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Not for everything, of course. Not for disease and war and famine and robocalls, but I do blame bagged salad for its lack of transparency.
Am I supposed to wash it? It says I don't have to. It says things like: Triple-washed! Ready to eat! But then it also says things like, "To refresh, rinse under cool water before serving."
This is a mixed message.
This is like saying, "Ready to eat. But cook first."
Or, "Pre-soaked. Soak before use."
I don't know what refresh means. Spritz it with cucumber water? Serve it a beer?
So, I just wash it. Again.
Occasionally I'll skip this step, but then I don't enjoy my salad as much. Then I feel guilty that I'm eating unrefreshed, tired, stressed out salad, and it doesn't taste as good to me. I think this is why I've basically stopped buying bagged greens. What's the point? Because I wash them again, there's no real time-savings. I also prefer to spend my money on other things, like twice as many non-bagged greens.
Do you ever buy greens at the farmers' market? It's fun to pick out baby everything there. Baby kale. Baby chard. Baby gem lettuces. Baby spinach. The farmers' market has lots of babies. I try not to pick up the human babies and just stick to the greens, but it isn't always easy.
Next time you make a salad, change up your normal greens routine. If you tend to grab romaine, get spicy arugula instead. Or try watercress. Or red leaf. Or butter lettuce. Or even cabbage. I know! Cabbage isn't even a lettuce! YOU CAN GO CRAZY!
Also, don't forget to make something quick and special to refresh your salad. It may have had a rough couple of days, and a handful of sweet, buttered nuts or crisp, homemade croutons would really show it how much you care.
A beer wouldn't hurt either.
Recipe for Salad in the Round with buttered agave walnuts
I had fun playing with the shapes and colors in this recipe. I was going to call it 1980s Bat Mitzvah Salad since every girl I knew who had a Bat Mitzvah in the 80s had a pink-and-green themed party, but I'm going with Salad in the Round instead. I like the way the radishes and cucumbers echo each other shapewise. Those of you celebrating Easter this weekend might like the spring colors as well.
Serves 2 as a lunch salad, 4 as a side
1 tablespoon unsalted butter
1 tablespoon agave nectar
1 cup walnut halves
1/4 teaspoon sea salt
4 generous handfuls (about 4 packed cups) mixed baby greens (I used mesclun, baby spinach, and baby arugula)
4 pretty radishes, sliced
1 Persian cucumber (a slender, narrow variety -- by all means, substitute any cucumber), sliced
Handful of mint leaves
For the vinaigrette: 1 tablespoon extra-virgin olive oil (plus more for drizzling), 1 tablespoon red wine vinegar, 1 teaspoon Dijon mustard, 1 teaspoon agave nectar, sea salt and black pepper
Line a baking sheet with parchment or a silicone liner.
Warm the butter and 1 tablespoon agave in a small, nonstick skillet over medium-high heat. When the butter melts and foams, add the walnuts and salt. Shake the skillet to coat the nuts well. Let the liquid bubble and the nuts toast, tossing a few times, about 3 minutes. Scrape onto the lined baking sheet to cool.
Combine the greens, vegetables, and mint leaves in a salad bowl or on a large platter. Scatter with the walnuts. Shake the vinaigrette ingredients in a small jar, or whisk until emulsified. Pour over the salad, toss, and serve. Refresh with a final drizzle of olive oil, in case it's thirsty.printable pdf


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Is HBOT Cost-Effective For Diabetic Foot Ulcers?
It is estimated that Medicare spends $1.5 billion annually to treat diabetic foot ulcers (DFU).1 The debate continues on the cost effectiveness of immediate amputation in comparison with "conservative treatment" using a variety of modalities.
The cost of healing a DFU is related to its severity but detailed "cost to heal" data stratified by Wagner grade are sparse. Primary amputation is costly not so much because of the expense of the surgical procedure itself but because of the consequences of amputation (e.g. rehabilitation and institutional care).
Couch et al., found that following a major amputation, only 76 percent of unilateral above-knee amputees could be rehabilitated. Furthermore, the surgical mortality of major leg amputation is 11 to 13 percent.2 The post-amputation five-year survival rates of 30.9 percent among patients with diabetes without renal failure and 14.4 percent among patients with diabetes and renal failure are similar to an aggressive cancer.3
"Limb salvage" usually requires revascularization and, regardless of whether the method is surgical or endovascular, secondary revascularization is likely to be necessary in three to five years. This is a substantial cost factor. The fact is that primary amputation can save costs and improve rehabilitation in patients who are likely to fail limb salvage interventions. Accordingly, ensuring proper patient selection is critical to the discussion of cost effectiveness. Hopf and Fife recently addressed whether HBOT has a role in limb salvage.4
What You Should Know About Hypoxia And Revascularization
Patients with purely neuropathic diabetic foot ulcers are not candidates for HBOT and one can usually manage such ulcers with aggressive offloading. Even so, diabetic foot ulcers are hard to heal. Margolis, et al., demonstrated that even with adequate arterial inflow, diabetic foot ulcers have only a 24 percent closure rate at 12 weeks and a 31 percent closure rate at 20 weeks.5
However, diabetes is a major risk factor for vascular disease leading to tissue hypoxia. Cutaneous perfusion is the critical physiological determinant of diabetic ulcer healing. Pecoraro, et al., showed there was a 39-fold increased risk of early healing failure when the average periwound TcPO2 is less than 20 mmHg.6
The appropriate treatment for hypoxia due to vascular disease is revascularization whenever possible but results of revascularization are disappointing. Among chronic limb ischemia (CLI) patients undergoing bypass for ischemic tissue loss, 63 percent required more than three months for complete healing with the mean time to healing being 86 days. More than 7 percent of these patients never healed.7
It seems that revascularization is not the final answer. In other words, tissue hypoxia, which prevents healing, persists even after revascularization, assuming it is possible and successful.
What Randomized Controlled Trials Reveal About HBOT
In an upcoming paper, we reviewed all randomized, controlled trials in the area of wound healing over a 10-year period from 1996 to 2006.8 All the trials excluded patients with significant vascular disease except those involving HBOT. After reviewing more than 1,000 papers, we found that only the HBOT studies tackled ischemic diabetic foot ulcers and/or DFUs with Wagner grades higher than II. While HBOT studies have been criticized for being small, they nevertheless stand alone in the literature.
In 1987, Baroni et al., demonstrated the efficacy of HBOT in reducing the incidence of major amputation in patients with diabetic gangrene (11 percent in the HBOT group versus 40 percent in controls).9 In 1990, Oriani, et al., reported a major amputation rate of 5 percent in patients who received HBOT in comparison to 33 percent in similar patients who either refused or had contraindications to HBOT therapy.10
Faglia et al., reported impressive results in a prospective, randomized trial of HBOT in diabetic foot ulcers. In this study, researchers showed an 8.6 percent major amputation rate (below knee or higher) in the HBOT patients in comparison to 33.3 percent for the controls.11 Most interestingly, Faglia and colleagues were also able to show that a course of HBOT improved baseline transcutaneous values to a statistically significant degree, inferring an improvement in the vascular supply to the area.
From 1987 to 1996, six studies involved 435 patients who underwent HBOT with an 80 percent success rate. A retrospective study of the outcome of 1,144 diabetic foot ulcer patients receiving HBOT showed a 76 percent overall success rate, including a 42 percent benefit rate among patients with foot gangrene.12
Remember that patients with foot gangrene have been excluded from all prospective pharmaceutical trials since 1996. Although there are ongoing clinical trials of stem cells for revascularization, HBOT is the only modality that can improve tissue oxygen levels of DFUs, according to the currently published research.
Does The Data Support The Cost-Effectiveness Of HBOT?
In a review of HBOT and DFU, the Cochrane collaboration evaluated three randomized controlled trials, including a total of 118 patients, for whom the relative risk for major amputation was 0.31. The study concluded it is necessary to treat four patients with DFUs with HBOT in order to avert one major amputation.13
Guo et al., subsequently performed a study to evaluate the cost benefit of HBOT.14 The study population was a hypothetical cohort of 1,000 patients who were 60 years of age and had severe DFUs. Researchers constructed a decision tree model to estimate the cost effectiveness of HBOT in the treatment of diabetic foot ulcers at one, five and 12 years.
In this theoretical cohort, the HBOT group had 45 more minor amputations. However, 155 major lower extremity amputations would be averted and these patients gained approximately 50, 265 and 608 quality-adjusted life years (QALY) at one, five and 12 years respectively. This exercise suggests the benefits of HBOT accrue over time in part due to savings from averted major amputations.
Apelquist et al., analyzed the three-year follow-up costs for patients with diabetic foot ulcers from the time of healing (with or without amputation).15 Total average costs for patients who achieved primary healing and did not have critical ischemia were $16,000 (in 1995) in comparison to $63,000 for patients who had required major amputation. This suggests that a course of HBOT in appropriately selected patients is cost-effective.
As a result of the data to support its benefit, hyperbaric oxygen therapy has garnered recommendations from seven independent evidence-based reviews: Blue Cross Blue Shield (1999), the American Diabetic Association Foot Council (1999), the Wound Healing Society (2006), the British Journal of Medicine (2001-2002), the Agency for Healthcare Research and Quality (AHRQ) Report to CMS (2001) and the Medical Services Advisory Committee of Australia (2000).
The Centers For Medicare and Medicaid Services (CMS) issued a Coverage Decision for HBOT in Diabetic Foot Wounds in 2002. The CMS maintains that HBOT is reasonable and necessary in the treatment of limb-threatening diabetic wounds of the lower extremity if the ulcer is a Wagner grade III or worse with no measurable signs of healing for at least 30 days despite standard wound therapy.
Keys To Gauging Proper Patient Selection
The cost effectiveness of HBOT is dependent on ensuring that patients who would heal anyway do not undergo HBOT, and patients who cannot benefit from HBOT are similarly excluded.
Transcutaneous oximetry has been suggested as one way of enhancing patient selection. An evidence-based approach to the use of transcutaneous oximetry is in press.16 The first step is to assess whether wounds are likely to heal spontaneously by using baseline TcPO2.17After vascular status has been optimized, repeat transcutaneous oximetry can assist in determining whether healing is likely.
It may be possible to determine the benefit of HBOT using in-chamber TcPO2. In-chamber values of 200 mmHg or better among patients with diabetes are associated with a high likelihood of benefit from HBOT. However, a trial of HBOT may still be appropriate even in patients with low in-chamber values since the predictive value of TcPO2 is less than 70 percent.12 Retrospective data suggest that among patients who benefited from HBOT, the average number of treatments was 36. One should discontinue treatments as soon as continued healing seems likely.
In Summary
Data confirm that many wounds remain hypoxic even after revascularization. Healing will not occur unless one corrects the hypoxia. Among all modalities tested over the past 10 years, the currently available research has demonstrated that only HBOT corrects tissue hypoxia.
Studies confirm that HBOT reduces the rate of major amputation and increases quality of life years when one ensures proper patient selection. Given the low likelihood of rehabilitation after a major amputation and the high morbidity and mortality, it is not difficult to demonstrate the cost-effectiveness of HBOT in appropriately selected patients.
In Britain, the National Institute for Health and Clinical Excellence (NICE) has concluded that $45,000 is the maximum amount they will pay to increase a life by one "quality-adjusted" year.
The U.S. government has recently embraced creation of similar "comparative effectiveness" research, carving out $1.1 billion from H.R. 598, the $825 billion economic stimulus bill. Accompanying report language says "more expensive" medical products "will no longer be prescribed." The bill will create a "federal health board" to rate medical products and create central controls on access. Where shall we set the bar on the cost of quality-adjusted life years?
Dr. Fife is an Associate Professor in the Department of Medicine within the Division of Cardiology at the University of Texas Health Science Center in Houston. She is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine.
Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons
For further reading, see "Is There A Role For HBO In Limb Salvage?" in the August 2008 issue of Podiatry Today, "A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds" in the December 2007 issue or "What You Should Know About Using HBO In Diabetic Wounds" in the May 2003 issue.
To access the archives or get information on reprints, visit www.podiatrytoday.com.
1. Harrington C, Zagari MJ, Corea J, Klitenic J. A cost analysis of diabetic lower-extremity ulcers. Diabetes Care 2000; 23(9):1333-8.
2. Couch NP, et al. Natural history of the leg amputee. Am J Surg 1977; 133(4):469.
3. Aulivola B, et al. Major lower extremity amputation, outcome of a modern series. Arch Surg 2004; 139(4);395-399.
4. Hopf H, Fife CE. Is there a role for HBO in limb salvage? Podiatry Today 2008; 21(8):56-64.
5. Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. Diabetes Care 1999; 22(5):692-5.
6. Pecoraro RE, Ahroni JH, Boyko EJ, Stensel VL. Chronology and determinants of tissue repair in diabetic lower-extremity ulcers. Diabetes 1991; 40(10):1305-13.
7. Goshima KR, Mills JL Sr, Hughes JD. A new look at outcomes after infrainguinal bypass surgery: traditional reporting standards systematically underestimate the expenditure of effort required to attain limb salvage. J Vasc Surg 2004; 39(2);330-5.
8. Carter MJ, Fife CE, Walker D, Thomson B. Estimating the applicability of wound-care randomized controlled trials to general wound care populations by estimating the percentage of individuals excluded from a typical wound care population in such trials. Advances in Skin and Wound Care, 2009, in press.
9. Baroni GC, et al. Hyperbaric oxygen in diabetic gangrene treatment. Diabetes Care 1987; 10:81-86.
10. Oriani G, et al. Hyperbaric oxygen therapy in diabetic gangrene. J Hyperbaric Medicine 1990; 5(1):171-5.
11. Faglia E, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcers. Diabetes Care 1996; 19:1338.
12. Fife CE, Buyukcakir C, Otto GH, et al. The predictive value of transcutaneous oxygen tension measurement in diabetic lower extremity ulcers treated with hyperbaric oxygen therapy: a retrospective analysis of 1,144 patients. Wound Repair Regen 2002; 10(4):198-207.
13. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). In: The Cochrane Library, Issue 2, John Wiley & Sons, Ltd, Chichester, UK, 2004.
14. Guo S, et al. Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers. Int J Technol Assess Health 19(4):731-737, 2003.
15. Apelquist J, et al. Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting. Foot Ankle Int 1995; 16(7):388-94.
16. Fife CE, Smart DR, Sheffield PF, Hopf HW, Hawkins G, Clarke D. Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence. UHM 2009; 36(1)1-11.
17. Hanna GP, Fujise K, Kjellgren O, et al. Infrapopliteal transcatheter interventions for limb salvage in diabetic patients: importance of aggressive interventional approach and role of transcutaneous oximetry. J Am Coll Cardiol 1997;30(3):664-669.

subset: commoncrawl


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Here are just a few of the wonderful discoveries this week to educate and entertain.
The holiday craft season has begun in earnest! Check out The Graphics Fairy and Vintage Catnip for free clip art for your projects.
Thomas MacEntee of Destination: Austin Family treats us to Leftover Ancestors - 2011 Edition.
Speaking holidays, come blog your holiday memories with Advent Calendar of Christmas Memories hosted by GeneaBloggers.
Susan Petersen of Long Lost Relatives shares a very thorough review with Kindle Fire - Not Just for Books.
StoryCorps announces today is the National Day of Listening.
Heather Rojo (my hubby's new-found cousin-in-law) of Nutfield Genealogy shares A Most Memorable Thanksgiving. This is the best story of adaptability in the face of adversity! Proves all you need is a little perseverance and a bottle of Spanish wine.
Barbara Poole over at Life From The Roots asks RootsWeb-Have You Used This Source?
Wonderful recipe for carmel apple pie from Becky of Family Heritage Recipes.
Marian Pierre-Louis over at Marian's Roots & Rambles shares great tips on How To Take Better Gravestone Photos.
Thanks to Lynn Palermo of The Armchair Genealogist for providing helpful tips in From Blog to Book - Transforming Your Family History. My ultimate goal is to create a family history book with posts from this blog.
A new blog discovery this past week was Renaissance and Regency Rummage Repository. There I found the Guest Blog - Mike Rendell with a Georgian Treasure Trove. Mike tells a tale of discovery which ultimately lead writing a book.
I love the photograph An Array of Wedding Hats - 1910: Wedding Wednesday by Susan D. of Family History Fun. Don't think I have ever seen that many hats in on picture!
Over at The Symbolic Past you will find the Interview with John Thomas Grant, author of Final Thoughts by Marian Pierre-Louis.
Writer's block? Check out Tips from the Pros: Kemp, Pauley, and Cordell on How to Wrangle Your Muse by Susan J. Morris of Omnivoracious.
Bill West of West in New England announces The Third Annual Great Genealogy Poetry Challenge Is Here!
Elizabeth O'Neal of Little Bytes of Life shares Tuesday's Tip: Colorado Historic Newspapers Collection.
From DearMYRTLE we have SOURCES: Research logs are not proof arguments.
Are you preserving something of yourself? That is what Jasia of Creative Gene asks with Plan to be Remembered, Revisited. Included are great suggestions to create your family history time capsule.
A must read is the article Kids Genealogy: Activity - Write A Story About Your Thanksgiving Traditions by Jennifer Holik-Urban. Great tips to involve the younger generation in family history.
The following geneabloggers are celebrating their blogiversary. Stop by to offer congratulations!
Blood and Frogs
Caro's Family Chronicles
Everything's Relative
Sue's Genblog
Blogs I started following this week:
Call Me-shell
Explorations in Connecticut
Jollett etc.
Lynn's Waffles
Kevin's Irish Research
Retracing the Past
Make sure to read this weeks GeneaBloggers article May I Introduce To You...Ryan W. Owen by Gini Webb of Ginisology.
GeneaBloggers Radio will be taking a break this week returning Friday, December 2, 2011.
Happy Follow Friday!


text: NEW Cooperative has announced the recipients of scholarships for the upcoming school year. Students must major in an agricultural program and be the dependent of a NEW Coop member or employee to be eligible. The winners include Hannah Corey from Lake City, Leslie Loehr from Moorland, Ethan Lenz of Manson, and Brad Richardson from Manson. In the last twenty years, more than $200,000 has been awarded to students.


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21st March to 20th April
You are likely to remain careful and watchful today, foretells Ganesha. And because you'll be invited to parties and oth See More
21st April to 21st May
Luck is a four-leaf clover in your pocket. You might get the long desired success in education related matters today — See More
22nd May to 21st June
Today, you may encounter unusual challenges, says Ganesha. You will come up with new thoughts and tactics, which will br See More
22nd June to 22nd July
Today, there is a strong possibility that you may face unexpected job changes. You are likely to spend lavishly to pleas See More
23rd July to 22nd Aug
Today, Ganesha advises you to keep the Bhagavad Gita's verses in mind, and persist in fulfilling your duties without bot See More
23rd Aug to 22nd Sept
Ganesha advises you to quantify your worth in the spheres of emotions and sentiments. You will prepare yourself for ever See More
23rd Sept to 22nd Oct
Ganesha says that for people you may appear to be a miser but when it comes to your closed ones you will never hold back See More
23rd Oct to 22nd Nov
Do not get carried away by sentiments and act like an emotional fool, tips Ganesha. Today, you will be in a dilemma as y See More
23rd Nov to 21st Dec
Going to private parties is a high probability today. All in all, make the most of it as you get nostalgic with old frie See More
22nd Dec to 20th Jan
Whether you're an artist, performer, professional or an entrepreneur, career issues will take the foreground today, whil See More
21st Jan to 18th Feb
You zoom in on research and development today. Your fabulous work speaks volumes and your commitment pays off. You're ke See More
19th Feb to 20th March
For you, today may all be work and no play, says Ganesha. This, however, will not stop you from putting in extra efforts See More