic, which serves several culinary purposes. Spices:

• give food a pleasant, mouthwatering aroma that stimulates the appetite and increases the enjoyment of food.

• blend into new and pleasing taste sensations.

• impart a characteristic flavor, be it sweet, sour, tangy, or hot.

• serve as a natural tenderizer for tough but economical meats.

• add body and texture to a dish, with some acting as thickeners and binders for sauces.

• color a dish, making it appetizing to look at.

• assist the digestive process.

All spices perform several of these tasks. Turmeric and saffron, for example, add both brilliant color and aroma to food. Coriander acts as a thickener, while also giving a dish a nutty flavor. Ginger enlivens taste and aids digestion.

However, sniff any raw spice and you’ll detect little, if any, aroma. That’s because, with few exceptions, spices are just like any other food—something to cook. Most raw spices are dried organic matter—roots, bark, leaves, dried fruit, and the seeds of shrubs and trees. Those raw items are difficult to digest and may leave you with an upset stomach if you try.

In India, where highly spiced foods are a cherished way of life, cooks typically add spices to hot oil at the beginning of food preparation, just before adding other ingredients. This releases the spices’ volatile oils, which flood the senses with heady aromas. Spices are again added at the end of cooking. As you read about how to cook with spices, you’ll develop a sure sense for how to add spices to your at-home meals. And you’ll discover that cooking with the healing spices is easy. So is the first step: obtaining them.

Finding Spices

All the healing spices are easy to obtain, although it may take some ingenuity to find some of them, depending on where you live. You’ll discover that they needn’t be expensive, either.

Half of all Americans live within 50 miles of a major city that includes large Asian, Indian, and Latin populations, and most of these cities have at least one Asian, Indian, and Latin grocery store. Those stores are where you’ll find some of the more unusual healing spices, such as amchur, cardamom, kokum, galangal, and tamarind. You can find these markets by looking in the phone book or on the Internet, as they generally do not advertise. (And Oriental sections of national and regional supermarkets continue to get more expansive, with many spices that you couldn’t find a few years ago—such as fenugreek, lemongrass, star anise, and wasabi—appearing on shelves.)

Many of these markets, particularly the Indian markets, sell spices in bulk, packaged in tins or plastic bags of 14 ounces or more. (Spices purchased in bulk keep best if you remove them from their plastic wrapping and store them in airtight glass containers.) The cost of buying bulk is much less than buying 2.5-ounce bottles of the same spice in a large chain supermarket. Or you can share the cost, splitting the bulk purchase with family or friends.

There are also many spice retailers that sell through the Internet. But compare prices, as spices bought via the Internet are generally more costly than those from a local market. You’ll find a helpful list of Internet spice retailers in the “Buyer’s Guide”.

Purchasing and Storing Spices

Spices are typically sold in one- or two-ounce tins or glass containers. Spices sold in bulk generally come in plastic. (Stay away from cardboard packaging, which doesn’t preserve freshness.) As mentioned earlier, if the spice isn’t sold in tin or glass, it’s best to transfer it as soon as you get home into an airtight tin or glass container in order to preserve freshness.

You can purchase spices fresh, dried, whole, cracked, coarsely ground, and finely ground. But you’ll get the most aromatic pleasure out of your spices if you buy them whole and grind them yourself. That’s because whole spices start to “leak” aroma and flavor as soon as they are ground. This is why whole spices have very little, if any, aroma until they are ground.

If you grind your spices, store them in small spice jars that you can purchase at many discount stores, supermarkets, major retailers that sell kitchen equipment, or Internet sites that sell spices.

Store all spices in a cool, dark place. Heat, moisture, and direct sunlight accelerate the loss of flavor and can break down the aromatic chemical components. Ideally, store spices at a temperature between 50° and 60°F. High temperatures can cause spices to cake or harden, and change or lose color.

When using spices, don’t let them sit around the stove. Tightly close the container immediately after its use and return it to its cool storage space as soon as possible.

Under ideal conditions, ground spices will keep for about a year and whole spices for two or three years.

Old spices lose flavor and healing power. If a spice in your pantry is past its prime, throw it out. You can test ground spices by opening a bottle and holding it up to your nose—if there is little aroma, toss it. To test whole spices, rub them lightly between your fingers. If they are still fresh, they will release a little volatile oil that you can feel and smell.

Spice Equipment

Cooking with the healing spices requires only a few pieces of equipment.

Mortar and pestle. This common device is essential for crushing spices in small amounts—a teaspoon or less. Chances are you already own one. Make sure the pestle fits snuggly in the mortar. If not, it will make crushing and grinding more difficult. The best mortar and pestles are marble. (Those made of wood retain the aroma of volatile oils, creating an unwanted addition to the aroma of other spices.)

An alternative to a mortar and pestle is a rolling pin—put the spice between two pieces of wax paper and crush it by rolling over it repeatedly with the pin.

Spice grinder. Grinding more than a tiny amount of spice requires an assist from electric power. There are three kinds of appliances suited to the job: a spice grinder, a coffee grinder, or a hand-held mini food processor. You’ll get spices ground to a smooth powder in seconds, compared to the task of doing it by hand with a traditional mortar and pestle. And no skill is involved. Just drop the spice in and turn on the appliance. (Make sure to follow the manufacturer’s directions.) If you start to detect an odor in the appliance after several uses, grinding sugar or rice should make it disappear.

Small heavy skillet. You will need this for dry roasting, a technique required before grinding many whole spices and seeds. (See below.) The best kind is an old-fashioned, treated cast iron skillet. Not only does it work the best, it’s also inexpensive compared to many of today’s top-of-the-line pots and pans. A smaller pan is ideal for cooks preparing spices at home.

Roasting Spices

Most (but not all) whole spices benefit from a light, dry roasting before grinding. It’s important that you do this properly. The goal is to brown them without burning them. If it’s your first try, be prepared to lose a batch or two.

To begin, heat a small heavy frying pan (preferably one made of cast iron) over medium heat until it gets nice and hot, about two minutes. Add the spices. Grab the handle (make sure to use an oven mitt or potholder, as the handle gets very hot) and shake the spices around. At the same time, stir the spices continuously with a wooden spoon so they don’t burn. For the first minute or two while the spices are losing their moisture, nothing will happen. As they continue to fry, they will start to smoke. Your nose will sense the fragrance as they start to release their aroma. Continue to fry until they are a deep brown. If they are cooking too fast, turn down the heat. Transfer the spices to a clean plate to cool before grinding.

Spices are generally roasted individually, even if you are making a blend, as they don’t brown at the same rate.

The whole process can take anywhere from a few to 10 minutes. The time element depends on the type of spice you are roasting, the amount of spice, and the size of the pan. The larger the pan, the faster the spices will brown.

Spices are beautiful to behold, pleasing to smell, and memorable to taste.

Otitis Media – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Inflammation of the middle earAcute otitis media (AOM): Inflammation of the middle ear often following a viral upper respiratory infection (URI): Rapid onset; cause may be infectious, either viral (AOM-v) or bacterial (AOM-b), but there is also a sterile etiology (AOM-s)Recurrent AOM: =3 episodes in 6 months or =4 episodes in 1 yearOtitis media with effusion (OME): Persistent middle ear fluid that is associated with AOM but can arise without prior AOMChronic otitis media with or without cholesteatomaSystem(s) affected: Nervous; ENTSynonym(s): Secretory or serous otitis media

Epidemiology

Incidence

AOM: Predominant age: 6–24 months; declines >7 years; rare in adultsPredominant sex: Male > FemaleBy age 7 years, 93% of children have had =1 episodes of AOM; 39% have had =6.Placement of tympanostomy tubes is 2nd only to circumcision as the most frequent surgical procedure in infants.Increased incidence in the fall and winterOME: 90% of children aged 6 months–4 years have at least 1 episode.

Prevalence

Most common infection for which antibacterial agents are prescribed in the USDiagnosed 5 million times per year in the US

Risk Factors

Premature birthBottle-feeding while supineRoutine daycare attendanceFrequent pacifier use after 6 months of ageSmoking in householdMale genderNative American/Inuit ethnicityLow socioeconomic statusFamily history of recurrent otitisAOM before age 1 is a risk for recurrent AOM.Presence of siblings in the householdUnderlying ENT disease (e.g., cleft palate, Down syndrome, allergic rhinitis)

Genetics

Strong genetic component in twin studies for recurrent and prolonged AOMMay be influenced by skull configuration or immunologic defects

General Prevention

PCV-7 immunization reduces number of cases of AOM by about 6–28% (however, evidence shows that this is offset by an increase in AOM caused by other bacteria) (1)[C].Influenza vaccine reduces AOM by about 30% in children older than age 2 (by preventing influenza).Breastfeeding for =6 months is protective.Avoiding supine bottle-feeding, passive smoke, and pacifiers >6 months may be helpful.Secondary prevention: Adenoidectomy and adenotonsillectomy for recurrent AOM has limited short-term efficacy for children older than 3 years of age and is associated with its own adverse risks.

Etiology

AOM-b (bacterial): Usually, a preceding viral URI produces eustachian tube dysfunction: S. pneumoniae: 20–35%H. influenzae: 20–30%.M. (B.) catarrhalis: 15%Group A streptococci: 3%S. aureus: 12% produce ß-lactamases that hydrolyze amoxicillin and some cephalosporins.AOM-v (viral): 15–44% of AOM infections are caused primarily by viruses (e.g., respiratory syncytial virus, parainfluenza, influenza, enteroviruses, adenovirus, human metapneumovirus, and parechovirus).AOM-s (sterile/nonpathogens): 25–30%OME: Eustachian tube dysfunctionAllergic causes are rarely substantiated.

Commonly Associated Conditions

Diagnosis

AOM: Acute history, signs, and symptoms of middle ear inflammation and effusion: Earache (LR = 3–7.3)Preceding or accompanying URI symptomsDecreased hearingInfectious AOM: Fever (although it is debatable whether OM itself causes fever or fever is due to accompanying viral illness)Decreased eardrum mobility (with pneumatic otoscopy) (LR = 51)Eardrum bulging (LR = 51), cloudy (LR = 34), distinctly red (LR = 8.4). Presence of air–fluid level behind the tympanic membrane [B].Redness alone is not a reliable sign.Otorrhea if eardrum is perforatedAOM in infants and toddlers: May cause few symptoms in the 1st few months of lifeIrritability may be the only symptom.OME: Usually asymptomaticDecreased hearingEardrum often dull but not bulgingDecreased eardrum mobility (pneumatic otoscopy)Presence of air–fluid levelWeber test is positive for an ear with effusion.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

WBC count may be higher in bacterial AOM than in sterile AOM, but is almost never useful.

Diagnostic Procedures/Surgery

To document the presence of middle ear fluid, pneumatic otoscopy can be supplemented with tympanometry and acoustic reflex measurement.Hearing testing is recommended when hearing loss persists for =3 months or at any time language delay, significant hearing loss, or learning problems are suspected.Language testing should be performed for children with hearing loss.Tympanocentesis for microbiologic diagnosis is recommended for treatment failures; may be followed by myringotomy.

Differential Diagnosis

TympanosclerosisRedness because of cryingTraumaAOM vs OMEAOM-b vs AOM-v vs AOM-sReferred pain from the jaw, teeth, or throatOtitis externa

Treatment

Medication

First Line

AOM: AAP-AAFP Consensus Guideline recommends amoxicillin 80–90 mg/kg/d; children >2 years old with no complications, 5- to 7-day course [A]; 10-day course for children <2 years old. It is unclear if daily or b.i.d. dosing is as effective as t.i.d. or q.i.d. dosing (2)[A].If penicillin-allergic:Non–type 1 hypersensitivity reaction: Cefdinir 14 mg/kg/d, cefpodoxime 10 mg/kg/d, or cefuroxime 30 mg/kg b.i.d.Type 1 hypersensitivity to penicillin: Azithromycin (10 mg/kg/d [maximum dose 500 mg/d] as a single dose on day 1 and 5 mg/kg/d [maximum dose 250 mg/d] for days 2–5)Other alternatives: Clarithromycin 15 mg/kg/d (b.i.d. dose), erythromycin-sulfisoxazole (50 mg/kg/d), or sulfamethoxazole–trimethoprim (6–10 mg/kg/d based on trimethoprim)A single dose of parenteral ceftriaxone (50 mg/kg) is as effective as a full course of antibiotics in uncomplicated AOM.A single dose of azithromycin has been approved by FDA, but studies did not include otitis-prone children or have criteria for AOM diagnosis [B].OME: See General Measures; no benefit to treatment. Medications promote transitory resolution in 10–15%, but effect is short lived.

Second Line

Alternative antibiotics are indicated for the following AOM patients: Persistent symptoms after 48–72 h of amoxicillinAOM within 1 month of amoxicillin therapySevere earacheAge <6 months with high feverImmunocompromised: Amoxicillin-clavulanate 90 mg/kg–6.4 mg/kg/d, b.i.d.Ceftriaxone 50 mg/kg IM or IV q24h for 3 consecutive days can be reserved for those who are too sick to take oral medications or fail amoxicillin-clavunate. Neither erythromycin-sulfisoxazole nor trimethoprim-sulfamethoxazole should be used as a 2nd-line agent in treatment failures.Recurrent AOM: Antibiotic prophylaxis for recurrent AOM (>3 distinct, well-documented episodes in 6 months) with amoxicillin 20 mg/kg/d for 3 months resulted in a benefit of ~1 fewer episode per child per year. The risks of increased resistance and side effects are not thought to be worth it.

Additional Treatment

General Measures

Assess pain.Acetaminophen, ibuprofen, benzocaine drops (additional but brief benefit over acetaminophen)Significant disagreement exists about the usefulness of antibiotic treatment for this often self-resolving condition. Studies suggest that ~15 children need to be treated with antibiotics to prevent 1 case of persisting AOM pain at 1–2 weeks (NNT = ~15); the NNT to cause harm (primarily diarrhea) is 8–10.81% of patients over 2 years of age are better in 1 week vs 94% if antibiotics are used.Delay of antibiotics found a modest increase in mastoiditis from 2/100,000 to 4/100,000.The AAP/AAFP guideline committee recommends the following for observation vs antibacterial therapy, although these guidelines are not rigorously evidence-based: <6 months of age: Antibacterial therapy should be administered to any child, regardless of the degree of diagnostic certainty.Children >6 months: Antibacterial therapy is recommended when the diagnosis of AOM is certain and the illness is severe (i.e., moderate-to-severe otalgia or fever =39°C in the previous 24 h).Observation is an option when the diagnosis is certain, but illness is not severe, and in patients with an uncertain diagnosis.OME: Watchful waiting for 3 months per AAP/AFPP guidelines for those not at risk (see Complications). 25–90% will recover spontaneously over this period: No benefit of antihistamines or decongestants (3)[A] or antibiotics or systemic steroids

Complementary and Alternative Medicine

It is unclear whether alternative and homeopathic therapies are effective for AOM, including mixed evidence about the effectiveness of zinc supplementation of reducing AOM.Xylitol, probiotics, herbal ear drops, and homeopathic interventions may be beneficial in reducing pain duration, antibiotic use, and bacterial resistance.

Surgery/Other Procedures

Recurrent AOM: Consider referral for surgery if =3 episodes of well-documented AOM within 6 months, =4 episodes within 12 months, or AOM episodes that occur while on chemoprophylaxis.Tympanostomy tubes may be effective in selective patients.Adenoidectomy has limited or no effect.Adenotonsillectomy reduced the rate of AOM by 0.7 episode per child only in the 1st year after surgery and had a 15% complications rate.OME: Referral for surgery for tympanostomy should be individualized. It can be considered if >4–6 months of bilateral OME and/or >6 months of unilateral OME and/or hearing loss >25 dB or for high-risk individuals at any time.Tympanostomy tubes may reduce recurrence of AOM minimally, but it does not lower risk of hearing loss (4)[A].Adenoidectomy is indicated in specific cases; tonsillectomy or myringotomy is never indicated (5)[A].

In-Patient Considerations

Initial Stabilization

Outpatient treatment except when surgery is indicated or for AOM in febrile infants <2 months old or children requiring ceftriaxone who also require monitoring for 24 h

Ongoing Care

Follow-Up Recommendations

Patients with otitis media who do not respond within 48–72 h should be re-evaluated:

If therapy was delayed and diagnosis is confirmed, start therapy with high-dose amoxicillin.If therapy was initiated, consider changing antibiotic; options are limited because macrolides have limited benefit against H. influenza over amoxicillin, and most oral cephalosporins have no improved outcomes.

Patient Monitoring

AOM: Up to 40% may have persistent middle ear effusion at 1 month, with 10–25% at 3 months.OME: Repeat otoscopic or tympanometric exams at 3 months as indicated, as long as OME persists or sooner if red flags (see above).

Prognosis

See Treatment under General Measures.Recurrent AOM and OME: Usually subsides in school-age children; few have complications.

Complications

AOM: Serious complications are rare: Tympanic membrane perforation/otorrheaAcute mastoiditisFacial nerve paralysisOtitic hydrocephalusMeningitisHearing impairmentOME: Speech and language disabilities may occur. Hearing loss is not caused by OME, but in children who are at risk for speech, language, or learning problems (e.g., autism spectrum, syndromes, craniofacial disorders, developmental delay, and children already with speech/language delay), it could lead to further problems because they are less tolerant of hearing impairment.Recurrent AOM and OME: Atrophy and scarring of eardrumChronic perforation and otorrheaCholesteatomaPermanent hearing lossChronic mastoiditisOther intracranial suppurative complications

References

1. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med. 2001;344:403–9.

2. Thanaviratananich S, Laopaiboon M, Vatanasapt P. Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media.Cochrane Database Syst Rev. 2008;CD004975.

3. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008;CD001727.

4. Lous J, Burton MJ, Felding JU, et al. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev.2005;CD001801.

5. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics. 2004;113:1412–29.

Additional Reading

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004; 113:1451–65.

Gould JM, Matz PS et al. Otitis media. Pediatr Rev. 2010;31:102–16.

Shaikh N, Hoberman A, Kaleida PH, et al. Videos in clinical medicine. Diagnosing otitis media–otoscopy and cerumen removal. N Engl J Med. 2010;362:e62.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Ear pain

Codes

ICD9

381.00 Acute nonsuppurative otitis media, unspecified381.3 Other and unspecified chronic nonsuppurative otitis media381.10 Chronic serous otitis media, simple or unspecified381.4 Nonsuppurative otitis media, not specified as acute or chronic382.00 Acute suppurative otitis media without spontaneous rupture of eardrum382.3 Unspecified chronic suppurative otitis media382.9 Unspecified otitis media381.01 Acute serous otitis media

Snomed

65363002 otitis media (disorder)81564005 chronic serous otitis media (disorder)43561008 chronic exudative otitis media (disorder)194281003 acute suppurative otitis media (disorder)359609001 acute nonsuppurative otitis media (disorder)194240006 acute non-suppurative otitis media – serous (disorder)

Clinical Pearls

Pneumatic otoscopy is single most specific and clinically useful test for diagnosis.Consider a delay of antibiotics for 24–48 hours in uncomplicated children >2 years old.1st-line treatment is amoxicillin 80–90 mg/kg/d for 10 days for children <2 years old; consider 5- to 7-day course in children >2 years old.Erythema and effusion can persist for weeks.Antibiotics, antihistamines, and steroids are not indicated for OME.

Childhood Cancers: Retinoblastoma

Retinoblastoma is the most common childhood malignant tumor of the retina, the membrane at the back of the eyeball. About 300 children in the United States develop this cancer each year. The vast majority of retinoblastoma cases occur in very young children: 66 percent occurring before age two and 95 percent before age five. In some instances, retinoblastoma is diagnosed at birth. The tumor may occur in one eye (75 percent) or both eyes (25 percent).

How It Spreads The tumor may be confined to the retina or extend directly to other parts of the eye (commonly the optic nerve). In its later stages, it may spread to the central nervous system or other parts of the body.

What Causes It There are hereditary (40 percent) and nonhereditary (60 percent) forms of retinoblastoma. The hereditary form may be unilateral (one eye) but more typically is bilateral (both eyes). When there is disease in both eyes, it is almost always the hereditary form. There is no racial or gender predilection. The retinoblastoma (RB) gene has been identified on chromosome 13. Retinoblastoma is the best example of a genetic predisposition to cancer. Children who inherit defects in the RB gene have a 90 percent chance of developing retinoblastoma. The incidence of retinoblastoma is increasing because survivors of childhood retinoblastoma are now of an age to have their own children. Families of children with retinoblastoma should have genetic counseling.

Diagnosis

Most children in the United States are diagnosed while the tumor remains within the eye. The tumor is detected by shining a light into the child’s eye and looking for what is called a cat’s eye—a white spot in place of the dark pupil. There may also be symptoms such as poor vision and strabismus (squinting).

It is important for children with retinoblastoma to be seen in a specialized center where physicians have experience in evaluating the size of the tumor and the extent of the disease.

Staging

Several staging systems are used, but for purposes of treatment, retinoblastoma is divided into intraocular (within the eye) and extraocular (spread beyond the eye) disease.

Treatment Overview

Standard Treatment In some cases, it may be possible to destroy the tumor within the eye by using light (laser) treatment (photocoagulation), freezing (cryotherapy), or heat treatment (thermotherapy). Other options include enucleation (removal of the diseased eye), with eventual replacement with an artificial eye, and radiation therapy (brachytherapy or external-beam).

Which of these procedures is used depends on the size of the tumor and whether the child has potentially useful vision.

The use of chemotherapy requires additional investigation, although tumors generally respond in a satisfactory manner to a number of chemotherapy drugs.

Five-Year Survival Over 90 percent if disease is confined to the eye; less than 10 percent if it has spread beyond the eye

Treatment Follow-Up

Children with retinoblastoma, especially the hereditary form, have an increased risk for developing other malignancies later in life and so should be followed closely. Up to 8 percent, for example, may develop bone tumors after eighteen years, and the percentage may be higher with longer follow-up. Second cancers may develop spontaneously or be the result of treatment.