Draft of House Health Insurance Bill

July 31, 2009

If you are addicted to punishment you might want to page through the draft of the House’s health insurance bill. Not only have most congressmen not read it, they would have to understand bureaucratease – the language in which the bill is written. This is the June 19th version and comes in at a concise 852 pages. I must admit that I haven’t gotten all the way through it, but I’m sure its just what the doctor ordered. I’ll post a follow-up when I’ve digested the monster. In the meantime have a crack at it.

healthcare bill

Here’s the July 14 version of the bill. It has 1018 pages. As soon as I find the latest one I’ll add it.

July 14 healthcare bill


Trans Fats, Big Brother, and Sloppy Science

July 26, 2009

Be afraid. There’s a plot to poison you with fat, trans fats to be precise or trans fatty acids to be even more exact. There are two articles in the Annals of Internal Medicine (here and here) which give a pretty good idea where medicine is heading. You’ve likely heard about trans fats. Their chemical structure is shown below compared to cis fats.

Structure of cis and trans fatty acids

Structure of cis and trans fatty acids

Following Denmark’s lead New York City has made it illegal for restaurants to use the stuff in preparing food. The reason for banning trans fats is that doing so will convey a health benefit. No matter that no study has shown that doing so actually reduces the risk of heart attacks, what counts is that there is “no nutritional benefit” from this lipid. I guess a calorie doesn’t count. By this standard chocolate has no nutritional benefit. I’m not sure what epidemiologists and nutritionists mean when they talk this way, but they get a lot of attention by doing so. What they should be saying is that trans fat intake has effects on cholesterol metabolism that may be harmful. They’re not going to get a lot of press saying that and they’re also not going to get the law changed so they stretch the facts.

The first paper in the Annals says that trans fats “poses a substantial risk to heart health.” The next sentence concedes that there are no randomized controlled studies demonstrating that reducing dietary trans fat conveys a cardiac benefit. You’ll have a hard time finding that lowering cholesterol by itself conveys a benefit. The reason? It doesn’t. Let me explain. Lowering cholesterol is unquestionably beneficial in patients with other cardiac risks, eg hypertension, diabetes, family history, pre-existing heart disease, perhaps obesity. But if your cholesterol is high and you have no other risk factor for heart disease lowering cholesterol (so called primary prevention) has never been show to be beneficial. The authors of this first article who work for the New York City Department of Health are frustrated. They warned the public about the putative ill effects of trans fats, but the public didn’t listen. So the Department decided on coercion. “Because artificial trans fat is both harmful and fully replaceable, allowing continued use, even with disclosure, could not be justified.” These guardians of the public’s health are not impressed with their regulations being called “nanny state meddling”.They know what’s good for you and if you don’t like it eat in a different city.

The second paper is an editorial by the former director of the Centers for Disease Control. Another bureaucrat, she’s even more sure of the harm of trans fats than the New Yorkers. “The scientific rationale for eliminating exposure to artificial trans fatty acids is rock solid…..they are certainly harmful.” In the next paragraph she too concedes that this certainty “is still untested.” She means that lowering dietary trans fat intake has not yet been shown to reduce heart disease. Yet she wants everyone to stop eating it even if they are in a group that could not possible benefit from dietary parsimony.

Would it surprise me if eliminating trans fats from New York’s or the nation’s or the world’s food supply had a beneficial effect? No. But it couldn’t be very large given all the other variables that cause heart disease. But the issue is not trans fats. It’s government deciding that educating the public is only worth while if the public listens. It’s unelected officials taking it on themselves to tell the unenlightened how they should behave. It’s enlightened force. It’s a harbinger of what’s to come as the government gets even more involved with medical care as it certainly will. Expect someone with a slippery grasp on both science and ethics to increasingly order you to live the way they think is best for you even if you disagree. Keeping the drinking water safe and eliminating infectious disease apparently are not enough for the folks in the Department of Health, they want watch over you at every step. Remember intentions and outcomes are synonymous.

Opening Night at the Santa Fe Chamber Music Festival

July 20, 2009

Sunday, July 19, marked the beginning of the season for the Santa Fe Chamber Music Festival. The first half of the program was devoted to French music. The second half consisted solely of Brahms’ Piano Trio No.1 in B major.

Ralph Kirshbaum

Ralph Kirshbaum

First up was Faure’s lovely Elegy in C minor. This short piece was beautifully played by cellist Ralph Kirshbaum and pianist Marc Neikrug. The same duo followed with Debussy’s Sonata for cello and piano. Written in 1915, Debussy’s sonata is a severe test for a cellist. Kirshbaum was more than up to it. He has a great technique and a wonderful line to his playing. A virtuoso performance.

The succeeding two works were writen for narrator and instruments. They were doubtless programmed to give actress Claire Bloom something to do. Both exemplify the general rule that works for narrator and music are not for adults. If you’re paying attention to the speaker the music is like movie music. And if you’re listening to the music the speaker only a distraction. If you want words with music they should be sung.

Claire Bloom

Claire Bloom

The first of these two was Debussy’s setting of Pierre Louÿs’ hoax poems Songs of Bilitis. Madame Bloom recited only 12 of the 143. It seemed like she was going through all 143. The first half of the evening, which seemed of Wagnerian length to me, concluded with Poe’s Masque of the Red Death with incidental music by André Caplet. Here are the full details:

DEBUSSY Chansons de Bilitis
Claire Bloom, narrator; Tara Helen O’Connor, flute; Bart Feller, flute ; June Han, harp ; Giuseppina Ciarla, harp; Marc Neikrug, celesta
ANDRE CAPLET Conte Fantastique (Masque of the Red Death)
Claire Bloom, narrator; Johannes String Quartet: Soovin Kim, violin; Jessica Lee, violin; Choong-Jin Chang, viola; Peter Stumpf, cello; with June Han, harp

When the intermission finally arrived there was a stampede to the bathrooms reminiscent of the Oklahoma land rush. The audience was so gray that only an emergency urology consult allowed the men’s room to empty in time for the Brahms. But then Brahms and we had to wait for an award presentation the significance of which was lost on me and probably much of the audience.

But the trio was worth the delay. It’s so good that it had to be presented by itself. It would have dwarfed any of the earlier pieces had they been in closer proximity. Soovin Kim, violin; Peter Stumpf, cello; Shai Wosner, piano had the audience on their feet cheering at the end of this great piece. Brahms chamber works are in the artistic heavens with those of Haydn and Beethoven. The trio was written early in Brahms’ career and then revised near its end. No matter, it has all the beauty and complexity unique to its author. The three players found the right balance preventing the piano from taking over as often happens in piano trios or quartets. My only quibble is that the violin’s intonation was occasionally slightly off.

The Saint Francis Auditorium where this concert was held has clear and bright acoustics. If it weren’t for the very hard benches it would be an ideal location for chamber music. The series runs until August 24. Highly recommended, but bring a cushion.

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Don Giovanni Returns to Santa Fe

July 19, 2009

santa fe opera

Last performed by the Santa Fe Opera in 2004, Director Chas Rader-Shieber production of Don Giovanni returned to the company’s stage last night (July 18, 2009).  Designer David Zinn clothed even the trees in red and hot pink. His movable sets adjusted the changing scenes with great dramatic effect. The opera’s famous penultimate scene was mounted with stunning and chilling tension. The Commendatore appears from stage left and then from stage right and finally from within a cabinet in rapid succession. These multiple iterations of fate’s vengeance on the Don ends with him jumping into a brightly lit drop to hell that opens from a cabinet that has grown to be about 10 feet tall. The scene capped what is a very good staging of Mozart’s masterpiece.

The costumes ranged from early 19th century to well into the 20th. This ambiguous chronology fits into the ambiguous nature of Da Ponte’s libretto.

Lucas Meachem

Lucas Meachem

It was the production, design, and fine conducting by Lawrence Renes that made this presentation a success. In general the acting was quite good. The singing only occasionally exceed the adequate. All the singers are young and are thus works in progress. Their youth was, of course, beneficial to the drama.

Lucas Meachem portrays the Don as mean and dangerous in addition to being sex crazed. A valid interpretation that would benefit from a little more charm and a little less nastiness. His Don is clearly a very dangerous guy whom you would not want to be around. He kills the Commendatore with a knife rather than a sword and threatens almost everyone with a pistol. His singing was smooth and effective. His impersonation will likely grow with repetition.

Leporello, the Don’s prosaic alter ego, was bass Matthew Rose making his Santa Fe Opera debut. Another young singer new to his role, Rose presented another emerging portrayal. “Madamina, il catalogo è questo” was well sung and well acted. The book containing the names of the Don’s conquests (or victims) was red as was most everything else in this staging. I’m almost certain that a few more years will broaden and polish his Leporello.

Donna Anna was the South African soprano Elza van den Heever. She has a very big spinto voice that goes shrill and sometimes sharp when under stress. Another relatively young artist, her future trajectory is hard to guess. Susanna Phillips was a little more comfortable as the discarded Donna Elvira. A graduate of Santa Fe’s apprentice Singer Program, she was vocally smooth and appropriately persistent as the only woman on stage that the Don was not interested in. “Mi tradì quell’alma ingrata” was very well sung – a promising voice.

Kate Lindsey’s Zerlina was a combination of randiness and mugging. Amusing, but a little over the top. Another graduate of the Apprentice Program, her light soprano had all that was needed for the role. She projected the combination of appetite and innocence that is Zerlina’s personality. Corey McKern, yet another ex-apprentice singer, was suitably bumptious as the jealous peasant Masetto. Bass Harold Wilson did all that was required from the Commendatore.

This leaves Charles Workman – Don Ottavio, perhaps opera’s biggest nebbish. The tenor, a native of Arkansas but based in the UK, has a rather gruff voice that lacks the flexibility needed for this challenging role. “Dalla sua pace” was under par; it lacked a firm line and was awkwardly delivered. Surprisingly, “Il mio tesoro” was much better. Workman’s breath control was good and the aria’s runs were delivered effectively. The voice remains rather unattractive.

The young, appealing, and convincing cast in a first rate setting directed by a director with a valid vision of Mozart’s and Da Ponte’s masterwork made for a splendid evening. Highly recommended. Catch this show if you can.

Don Giovanni hits home in so many ways that there are many ways to present it. For a review of a deranged mounting that I saw in London five years ago see below

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L’Elisir d’Amore in Santa Fe

July 16, 2009
Dimitri Pittas in his hometown

Dimitri Pittas in his hometown

The Santa Opera presented its new production of Donizetti’s comic ruby last night (July 15, 2009). Stephen Lawless set the action in an Italian village just at the conclusion of World War II. Why? Who knows. But the show works despite a few contradictions induced by the change in setting.

Sergent Belcore in his officer's uniform

Sergent Belcore in his officer's uniform

Sergent Belcore is in the US Army.  He and his men arrive in a broken Jeep. He wears an officer’s uniform rather than that of a non-com. His pants and boots are not US Army regulation and if they were only General Patton would have worn them. Also the Italian Nemorino joins the American army. But this is opera and Stephen Lawless has a lot more stage sense than Mary Zimmerman of recent La Sonnambula infamy. He also didn’t have to work with Natalie Dessay. She’s on campus, but is in another show.

Adina is a haughty school teacher. She writes the alphabet on a blackboard early in the first act. Unlike Zimmerman’s blackboard very clever use is made of it. Many in the audience wondered at intermission about the missing letters; the Italian alphabet has only 21 letters. When Adina explains to Nemorino why she’s so hard to get she writes “NATURA” on the blackboard. Nemorino, (opera’s ultimate booby) in a unexpected burst of intelligence erases all but the N and A, separates them with a +, and draws a heart around them.

The love struck Nemorino is an auto mechanic who putters with a small red convertible throughout the opera. Dr Dulcamara, who has a potion for everything from warts to impotence, is dressed like a sharpie out of a Fellini movie. The staging was fast paced and fun; it fully captured the work’s gentle humor.

The star of the evening was the young New York born tenor Dimitri Pittas. He has a lovely limpid lyric tenor which he uses with grace and Italianate style. He’s newly emerged on opera’s main screen. If he can avoid the self destruction that haunts his vocal type he’s destined for a great career. His acting was as good as his singing. He has a fine comic sense and connects with the audience in a way that can’t be taught. He’s got everything needed for success as a tenor; he’s losing his hair, his shape is shifting to that of a squash, and his voice is beautiful. Faust, Edgardo, and Rodolfo, in addition to Nemorino, are the type of roles he should concentrate on.

Quanto è bella was sung with pathos and a long line. Una furtiva lagrima, which is so famous and so great that it can overwhelm the entire opera, was delivered with restraint and subtlety. Of course it got the most applause of the evening. It was almost as good as Carlo Bergonzi’s reading that I heard in Chicago about 30 years ago.

Black, Pittas, and the red car

Black, Pittas, and the red car

Jennifer Black, recently Lisa in Zimmerman’s goofy Sonnambula, was Adina. She has a fine voice which handled her role with ease. She went a little shrill at the top of her range, but this is a quibble. Her main problem is that she doesn’t have a sound that stays with the listener. She acted her part with verve and skill. All and all a fine job.

Patrick Carfizzi was Belcore. He had the required swagger but his bluster tended to extend to his singing. He bellowed from time to time. Thomas Hammons was a late replacement for John Del Carlo who was originally announced as Dr Dulcamara. He was underpowered for the role. At time he was almost inaudible. he made nothing out of Dulcamara’s great entrance aria “Udite, udite, o rustici”.

Corrado Rovaris conducted in white tie and tails. Santa Fe has been hit with an unusual heat wave that has lasted into the evening. That Maestro Rovaris didn’t succumb to heat stroke garbed as he was indicates great conditioning. His conducting was idiomatic and kept Donizetti’s sparkling score moving along briskly.

In summary, an outstanding presentation of one of opera’s greatest comedies. The evening’s highlight was the emergence of Dimitri Pittas as a potential great tenor. Keep your digits crossed.

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Which Leg Bone Did She Break?

July 8, 2009

Last Saturday American mezzo-soprano Joyce DiDonato fell during a performance of Rossini’s Barber of Seville and broke her leg. The singer described the event on her blog and posted a picture of herself with her new cast. In the grand tradition of the stage she finished the performance and is singing subsequent shows from a wheel chair.

DiDonato broken leg

The injured bone was initially identified as her right “fibia”. This is a conflation of the two bones in the leg – the fibula and the tibia.

leg bones

The affected bone was subsequently identified as the fibula. I suppose this is the only web site interested in opera that would care about the names of the bones in the leg. Regardless, I hope Ms DiDonato makes a speedy recovery.

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More on Angiotensin Blockade and Diabetic Nephropathy

July 6, 2009

I recently reviewed a paper that indicated that angiotensin blockade with an angiotensin receptor blocker (ARB) did not protect against the development of diabetic nephropathy in diabetic patients with normal renal function. Despite what that paper concluded angiotensin blockade with and an angiotensin converting enzyme (ACE) inhibitor offered protection.

Two papers in the July 7 Annals of Internal Medicine looked at the effect of ARBs in patients with renal disease. The first study included patients with high vascular risk but who did not have microalbuminuria; about a third were diabetic. In these patients the ARB telmisartan had no effect on major renal outcomes.

The second study was of normotensive diabetic patients. Candesartan (another ARB given at a maximum dose of 32 mg daily) did not prevent microalbuminuria in patients with either type 1 or type 2 diabetes. This makes three studies which indicate no salutary renal effect of ARBs.

The clinician is left wondering if ACE inhibitors are better for the kidney than ARBs or other anti-hypertensive medicines. This question may remain unresolved because ACE inhibitors are available in generic form while ARBs are still on patent. Thus there is little incentive for drug companies to fund long and expensive research projects which are not likely to help them market their product. The NIH should be encouraged to mount additional studies of ACE inhibitors on patients at great risk for serious renal disease who are at an early stage of their disease.

The best practice in the absence of such studies would be to continue to prescribe ACE inhibition in diabetic patients and other at increased renal risk and to do so early in their disease. The worst that will happen from this treatment is that blood pressure will be reduced and the retina will be protected; there is no down side. I think that ARBs should be avoided  unless the patients cannot tolerate ACE inhibition, usually because of cough and rarely because of angioedema.

If there turns out to be a different effect on clinical outcomes between the two types of angiotensin blockers the explanation for the difference will be of intense interest. One possible explanation for a difference between ACE inhibitors and ARBs is that the former decreases angiotensin levels while the latter increases them. ARBs block the AT-1 receptor. If angiotensin exerts a harmful effect mediated by a mechanism other the via the AT-1 receptor then ARBs would make things worse while ACE inhibitors would be beneficial.

I suspect when the fog lifts that ACE inhibition will be shown to have a beneficial effect on patients at high risk for progressive renal disease. But well designed research will have the final word.

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