Author Archives: michelesullivan

H5N1: Keep That Genie in the Bottle

Throw out a hint of some meaty research and say “Don’t Ask! Don’t Tell!”  You might as well draw a map to the Christmas cache and tell the kids, “Don’t follow this trail!”

The U.S government seems to be engaging in the worst kind of this delusion by asking the journals Science and Natureto withhold the methodology sections of two important papers on H5N1 viral mutation.

Michele G. Sullivan/Elsevier Global Medical News

The papers, one by University of Wisconsin-Madison veterinary virologist Yoshi Kawakoa and one by Dr. Ron Fouchier of Erasmus Medical Center in Rotterdam, Netherlands, detail their work on avian flu H5N1 mutation. Each describes genetic engineering that created a new strain almost 100% lethal to ferrets — generally considered the best animals to model a human respiratory infections.

Presumably, Drs.  Kawakoa and Fouchier conducted their experiments with the goal of helping to protect mankind against the virus’ inevitable change. But the National Science Advisory Board for Biosecurity sees a dark side. The agency’s official plea to both journals suggests that publishing “the  methodological and other details … could enable replication of the experiments by those who would seek to do harm.”

Their concern is not unfounded: It goes without saying that an individual, or even  a country, could use this with evil intent.  A weaponized bird flu with a 90% or higher mortality rate would make the anthrax letters of  2001-2002 look like a scuffle in a kindergarten sandbox.

But is censoring going to keep this knowledge hidden?

Scientific discoveries almost always build upon prior knowledge in a long, nearly unbroken, chain of meticulous research. Researchers publish long strings of studies on the same topic, each one evolving just slightly from the last. Others with a passion for the same topic climb on board as well, so that eventually everyone benefits.

A clear representation of this? At least some of the research that so troubles our government has already been disseminated.

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold). Courtesy the Centers for Disease Control and Prevention

Last year, Dr. Kawakoa described his lab’s creation of an H5N1 mutation almost universally lethal to ferrets.  The study describes his work with the two most virulent forms of H5N1, both isolated from humans and both with a human kill rate of up to 80%. Dr. Kawakoa and his colleagues manipulated the genes in both to create a novel virus that appeared even more lethal, killing all of the intranasally inoculated ferrets.

The paper not only identifies the genes — hemagglutinin (HA) and nonstructural protein (NS) — but the method of reverse engineering and  the modifications’ chromosomal positions. Its purpose was not to create a super-pandemic among humans, but to identify the genes and loci that most contribute to H5N1’s uniquely dangerous potential.

His new paper, according to the National Institute of Health’s  comment,  shows “that  the H5N1 virus has greater potential than previously believed to gain a dangerous capacity to be transmitted among mammals, including perhaps humans.”

Last September, Dr. Fouchier presented his now-to-be-edited work at the Fourth ESWI Influenza Conference. During an oral presentation, he described work that resulted in some potent H5N1 mutations. According to the conference daily, the researchers infected ferrets with the new H5N1, also formed by plasmid reverse engineering and also manipulating hemagglutinin.  The infected ferrets died, but didn’t transmit the virus.

The team then let the virus do its own thing,  just moving it repeatedly from a sick ferret’s nose to a healthy nose without tinkering – the way a virus would naturally mutate by adapting to each new host.  Dr. Fouchier found a new H5N1 with new mutations: It became an airborne form after 10 transmissions, suggesting that avian flu can mutate within one species, rather than requiring a “mixing bowl” animal, like a pig.

“This virus is airborne and as efficiently transmitted as the seasonal virus,” the paper quoted Dr. Fouchier as saying. “This is very bad news, indeed.”

The meeting wasn’t secret. Journalists were there, and some even wrote about it. New Scientist ran a piece about the research, as did Scientific American.

If this much information is already out there, might it just be possible that a “rogue scientist” could come up with much, much more? And is the National Science Advisory Board for Biosecurity really suggesting that only two scientists in all the world have so advanced this virus?

It might even be possible that there are labs in other countries working on the same thing. And that some of those countries might want to suppress important findings — holding them close the vest to “protect” the populace.

We wouldn’t want that now. Would we?

—Michele G. Sullivan

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Filed under Epidemiology, Genomic medicine, Health Policy, IMNG, Infectious Diseases

For Baby Beds, It’s Back to Basics

(Full disclosure: As a grandmother of two I have gone bonkers at every baby store in Northern Virginia. And the first night after baby Allison came home, I kept her in my own bed … allegedly so her mom could get a good night’s sleep.)

You’re an OB. You love pregnant women and babies and all that this wonderful time entails. And since you’re a good OB, you listen to your moms and relish their nesting behavior. It’s a good sign when they begin talking about Baby’s room and bed, all the cute stuff they’ve gotten from loving family and friends.

Now you – and your pediatric colleagues – are  going to have to let your moms down gently.

To prevent SIDS, AAP recommends against newborns sleeping in cribs set up like this. Sarah G. Breeden/Elsevier Global Medical News (2)

Bumper pads, stuffed toys, crib canopies (made popular by Jennifer Lopez’s royal nursery pictures), and even the fuzzy baby blanket Grandma crocheted – none of it belongs in a newborn’s bed.  And experts at the American Academy of Pediatrics (AAP) are targeting the issue in big way. On Oct. 18, the group issued a new policy statement on safe sleep for infants.

It turns out that the newest  best place for a baby to bed down is totally retro: a nearly bare (but consumer-safety approved) crib with a firm mattress and a single tight-fitting sheet.  PJs should be  a sleeper appropriate to the room’s temperature without a chance of overheating Baby, who should be sleeping on his back without so much as a blankie. And that’s it.

Virtually every OB and pediatrician discusses the topic of Sudden Infant Death Syndrome (SIDS) and supports AAP’s  17-year-old “Back to Sleep” campaign. The push resulted from research that pinpointed stomach- and side-sleeping as significant risk factors for SIDS. Since its adoption, there’s been up to a 66% decrease in SIDS deaths in the U.S.

But, Dr. Rachel Moon said at AAP annual meeting, this encouraging trend has a dark twin – a quadrupling in the number of infants who’ve died from suffocation and entrapment. And many of these deaths have been linked to getting stuck in loose bedding, or even from stuffed animals who topple over in the night and obstruct breathing.

Sleeping with parents is a big problem too, Dr. Moon said. Many groups – and not a few doctors – have promoted bed-sharing as the most natural way to care for a newborn, especially facilitating breastfeeding, a mighty defense against SIDS. But unfortunately, cross-eyed lethargy – a state familiar to every new parent – does not a safe bedfellow make.

And it goes without saying that a parent on pain meds  (any of your patients ever have an episiotomy or C-section?), or who is using other drugs or alcohol, is more likely to roll over on Baby. Deaths don’t necessarily have to be dramatic – like being crushed under adult weight, squashed between parents, or dropped on the floor. Even an arm that moves over a newborn’s mouth can obstruct breathing enough to kill.

Make sure family caregivers and daycare providers know the rules too, AAP advises.  Infants in child care settings are significantly more likely to die from SIDS,   perhaps because providers aren’t following the advice for safe sleep

Babies who sleep in plain cribs with firm mattresses and tight-fitting sheets are at a lower risk of SIDS.

More AAP advice? After the 4 a.m. feeding, stress that Baby goes back to her own crib, positioned safely  supine, uncovered, and hopefully with a pacifier.

Yes, the much-loved binkie now has a justified place in the scientific literature. It seems that pacifiers help reduce the risk of SIDS, probably by occasionally arousing the baby during sucking frenzies.

So tell  your patients’ thrilled Grandmas to relax  and rejoice by contemplating  how many pacifiers they can buy for the price of just one coordinated Peter Rabbit crib set.

—Michele G. Sullivan

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Filed under Emergency Medicine, Family Medicine, Health Policy, IMNG, Obstetrics and Gynecology, Pediatrics

Chew on This!

Grandmothers the world over are the same when it comes to some things.

Sneaking candy behind mom’s back.

Big cuddly hugs.

Best. Cooking. Ever.

And advice about how to eat said cooking.

A slow eater. Credit: Håkan Svensson, Xauxa/ Wikimedia Commons

“Slow down! This isn’t a race you know! Chew each mouthful 100 times!”

Japanese grandmas are no different – and even the Japanese government has jumped on the chewing bandwagon, Dr. Masaaki Eto said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Eto described his study of 9 obese – but not diabetic –  subjects with a mean body mass index 27 k/m2 (in Japan, obesity begins at a BMI of 25 kg/m2). At baseline, the volunteers’ mean fasting plasma glucose was 99 mg/dL. They all ate the same 630-calorie meal on two separate days: bread, butter, a hard-boiled egg, steamed vegetables, a banana, and milk.

On day one, they had to finish it in 20 minutes, chewing each bite 5 times. On the second test day, they ate the same meal, also in 20 minutes, but chewed each mouthful 30 times.

Dr. Eto and his colleagues measured two satiety hormones – glucagon-like peptide (GKP-1) and peptide YY (PYY) before and after each meal.

The results will please grandmas worldwide.

Chewing each bite 30 times significantly increased the levels of both hormones over chewing 5 times, said Dr. Eto of Ohu University, Fukushima, Japan.

Among the 5-chew gulpers, plasma PYY increased from 36 pg/mL to 41 pg/mL – not a significant change. But the slow chewers had quite a different outcome. “The 30-times chewing group had a significant increase in plasma PYY,” Dr. Eto said. Their levels jumped from a mean of 36 pg/mL to 66 pg/mL.

The story was repeated with GLP-1. The fast-chewers did have an increase – although not significant (5 pmol/L to 17 pmol/L).  But the slow-chewers had much better results, increasing their GLP-1 from 5 pmol/L to a whopping 29 pmol/L.

“This is the first report that thorough chewing stimulates postprandial increases in the two hormones,” Dr. Eto said. “These hormones reduce appetite and food consumption, so thorough chewing may help obese subjects to lose weight.”

Besides, he said, Japanese grandmothers “since the old days” have advised kids to do a lot of chewing.  So much so, he added, that the Japanese government has issued a recommendation to  chew each bite of food 30 times – to help avert the country’s growing obesity problem. “That is why we picked 30 times chewing,” for the study, Dr. Eto said.

Some audience members weren’t completely convinced that the good results are related to the combination of chewing and food intake. One questioned whether the mechanics of chewing was key benefit, stimulating the vagusl nerve to release GLP-1. “For instance,” he asked, “what if the subjects chewed the food and then spat it out? What would the results be then?”

To which moderator Dr. Davide Carvalho replied, “I believe chewing and spitting out the food could be the best diet we could invent.”

—Michele G. Sullivan

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Breakfast in Bed, Anyone?

What do beds and pancakes have in common?

Nothin' says lovin' like dust mites from from the... frying pan? Photo by Flickr Creative Commons user Kalavinka

A: Romantic interlude

B: Snuggly Sunday treat

C: Wonderfully considerate partner

D: Potentially lethal mites

Answer:  All of the above

If you’re lucky in love, you get some romance along with your hot pancakes, propped up on your comfy mattress and fluffy pillows.

If you’re not so lucky, you suck in a lungful of Dermatophagoides pteronyssinus from your comforter and slug down a syrup-coated helping of its wheat-loving cousin, Dermatophagoides farina. And if your immune system is easily triggered, this relaxed repast can turn into a choking, wheezing trip to the hospital.

The tiny (300 micron), translucent house dust mite frequently haunts human beds, thoughtfully cleaning up mold, fungi, bacteria, pollen, your dead skin cells, and maybe that other white sock you lost a couple months ago.

Dermatophagoides pteronyssinus - a species of house dust mite. Photo by Flickr Creative Commons user Giles San Martin

Because of their tiny size and adaptive nature, these guys traveled with us from our damp, dark caveman homes to our modern hang outs and creature comforts:  beds, blankets, sofas, rugs, and cuddly stuffed animals.

For most of us, house dust mites cause no problem. They’re so tiny we can’t see them. They don’t sting or bite. And even if 100 were creeping up your leg – which they will probably do tonight – you would never know.

But unfortunately, they can seriously bug people with atopy. It’s not the mite per se, but its numerous droppings that cause issues among the allergic.  Inside those tiny poo balls are bits of undigested food and the digestive enzymes meant to break them down. All it takes is a breath of air – or a dip in pancake batter – for the “stuff” to melt away,  activating these enzymes.

Inhalation reactions start when the molecules come into contact with lung epithelium. Scavenger cells get the inflammatory process up and running, aggravating asthma and other allergic reactions, like atopic dermatitis, allergic rhinitis, conjunctivitis, and otitis media.

Pancake syndrome is a variation of the inhalation reaction. Whenever cooks use mite-infested flour, there is potential for danger. The medical literature contains case reports and series of both children and adults who experienced an anaphylactic reaction after eating mite-infested wheat-flour based foods. The reactions varied from mild to lethal.

In all cases, the flour used was replete with dust mites of several species – and full of the cell-destroying Der enzyme, cysteine protease. Among its many talents: direct damage to airway epithelium; destruction of the body’s epithelial tissue damage defense system; disruption of intercellular junctions; and of course, stimulating those pesky proinflammatory mediators.

Infested flour is more likely to be found in temperate, humid areas, and in poorly stored wheat flour or flour-based mixes – or products that have been opened for a long period and never used. In 2009, the World Allergy Organization published a dust mite oral anaphylaxis paper, suggesting that all grain flours be stored in airtight containers in the refrigerator or freezer.

So the next time a half-empty box of pancake mix gets you in the mood for some snuggly breakfast in bed – try switching to eggs. – Michele G. Sullivan

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Filed under Allergy and Immunology, Blognosis, Dermatology, Family Medicine, Gastroenterology, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Internal Medicine News, Pediatrics, Primary care, The Mole, Uncategorized

The Little Ant With the Big Bite

Just speaking with Dr. Ronald Rapini during the summer meeting of the American Academy of Dermatology  is enough to make you itch. That’s how good he is at describing the vicious attack of the fire ant – as it bites and stings its way northward from its Southern roots.

A native of South America, this aggressive invader established the first Fire Ant Town around Mobile, Ala., in the early 1900s. Rumor has it that the little buggers were stowaways on steamers. Apparently they found American soil so friable (and American flesh so tender) that they have engaged in a relentless northern march, traveling first throughout the southeast and now up both the Eastern and Western seaboards.

Fire Ant

Fire ants belong to the same species as wasps and bees. (Photo courtesy Agricultural Research Service, USDA)

Fire ants sport a chillingly descriptive Greek name – Solenopsis invecta, “Unvanquished Channel-Faced.” I leave it to you to decide if the imported red fire ant is “channel-faced,”  but I defy you to deny that it is unvanquished.

These are a species of the Hymenoptera, the insect order that includes wasps and bees, and they share some basic characteristics. Unlike their cousins, fire ants are only winged during the spring, when the await Eros’ call to fly from their nests in a mating frenzy – after which their diaphanous wings drop away and they build ever-more-complicated colonies that can spread throughout entire fields.

They also adhere to their order’s inclination to live in large, hierarchical societies arranged around a queen, with armies of workers bent on aggressive nest defense — much to the dismay of bumbling human feet.

If you invade their space, the ants swarm out with a
double-ended defense, Dr. Rapini, chair of dermatology at the University of Texas Medical School, Houston, said in a video interview.

“Unlike most ants, which just bite you, these guys bite with their huge jaws and then pivot around and sting you,” with a venom filled dagger.

The resulting wounds are painful, itchy, and full of pus.  Although familiar to Southern physicians, who have seen the problem for years, Northerners are just coming to grips with these tiny purveyors of pustular pain.

“Sometimes doctors will even get a biopsy on this because they’ve never seen it before,” Dr. Rapini said.

Because a fire ant bite/sting feels pretty much like someone burning you with a lit cigarette, most  humans are cognizant enough to run hysterically away from a fire ant encounter, doing the “fire ant dance” to shake the critters off their legs and shoes and out of their trousers. But like drinking and driving, drinking and fire ant hills are not a good mix, Dr. Rapini said.

An inebriated man fell asleep on a fire ant hill with dire consequences. (Photo courtesy of Dr. Ronald Rapini)

“My worst case was a guy who got drunk and passed out on a fire ant hill and came in with hundreds of stings,” he said. The patient wound up in the hospital, desperately ill with a bacterial superinfection; treating him required both antibiotics and high-potency corticosteroids.

There have even been reports of fire-ant deaths.

For most folks, though, the bites are painful, but few. A prescription-strength corticosteroid cream will at least help get patients through the worst stages. “It basically is a self-limiting issue; the bites just go away over a week or two,” Dr. Rapini said. “You really have to try not to scratch, though. That’ll make a scab. And pickers get scars.”

And by the way, humans aren’t the only creatures to suffer at the jaws and stingers of fire ants. They can cause terrible injuries in reclining baby animals.

Pets can also be at risk.

As are, apparently  cute little caterpillars and tweeting birdies.

— By Michele G. Sullivan (on Twitter @MGSullivan)

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Not This Life, Dear — I Have a Headache

A headache specialist's meeting doodle - is this picture worth a thousand words?

A headache is a mighty pain

That changes the defenseless brain,

It may go away.

It may come and stay.

Or rear again, again, and again.

Maybe not great poetry.

But certainly a statement – especially when we assume the author is a headache specialist.

I found this poem on a note pad left in a lecture room between sessions at the annual meeting of the American Headache Society, right after a talk on the genetics of migraine.

After a  lecture on the increased incidence of migraine in young soldiers with posttraumatic stress disorder, I found another note pad. This one depicted a stick-person, helplessly splayed across a tangled spider’s web.

Both, I think, represent the feeling of frustration that bonds headache specialists with their patients.

“We know what can turn it on, but how do we turn it off? That’s the question,” said Dr. Till Sprenger of the University of California, San Francisco. “We still don’t know.”

Headaches unremitting in the face of any treatment strategy are by no means a rarity. Medicines that benefit one may be useless to another. And drugs that can help can also hurt.

Almost anything used for a headache, from acetaminophen to opioids, can backfire if used often enough. Medication-overuse headaches are harder to treat and can start a cycle of using more and more drugs that become less and less effective. Triptans, the mainstay for many migraine patients, are most successful when used at the earliest signs of a headache. But they’re expensive, up to $32/dose, and most insurance companies impose a monthly limit. To save their pills for their worst moments, patients delay the dose, trying to figure out how bad the headache will be. The longer they wait, the less effective the medication.

The physicians at the American Headache Society know this. A number of speakers expressed frustration, not only at their inability to really help some patients but also at the still-rudimentary understanding of headache etiology – the only foundation upon which more effective treatments can grow.

The doctors at this meeting were a sympathetic lot or, perhaps more accurately, an empathetic lot. About half of the physicians I chatted with during breaks and in interviews said their own chronic headaches motivated them to specialize in treating others. They described their job as a mix of satisfaction and exasperation – because they know all too well the blessing of pain relief, the fear of impending pain, and the panic of unremitting pain.

Studies back up my very nonscientific observation of headaches among those who treat them. The most recent appeared in Headache, the American Headache Society’s own journal. It suggested that up to 40% of neurologists who treat headache suffer with their own.  Another 2010 study on migraine management noted that 48% of the  neurologists surveyed were themselves migraineurs.

While there no patients spoke at this meeting, Dr. Dawn Buse became their voice. Despite continuous evolution in headache medicine, her study showed that many continue to suffer.

“Forty percent have at least one unmet need regarding their headaches,” said Dr. Buse of the Montefiore Headache Center, New York.  The top reasons for continued problems? Dissatisfaction with current treatment. Continuing headache-related disability. Overuse of opioids or barbiturates. Other issues that presented in the survey were excessive visits to the emergency department or urgent care center and cardiovascular disorders, which can turn physicians off to the idea of a triptan-based migraine program.

The literature is replete with data confirming what headache physicians confront every day – migraine and other cephalgias worsen almost every quality of life measure.

A 2009 meta-analysis, coauthored by Dr. Buse and Dr. Richard Lipton, past president of the AHS, perfectly captured headache’s often all-consuming impact. Patients with a high headache burden “had higher lifetime rates of depressive disorders, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, specific phobias, and suicide attempts than controls, were more likely to have missed work in the preceding month, to assess their general health as ‘fair’ or ‘poor,’ and to use mental health services.”

The relationship between headache and mental disorders is a complex one, not entirely understood, Dr. Buse told me during an informal chat. She likened it to the famous chicken-or-egg conundrum. “There is some evidence of bidirectionality – that each one predisposes to the other,” she said. “But if you think about it, it makes intuitive sense. If you are afraid of your next headache, you’re likely to be anxious,” which makes a headache more likely and can increase its severity.

The same thing goes for depression, she said. The neurotransmitter dysfunction associated with depression may predispose to headache, but months – or years – of intermittent pain very probably increase the risk of becoming depressed.

It was easy to see the concern in her eyes, and the caring of everyone who spoke at the meeting. Many of them, I suspect, have seen the doodle come to life …  Caught in that spider’s web, knowing that something bad is coming, but having very little power to stop it.

– Michele G. Sullivan

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Dermatologists in NOLA? … Eat!

Any dermatologist whose appetite is more than skin-deep is going to L-O-V-E next week’s American Academy of Dermatology meeting. New Orleans and food. They go together like fried chicken and waffles, praline bacon and stuffed French toast, beignets and chicory coffee.

Hot beignets are just a healthy jog away. Photo by Flickr user jyshun

Although there’s no shortage of tables in the Big Easy, reservations could be in short supply by now, with thousands of docs ready to pounce on the city’s specialties. So be a smart tourist and get on the phone, or hit opentable.com and line up your plan of attack. 

Breakfast

Most derms are probably going to hit the AAD’s breakfast tables before hitting the morning sessions. But if you just can’t take one more muffin-and-coffee meal, consider the following: 

Cafe du Monde. Do we really need to talk about this spot? Just do it.  It’s easy to incorporate into an early morning jog and the jog back eliminates any guilt (and all calories) about downing two or three sofa-pillow-sized pieces of fried dough.

You also might want to hop on the St. Charles Streetcar and head up to the white-colonnaded Camellia  Grill. The streetcar ride is a pleasure in itself, a leisurely trip through a grand old neighborhood of enormous moss-draped live oaks, Audubon Park, and some incredible old homes. Get off at Carrollton Avenue and open the door on the past – a long lunch counter served by (mostly) men in white uniforms and bow ties. Banter with the grill cooks and enjoy an enormous plate of eggs, waffles, French toast, or omelets. Since Camellia serves breakfast all day, you can still enjoy the experience at night, with the added bonus of a piece of pecan pie grilled in butter. Or what the heck – just have that pie for breakfast (626 South Carrollton Ave.; 504-866-9573).

Brunch

Brunch at the Court of Two Sisters in the French Quarter is a frustrating mix of dreamlike atmosphere in a vine-draped courtyard, and throngs of hung-over tourists lining up at the trough, um,  buffet line. The food is decent, but the courtyard not quite as lovely in February as it is in June. And, well, it can be a mob scene (613 Royal St. 504-522-7261).

How about a real surprise – something elegant, discreet, and lovely in the racy French Quarter? For about $60, you can listen to soft jazz and blues by the James Rivers Movement and relax in the Roosevelt  Hotel’s velvety Blue Room. For that price , you’ll get endless champagne and mimosas, one entrée off the brunch menu (anything from eggs Sardou to prime rib), and access to buffet of gumbo, chilled seafood, and a dessert table of mini-pastries, speciality cakes, and bananas foster – flamed tableside. For cool cocktails and hot jazz, check out the hotel’s Sazarac Bar, decked out in devilish red velvet for a devilish evening out. (123 Baronne St.; 504-648-1200).

Oysters

I know, I know – everyone will tell that Acme is THE place to go. But while 50 people are shivering in the outside line, facing an hour wait, you can saunter right across the street to Felix’s,  grab a bar stool, and have them shuck you out a dozen fresh, sweet oysters for $10.75. Manager Adrian Zado assured me that Louisiana oysters are still coming in, although the beds around the mouth of the Mississippi remain off-line. “Some were shut down for protection,” because authorities didn’t know how oily oysters would affect diner safety. Other beds died off when the state released more fresh water into the gulf to try to keep oil offshore. Slip  in on a Wednesday from 5-10 p.m., and you’ll get a free beer (the local Amber Abita is great) with every dozen oysters, although I like mine with one of those cute demi-bottles of champagne (739 Iberville St.; 504-522-4440).

Lunch and Dinner

Mother’s, close to the convention center, is a controversial place. Tourists love it because it’s in all the books. Locals come for a few specific things –the roast beef with debris particularly. But mostly it’s a long wait in a lunch line, followed by big servings of mediocre food (401 Poydras St.; 504- 523-9656).

Both Antoine’ s and Galatoire’s are old NOLA institutions, these two grand monsieur of the French Quarter offer a similar experience – a time trip back to the genteel era of ladies with feathery hats and the men who coddle them. Antoine’s  is the elder brother, established in 1840; Galatoire’s a mere 106-year-old. Antoine’s is heavily French-influenced; Galatoire’s proudly claims “The menu doesn’t change.” Aficionados of lighter, New American-style cuisine might be disappointed in the presentation and the flavors, but both draw devotees of these classic dishes (Antoine’s: 713 Saint Louis St., [504] 581-4422; Galatoire’s:  209 Bourbon St., [504] 525-2021).

In the Commercial District, my favorite place is still Herbsaint. It’s small, with a vest-pocket-sized bar, but survived Hurricane Katrina with most of its well-loved offerings, and some darn good new ones. My favorite meal? Shrimp and grits with Tasso ham, any of the pork dishes (the menu changes seasonally), and, for dessert, the brown sugar banana tart with fleur de sel caramel. Reservations all gone? Try the tart anyway; the recipe appeared a few years ago in Bon Appetite (701 St. Charles Ave.; 504-524-4114).

If you want to venture uptown, Brigtsen’s  is a great bet. Housed in a charming turn-of-the century wooden home, it serves up Creole classics with a little modern twist. Anything with pork, quail, or rabbit is a can’t miss (especially the panéed rabbit and spinach with the Creole mustard sauce). The “Shell Beach Diet” gives you six different little seafood  jewels, for $32. And what’s not to like about banana bread pudding with banana custard sauce? (723 Dante St.; (504) 861-7610).

For a local’s take on food, I turned to my colleague Alicia Ault, who has a long-standing love affair and virtual residency with NOLA. Here’s what she had to say:

Dick & Jenny’s has  become somewhat well-known over the years, and a big plus is that they are open on Mondays – there are few fine dining establishments open on either Sunday or Monday (4501 Tchoupitoulas St.; 504-894-9880).

Three Muses.  A new-ish place on Frenchmen Street, very small, good chef, has music sometimes. Small plates-type food. It’s getting a lot of hipster buzz  (536 Frenchmen St.; 504-298-TRIO).

Patois.  This is an old New Orleans place, too, also  uptown.  Fabulous food, almost impossible to  get in. Alicia – is that a challenge (6078 Laurel St.; 504-895-9441)?

Boucherie.   In the Carrollton area, it features very highly rated New American/New Orleans food, farm-to-table stuff. I can never get in here, partly because it’s small. And I’m  talking even when there’s nothing special going on in town (8115 Jeanette St.; 504- 862-5514).

Coquette. Fabulous cocktails (I had bacon-infused bourbon), some outside tables, nice atmosphere, very good food (2800 Magazine St.; 504-265-0421).

Ralph’s on the Park. A Brennan’s restaurant, Ralph’s is a locals-type special-occasion place on City Park. Service and food are great. A $35 three-course pre-theater menu and a $19 two-course lunch are on offer (900 City Park Ave.; 504-488-1000).

Ye Olde College Inn. Very solid New Orleans food with a noisy, party-type atmosphere. Locals love this place, and I end up eating here a lot because it’s easy and not too expensive (3000 S Carrollton Ave.; 504-866-3683). Also it’s right next to the Rock ‘N Bowl   so you can eat and then stumble over for music.

Well, that’s it. And now I’m calling my editor to complain because I’m being sent to cover a stroke meeting in L.A. next week – instead of delicious NOLA.

— Michele G. Sullivan (on Twitter @MGSullivan)

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