Why matzah is tasteless

From the Sfas Emes (translated & paraphrased by your host):

How can the wise child ask for the reason behind a Biblically ordained law? It does say in the Bible, "He gives his sayings to Jacob, his laws and ordinances to Israel." There are cases in which one does not understand the reason behind a practice, but by the very practice itself one comes to know the reason nevertheless. Thus is matzah without a taste [טעם]* - so that it can fade into the background, leaving the eating of the matzah itself as the reason. Similarly, the last food eaten at the Seder should be matzah.

*This word can also mean "reason." - ZB


I'm sad...and I don't speak English!

Never fear! Though the New York City Department of Health and Mental Hygiene seems to have pulled the translated PHQ-9 (depression diagnosis) forms off their site, Albion saves the day.


A catalog of signs and arrows

I'm working on a catalog of signs, of arrows
with stubby beaks like sparrows,
resting places for gazes. Tomorrow

I'll make final edits and post, broadcast
to all my readers. Exact directions cast
a net of goals and safety. Last

night we mourned, drank, and fought.
Who died: it could be anyone. I ought
to tell you more and show you what I've brought.


Statins, heart disease, and risk - a conversation

What gives? How can someone with high blood cholesterol levels for 30+ years end up with clean arteries, if indeed there is any causation between blood cholesterol levels and plaque accumulation. ... Perhaps actual blood cholesterol levels have no cause of heart disease on their own a-priori. And, if any of these crazy hypotheses are true, then how can a health system prescribe drugs like statins so casually and routinely to anyone with cholesterol over 230? This is particularly true, when the long term side effects of such drugs must still be unknown.

Lots of questions -- some scientific, some health-plan political... But mainly I am looking for just straight talk on this whole cholesterol/heart disease issue.

You ask a lot of good questions. Let me paraphrase them for ease of presentation.

1. How do statins help in heart disease - through lowering the cholesterol level or some other mechanism?

It's not clear - this is one of those topics where the pendulum of the literature swings back and forth, and I can't say that I've followed every swing. Some hold that statins lower cholesterol, cholesterol causes heart disease, and that's it (though all the details of what the worst cholesterol particles actually are, and how they work their deadly magic, are yet to be fully worked out). Others think that statins are "pleotropic" - i.e. they work in multiple ways, e.g. by reducing inflammation.

2. How could you have high cholesterol and still have clean coronaries?

It's quite possible. I would imagine pretty common. That's why one of the biggest statin-related controversies hasn't really hit the lay press yet. It's all about when to give the medicines. Should everyone be on a statin if their cholesterol is above a certain level ("treat to target," or what I think of as the "statin in the water" approach), or should a statin be used only if a patient's risk of coronary artery disease is above a certain level ("tailored treatment")? A recent study in the Annals of Internal Medicine supports the latter, but no one really does this yet since the guidelines of the major doctor groups favor the former.

3. How do I know if I need to take medicine for cholesterol?

One way to think of it is this: statins lead to a reduced risk of coronary artery disease. Great. But this only matters really if your ABSOLUTE RISK, before statins, is something that you, or your doctor, are concerned about. If your 10-year risk of heart disease is 1%, and the statin reduces it to 0.1%, that's a 90% risk reduction, but maybe you don't care about a 1% risk. (I might not.) One way to calculate your risk is the Framingham risk calculator.

4, Do clean coronary arteries on a coronary CT scan (i.e. a low calcium score) mean I can't have blockages in the heart arteries?



(When) Is the physical exam useful?

The hope that the physical exam might bridge the gap between provider and patient is natural and even salutary, but we should clarify why we think the physical exam is useful.

More at KevinMD.


How can patients and doctors talk about risk?

Check out this presentation (based on other people's research) that I'm giving tomorrow at the meeting of the Mid-Atlantic branch of the Society of General Internal Medicine. The Power Point version, prettier in its Microsoft way, is here.


A case of ... what?

Recently I was staying with relatives, which gave me the chance to read the New York Times in print. It felt old-timey. I chanced upon an article in Lisa Sanders's Cases series, whose tropes can be summarized as follows:

1. Woman faints.

2. The doctors can't figure out what's wrong with her.

3. Bad Doctor says it's all in her head:

A neurologist in New York carefully examined her and her now thick chart and pronounced definitively that there was nothing wrong with her and that she should try to relax and maybe take up yoga.
4. Good Doctor notices a few key features and makes the diagnosis:
Ledereich watched as the patient calmly sat up. “I know what you’ve got!” he told her excitedly. Her sudden collapse looked as if a switch had been thrown and all her muscles just turned off. Ledereich realized that although it looked like syncope, it wasn’t; she hadn’t actually lost consciousness. What she probably had, Ledereich told her, was something called cataplexy, and that meant that she also had narcolepsy.
So far so good. But the treatment didn't cure the attacks:
But for reasons that neither the patient nor her doctors understand, after about six weeks, [the fainting spells] returned. At first, just occasionally. Then almost daily.

Thereafter she is left to do (more or less) what the Bad Doctor suggested: integrate her new diagnosis into her life.
The patient has learned to cope with her unusual condition; she no longer drives. And when she feels the warning signs, she tries to alert those around her to tell them not to worry. She’s part of a small community, andby now, most know her well enough not to call 911.

There are implications left unexplored here. First: that diagnoses can be partially but not entirely therapeutic. As Up To Date says about cataplexy, "these symptoms are often improved by medications." Often, but not always.

Second, that so much hinges on how the diagnosis is conveyed. Bad Doctor indicated that the woman affected with cataplexy "should just relax" - an abrupt and unhelpful direction, but not, for all that, unfounded. There is a connection between anxiety and cataplexy (and other sleep disorders) remarked upon in the literature.

Finally, a question is left unanswered (and unasked) at the end of the piece. What does the patient know that she has? Does she identify with her diagnosis of cataplexy in a way in which she wouldn't identify with a diagnosis of anxiety or other psychiatric disorder? Does the partial failure of GBH to treat her cataplexy at all detract from her trust/confidence in the diagnosis? In short, what does the patient think of all this?


The Ten Contradictions of American Health Care

Uwe Reinhardt at the Health Affairs Blog points out the contradictory wishes of most Americans with regard to health care.

[A]s the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

  1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
  2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
  3. Keeps insurance premiums and taxes for health care low.
  4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
  5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
  6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
  7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
  8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
  9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
  10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.