Cut 1 / 2 cups very finely diced cucumber
Taste of salt
1 Lb Center cut Albacore or salmon fillet, chopped.
Small shallot minced 2
1 / 4 Cup chopped cilantro
2 Tablespoons fresh lime juice
1 Tbsp rice vinegar
2 Tablespoons extra virgin olive oil
Tablespoon 2 capers, drained and rinsed
Fresh ground pepper
Pinch Cayenne (optional)
Serve the leaf of lettuce and endive, red pepper square, cucumber rounds or toasted croutons
1? , Can sit while preparing the remaining ingredients with cucumber and salt, water, and 15 minutes. Then rinse and drain on paper towels. On the other hand, cover the bowl with cold water, place shallots. 5 Minutes, then drain, rinse and can once again sit drainage with a paper towel.
In medium bowl, cucumbers, fish, shallots, coriander, lime juice and capers 2. To throw, rice vinegar and olive oil. The season of the salt. If you add a little spice to the add a pinch of Cayenne. Taste and adjust seasoning. Until it can be cold (there is nothing but long too). Placing the endive leaves, red pepper square, cucumber rounds or Croutons, spoonfuls provides services.
Yield: 2 1 / 2 serving as hors d'oeuvres 10 Cup.
Note: this is great first light courses or dinner. It offers four to six.
Of advance preparation: before providing service should not be more than an hour. Cooked fish, lime juice and vinegar ", you will lose raw taste fresh and radiant appearance.
Nutrition information per serving: 106 calories; 6 grams fat; 1 g saturated fat; 0 G cholesterol; 1 g carbohydrate; dietary fiber 1 gram. 75 Mg sodium; (Not included in preparing to add salt) 12 g protein
Martha rose Shulman author "the very best of the healthy recipes..."
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“For some reason people respect headaches,” said Dr. Carlo Di Lorenzo, a leading pediatric gastroenterologist and a professor of clinical pediatrics at Ohio State. “I’ve never seen a parent or a pediatrician tell a child complaining of a headache, ‘You don’t have a headache — it’s not real.’ Bellyache is just as real as headache.”
Indeed it is. And recurrent abdominal pain in children is common, frustrating and often hard to explain.
Consider a girl who came to the clinic for her 10-year physical exam. She gets these bellyaches, she told me. Had a bad one that week, but her stomach wasn’t hurting right at the moment.
She’d been treated for constipation; she’d been tested for celiac disease and other problems. Every blood and stool test over the two years since the pain began was completely normal. One night the bellyache was so bad she went to the emergency room — and her abdominal X-rays were normal as well.
The diagnostic term for this common and perplexing condition is “functional abdominal pain”: recurrent stomachaches, as the American Academy of Pediatrics put it in 2005, with no “anatomic, metabolic, infectious, inflammatory or neoplastic disorder” to explain them.
When I was a resident, we often smirked when we spoke of functional abdominal pain, treating it as a code for a troublesome patient, dubious symptoms or an anxious family. But recent research suggests we were too biomedically narrow in our thinking.
Scientists are coming to understand that abdominal pain is transmitted by a specialized nervous system that may be hypersensitive or hyperactive in some children. Studies in which researchers inflated balloons in children’s intestines suggested that those with functional abdominal pain might be unusually sensitive to any distension on the inside.
“We think in terms of a biological-psychological-social model” for pain, said Dr. Joel R. Rosh, a pediatric gastroenterologist at Goryeb Children’s Hospital in Morristown, N.J., and an associate professor of pediatrics at New Jersey Medical School. “When a child says, ‘My belly hurts,’ what drives me crazy is people say, ‘No it, doesn’t.’
“Why would people say that? You’re feeling something! How much is biological, how much is psychological, how much is social?”
The improved understanding of how such pain develops — and can be treated — has changed the ways that pediatricians look at the problem, but it hasn’t necessarily made it easier to take proper care of these children, to worry over them enough but not too much and, above all, to make them feel better.
The problem may start with some initial insult, an infection or inflammation that may affect pain pathways in the child — and may also set up psychological patterns and anxieties in the child and response patterns and anxieties in the parent.
And then the child continues to be extremely aware of sensations coming from the gastrointestinal tract, even when the initial illness is over. The challenge to the parents — passed on to the pediatrician — is how diligently these pains should be investigated, how many tests a child should be subjected to, how much money should be spent.
“One thing fairly well established is that as soon as you make a referral to a subspecialist, cost increases by fivefold,” Dr. Di Lorenzo said. “We’re going to tend to do a lot more tests.” The more anxious the parent, he said, the more tests may be done for reassurance.
With the 10-year-old girl, I was trying hard not to refer her to a subspecialist. She was growing well, she didn’t have celiac disease, she had none of the red flags that signal a need for a medical work-up.
We suggested that she learn techniques to cope with her abdominal pain and maybe see a counselor to talk about anxiety. Her mother thought we meant the pain was imaginary.
“The vast majority of data suggest that what helps the children is working with the brain more than working with the gut,” Dr. Di Lorenzo said. “Hypnosis is clearly more effective than medication.”
And the medications that may work include those that work on the enteric nervous system (which uses serotonin as a neurotransmitter), so low doses of antidepressants are sometimes helpful with functional abdominal pain.
Miranda A. L. van Tilburg, a psychologist who is assistant professor of medicine at the University of North Carolina, was the lead author of a study published a year ago in Pediatrics, which showed good effects from a treatment called guided imagery.
“We would give them therapeutic suggestions,” Dr. van Tilburg said, “like imagining something in your hand that melts in your hand like butter and then you put it in your tummy and it makes it stronger, or imagine drinking your favorite drink and again the inside of your tummy is coated with this special layer.” The children were sent home with CDs and instructions to practice the imagery regularly as a prevention strategy.
Our patient said she didn’t want to see any more doctors. She didn’t want any more blood tests, and she didn’t want tests she had heard about that involved tubes. Her mother didn’t really want those tests either, since as she said, they never seemed to find anything wrong. Neither was enthusiastic about seeing a counselor, but they finally agreed.
It’s an appropriate strategy. “It’s very disempowering to have this alien living in your belly,” Dr. Rosh said. “How about if I learn that my belly doesn’t have to run my life?”
And how do you help doctors, parents and children get past the idea that functional abdominal pain is not “real,” that a child doubled up with pain is faking it, that it’s all in his head?
“If it was all in his head, he’d have a headache,” Dr. Rosh said. “Clearly there’s something happening in his belly.”
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