• How to learn Mahler 5, 1st movement trumpet solos

    Last night I auditioned for the solo trumpet part for an all-brass version of the first movement of Mahler’s fifth symphony, which the Mystic Brass Ensemble will be performing March 8, 2020. I played my best and am proud of it. I didn’t get the part, but the fellow whose musicianship I greatly admire did. That’s as it should be.

    I cannot emphasize how much I enjoyed practicing the challenging solos over the last couple months. I got deeply into this music. Maybe “life changing” is a little grandiose, but it was about as close to that type of experience with trumpet as I’ve had.

    In addition to consulting my teacher, I drew on a few resources that I thought, perhaps, other amateur trumpet players might like to know about, should they ever need to learn this part, or even if they don’t. Here they are, roughly in order of how valuable I found them:

    1. Philip Smith Trumpet Highlights: The first two tracks have the key solos, plus much (but not all) of the rest of the movement, as performed by the NY Phil. This, on loop, was my companion on many commutes.
    2. Interpretation Class: Mahler – Trumpet Solo from Symphony No. 5, with Benjamin Zander: This is the best video source I found that explains the meaning of the music. It’s long, but worth a watch at least once. Notice Zander’s comment about the quarter note triplet in the first solo. It differs from other advice, as conveyed below, and from how many of the masters play it.
    3. How to Play the Mahler 5 Trumpet Solo, with Russell DeVuyst: A nice “how to” on playing each phrase of the first solo, including the quarter note triplet.
    4. Boston Symphony Orchestra Brass Excerpts: In this collection (which really ought to be released as a set of MP3s!), you’ll find Tom Rolf’s interpretation of the solos. (There are a bunch more BSO excerpt videos on YouTube. Search and ye shall find. Again, someone turn these into MP3s, please, and I will gladly pay for them.)
    5. Mahler 5th Symphony: Seven trumpet solos: As the title suggests, this is seven people playing the opening solo, in sequence. I don’t know who they are. They’re definitely not all amazing.
    6. Carnegie Hall Trumpet Master Class: Mahler’s Symphony No. 5, with Gábor Tarkövi: This is the closest thing to watching a lesson with a mere mortal. Sometimes it’s nice to see that not everyone already knows how to kick the crap out of the opening solo. You are not alone. Tarkövi is so kind and a delight to listen to. Great advice.
    7. Sinfonia No. 5, I Mov; G. Mahler – Hércules Brass Ensemble: I found this one after I had written this post when I searched for an all-brass arrangement of movement 1. Of those I viewed on YouTube, this is the best. So, while it wasn’t valuable for me in preparation for the audition (because I hadn’t viewed it), it’s actually far more useful to me in preparing for the performance than any of the above.

    There’s lots more on Mahler 5 on YouTube and in recordings, of course. I did sample a few other things, but didn’t find them at all valuable. Naturally, I may have missed a gem, so if you know of one, tell me.

    @afrakt

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  • Healthcare Triage Podcast: Diabetes During Pregnancy has Long Term Implications

    Aaron Carroll talks to Dr. David Haas about gestational diabetes. You may know that women can develop diabetes during pregnancy, and may know that their blood sugar and insulin return to normal shortly after giving birth. What you may not know is that this condition is associated with a host of negative outcomes. Insulin treatment during pregnancy can impact the growth of the baby in utero. Experiencing gestational diabetes is also associated with a huge increase in risk for developing type II diabetes later in life. So, what can we do about this?

     

     

    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

     

    Available wherever you get your podcasts! Including iTunes.

    @DrTiff_

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  • Hypnic jerk (and a plantar fasciitis update)

    This is one of those N=1, my health story posts. If that’s not your thing, skip it. I like to document this stuff, as it’s how I “enjoy” my health problems. For those more interested in my plantar fasciitis story, see the very end for an update I’ve been meaning to provide for a while now.

    It seems to be my lot in life to experience all the major sleep disorders. I’ve already had and cured/addressed insomnia and obstructive sleep apnea. Now I get to “enjoy” persistent hypnic jerks (a.k.a., says Wikipedia, sleep starts, hypnagogic jerks, and predormital myoclonus). That’s the wonderful condition in which some of your muscles involuntarily and rapidly contract (jerk) just as you’re drifting off to sleep.

    No big deal if it only happens now and then and/or you sleep through it. I suspect hypnic jerks are pretty common, though I haven’t found a prevalence estimate I trust yet.

    What’s undoubtedly less common is to experience them every night, all night, causing the loss of many hours of sleep. Lucky me, that’s what I’ve been experiencing for over a week.

    Unless I’ve got some deeper disorder (doc visits pending, which may land me in the sleep lab again), my guess is it started from anxiety and stress, which are documented risk factors, among others that don’t seem to fit for me. It’s been a challenging few weeks.

    Another risk factor is fatigue. Well, if you are awakened by hypnic jerks every night for long enough, you’re going to be fatigued! I think I’m now in that vicious cycle.

    Magnesium is supposed to help, and some nuts (e.g., almonds and cashews) are full of it, so I’ve upped my intake. Doesn’t seem to have done much of good. There may be medications that could help (my docs will advise me on that). I do know from experience that Ambien will knock me out, and if I’m having them while on a full dose of it, I sure don’t notice! But that’s not a long term solution.

    None of this is good for a fragile sleeper like me, prone to insomnia. Wake me up enough in the night and I will definitely stay awake. Do it to me night after night and I’m re-digging that sleep maintenance insomnia groove I worked so hard to pave over.

    Concurrent with this, I’m probably experiencing the sleep-related signs of aging. And as one ages, melatonin levels fall, making sleep maintenance more difficult (or so I’ve read somewhere or other*). Another consequence of low melatonin is raised body temperature in the middle of the night (again, or so I’ve read somewhere*). I’ve been noticing both issues for much of this year, apart from allergy season during which I am blissfully drowsy enough all night to sleep 9-10 hours without a problem. I never thought I’d say it, but bring on allergy season!

    So, maybe melatonin supplementation is in order? I’ve started experimenting, but don’t have enough data to support results. I can say that years ago I tried it at bedtime and hated it. Made me feel like crap. Maybe the dose was too high. I don’t remember. Doesn’t matter, what I needed was CBT for insomnia and that’s what I eventually did. This time I’m trying something new: taking a dose if I wake before 2:30AM, as it only stays in one’s system for about 4 hours (or so I’ve read somewhere*). Last night, at 1:30AM, I took a very tiny dose, 75mcg (yeah, I split a 300mcg pill in quarters). I still didn’t sleep much between 1:30-5AM (because, you know, hypnik jerks), but I didn’t get hot, so that’s something. I think tonight I’ll double my dose.

    It’s a blessing I take few things personally, because “hypnic jerk” sure sounds pejorative. But it fits me to a tee.

    Other notes:

    • * Clearly my research is far from thorough. I’m just too busy. A little N=1 experimentation won’t do any harm and if something seems to work, I’ll dig into the research. In the meantime, I’ll be clear when I am not going on much and don’t trust any statements so annotated.
    • On that note, here’s a hypnic jerk review article I’ve yet to read.
    • On plantar fasciitis: As some of my posts earlier this year suggested, I don’t have it. I probably never did. The symptoms never matched. What I had/have is undiagnosed. Let’s call it an allergy to highly structured footwear. Basically, my feet hate closed-healed shoes and significant arch support, particularly support further toward the heal. Xero Terraflex shoes are the best I’ve found, perhaps because the footbed is so flat and wide in the heal. Oddly, Merrell barefoot shoes bother me, maybe because they’re just too tight in the heal. Most sandals are fine. Of those I’ve tried, Echos are the best. The contours of Birkenstocks don’t bother me. Keans are borderline. With waterproof socks, I have even worn sandals in the snow. It’s no problem at all! No, it’s not my fashion choice, but happy feet are worth it. Plus, I really don’t care what other people think.

    @afrakt

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  • Enforcing Work Requirements in Michigan is a Colossal Waste

    Or so I argue today in an op-ed in the Detroit News:

    State officials in Michigan … are still subject to the Snyder-era law requiring them to roll out work requirements in January. So far, the state has spent $28 million implementing them and is poised to spend $40 million more in the coming year. This month, for example, the Whitmer administration will have to spend $1 million just to send detailed compliance information to about 200,000 Michiganians.

    Even if you believe in work requirements, it makes zero sense to spend millions on a program that the courts are going to halt anyway. That’s why a bunch of deep red states, including Arizona, Indiana, and Montana, have all put their work requirements on pause while the litigation works its way to the Supreme Court.

    Michigan should do the same. The Legislature and Whitmer may be at each other’s throats over roads and budgets, but this is not a partisan issue. It’s about fiscal prudence.

    The Legislature, however, appears content to let taxpayer money burn.

    @nicholas_bagley

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  • Cannabis Use Among Teens in the Age of Social Media

    Alex Woodruff is a Policy Analyst at Boston University School of Public Health. He tweets at @aewoodru.

    Marketing has a powerful effect on shaping teens’ behavior. With recreational cannabis use legalized in many states, and on track to becoming legal in more, advertisement regulations could shape teens’ exposure to cannabis marketing.

    Cannabis marketing is booming. The industry is rapidly growing in the social media space for product promotion, especially to young audiences. Social media influencers display cannabis products as a key component to a complete and healthy life, with artfully crafted edibles, CBD lattes and lotions to fit the consumers’ taste. There are entire lifestyle brands that promote cannabis and CBD (one of the chemicals in marijuana without any psychoactive effects) as a treatment for anything from menstrual cramps to depression. These advertisements are readily available to teens and are undoubtedly alluring. It would be easy for teens to view cannabis products as a holistic treatment for the rising rates of anxiety and depression or simply as way to connect with trends on social media.

    But one of the few areas of consensus among public health officials and doctors about the effects of marijuana is that it is harmful to developing brains. Cannabis use among teens is associated with decreased cognitive functioning and psychosis later in life. Multiple organizations including the American College of Pediatricians and the American College of Adolescent Psychology have opposed legalization efforts on the basis that it puts teens at risk.

    While the causal effect of cannabis marketing on teens is unclear, it is established that the more time teens spend engaging with a product’s marketing — by following accounts, wearing branding, and sharing ads with friends, for instance — the higher the odds are that they use that product.

    Public health officials and activists have spent decades trying to protect teens from tobacco and alcohol marketing by encouraging restrictions on the types and locations of advertising for these products. But social media has changed the game. Ads are no longer generic TV commercials and billboards, but instead are targeted messages that latch on to viewers’ known interests.

    A group of researchers from across the country including Dr. Pamela Trangenstein, Dr. Jennifer Whitehill, Marina C. Jenkins, Dr. David Jernigan, and Dr. Megan Moreno, looked at how much teens in states with legalized non-medical cannabis are exposed to cannabis marketing. They found that over 90% were exposed to at least some kind of marketing. The majority came, unsurprisingly, from social media.

    New Research

    This same group of researchers recently took a deep dive into the relationship between cannabis marketing and teen use. (The authors of this study are affiliated with Boston University School of Public Health’s Department of Health Law, Policy and Management, University of North Carolina at Chapel Hill, University of Massachusetts Amherst, and University of Wisconsin Madison.) Across multiple states with legalized non-medical cannabis, they asked teens how much they interact with cannabis advertisements in their day-to-day lives and how that links to cannabis use.

    Using online surveys, they asked 482 teens, aged 15-19 years, questions about their experience with cannabis branding and social media. For example, they asked if teens were actively following social media accounts with marijuana marketing. Probing deeper, researchers asked teens what their favorite cannabis brand was, how likely they were to own or wear a cannabis branded item, and the extent that they used cannabis products.

    The researchers found that over a third of teens in states with legalized non-medical cannabis were interacting with cannabis promotions on social media. Teens were actively and intentionally following certain cannabis business pages on Instagram, Twitter, and Facebook. Instagram had the largest following, with Facebook close behind. Roughly a third of respondents said they were likely to own or wear a branded product, and 20 percent reported having a favorite brand.

    Overall, about a third of teens surveyed reported using marijuana in the past year. Teens that said that they like or follow a brand on social media were five times more likely to have used cannabis in the past year compared to their non-engaged peers. Those who said they do or would own a branded item were seven times more likely to have used cannabis in the past year. Those with a favorite brand were eight times more likely. Youth who reported past-year cannabis use did not differ by gender, race, or ethnicity, but were more likely report having parents with less than a bachelor’s degree.

    These findings underscore the link between youth and marketing. Teens who interact with marketing are much more likely to use cannabis products, putting them at greater risk for the mental health outcomes described above.

    Conclusions

    The explosion of legal cannabis brands means that there is a lot of interest in finding new ways to advertise products and gain an edge in the market. To date, there is significant variation in the restrictions states have adopted on cannabis advertisements. For example, Colorado has several restrictions on internet, pop-up, location-based, and out-of-state advertising, while Alaska has none.

    Plus, each social media platform has its own restrictions on cannabis advertising. For example, advertising cannabis on Facebook is banned, but a policy change in 2018 allows users to search and follow cannabis-related pages. Instagram users can search tags such as #legalmarijuana or #CBD and find hundreds of blogs and places to buy products.

    The new research suggests that we need to better understand how teens interact with cannabis advertisements. The evident variation in state marketing restrictions indicates there is a lack of consensus among policymakers on how best to protect this highly-susceptible group from harmful promotions. More data are needed to better determine how these advertisements can be effectively restricted to protect teens. It is a huge undertaking, but as we learned from tobacco and alcohol, it’s worth the effort.

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  • Plant Based Fast Food Isn’t Health Food

    Many fast food restaurants are now creating products with plant-based meat substitutes that are pretty convincingly meat-like. Some of these chains are positioning these foods as “healthier options.” Sorry to be a party pooper, but they aren’t really healthier than normal fast food.

     

    @DrTiff_

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  • If ‘Pain Is an Opinion,’ There Are Ways to Change Your Mind

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page A20 of the print edition on December 3, 2019.

    Some days I’m grumpy; other times, my head hurts or my feet or my arms do. Yet when I play the trumpet, my mood improves and the pain disappears. Why?

    Alternative medicine — including music therapy — is full of pain-relief claims. Although some are simply too good to be true, the oddities of pain can explain why others hold up, as well as why my trumpet playing helps.

    One thing we tend to believe about pain, but is wrong, is that it always stems from a single, fixable source. Another is that pain is communicated from that source to our brains by “pain nerves.” That’s so wrong it’s called “the naïve view” by neuroscientists.

    In truth, pain is in our brain. Or as the author and University of California, San Diego, neuroscientist V. S. Ramachandran put it, “Pain is an opinion.” We feel it because of how our brain interprets input transmitted to it from all our senses, not necessarily because of the inherent properties of the input itself. There are no nerves dedicated to sensing and transmitting pain.

    @afrakt

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  • Vaping Update: Policy Versus Reality

    We’ve been covering the news on recent vaping-related lung injuries, and a lot has happened since our last video. Time for an update!

     

     

    @DrTiff_

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  • Food Stamps, Hunger, and How Nutrition Assistance Works

    The second half of our two part series on food insecurity focuses on how food assistance programs like SNAP work, and how they affect health and well-being.

     

    @DrTiff_

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  • How Racial Bias May Have Saved 14,000 Black Lives

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It is jointly authored by Austin Frakt and Toni Monkovic.

    When the opioid crisis began to escalate some 20 years ago, many African-Americans had a layer of protection against it.

    But that protection didn’t come from the effectiveness of the American medical system. Instead, researchers believe, it came from racial stereotypes embedded within that system.

    As unlikely as it may seem, these negative stereotypes appear to have shielded many African-Americans from fatal prescription opioid overdoses. This is not a new finding. But for the first time an analysis has put a number behind it, projecting that around 14,000 black Americans would have died had their mortality rates related to prescription opioids been equivalent to that of white Americans.

    Source: National Center for Health Statistics, Centers for Disease Control and Prevention.

    Starting in the 1990s, new prescription opioids were marketed more aggressively in white rural areas, where pain drug prescriptions were already high. African-Americans received fewer opioid prescriptions, some researchers think, because doctors believed, contrary to fact, that black people 1) were more likely to become addicted to the drugs 2) would be more likely to sell the drugs and 3) had a higher pain threshold than white people because they were biologically different.

    A fourth possibility is that some white doctors were more empathetic to the pain of people who were like them, and less empathetic to those who weren’t. Some of this bias “can be unconscious,” said Dr. Andrew Kolodny, a director of opioid policy research at Brandeis University.

    This accidental benefit for African-Americans is far outweighed by the long history of harm they have endured from inferior health care, including infamous episodes like the Tuskegee study. And it doesn’t remedy the way damaging stereotypes continue to influence aspects of medical practice today. “The reason to study this further is twofold,” Dr. Kolodny said. “It’s easy to imagine the harm that could come to blacks in the future, and we need to know what went wrong with whites, and how they were left exposed” to overprescribing.

    The prescription-opioid-related mortality rates of black and white Americans were relatively similar two decades ago, but researchers found that by 2010, the rate was two times higher for whites than for African-Americans.

    Because African-Americans were less likely to receive those prescriptions, they were less likely to become addicted (though they were more likely to endure unnecessary and excruciating pain for illnesses like cancer).

    The researchers, Monica Alexander, a statistician with the University of Toronto; Mathew Kiang, an epidemiologist at Stanford; and Magali Barbieri, a demographer at the University of California, Berkeley; published their study in the journal Epidemiology.

    With additional analysis at The Upshot’s request, Mr. Kiang calculated that had the African-American population’s mortality rates caused by prescription opioids been equivalent to those of whites, black Americans would have experienced 14,124 additional deaths from 1999 to 2017.

    It’s a counterfactual analysis that relies on some large assumptions. Among other things, the projection assumes that the public health and medical response to the epidemic would have remained the same even if the African-American mortality rate had been higher. And it doesn’t take into consideration any potential changes in overdoses from heroin and fentanyl had African-Americans had greater access to prescription opioids. Still, Mr. Kiang found the results “fairly remarkable in at least two ways.”

    “First, it’s a good example of how more medical care is not necessarily a good thing,” he said. “Second, it’s an extremely rare case where racial biases actually protected the population being discriminated against.”

    A crackdown in recent years has reduced opioid prescribing over all, “and the racial/ethnic gap in opioid prescribing has narrowed,” said Mr. Kiang, but he said it was unclear whether the gap had closed entirely.

    In recent years, drug overdoses have risen sharply among black Americans, particularly among older heroin users in places where fentanyl has become widespread. One reason that the death rates from heroin and fentanyl have converged between black and white people may be simple: Heroin and fentanyl are readily available outside the health system, so they’re less affected by bias within it.

    The public response to drug epidemics also tends to diverge along racial lines. During the crack epidemic, there was a greater emphasis on punishment and incarceration. With the opioid crisis primarily affecting white people, there has been more emphasis on empathy and rehabilitation. (This same disparity was seen in crack versus powder cocaine.) Race played an obvious role in the policy response, Dr. Kolodny said: “From ‘Arrest our way out of it’ to, ‘It’s a disease.’”

    The response to drug epidemics also cuts along class lines, said Dr. M. Norman Oliver, Virginia’s health commissioner. “At the beginning, the opioid epidemic was centered in rural Appalachia, and as long as it involved poor rural whites, it did not get much attention,” he said. “When those prescription opioids hit the more affluent white suburbs around big cities, that’s when people started paying attention.”

    Race-based physiological myths have long influenced medical practice, he said. Even today, some doctors believe that African-Americans are more tolerant of pain. One study found that relative to other racial groups, physicians are twice as likely to underestimate black patients’ pain.

    Several years ago, researchers at the University of Virginia, including Dr. Oliver, probed the beliefs of 222 white medical students and residents and published results in the Proceedings of the National Academy of Science. Half held false physiological beliefs about African-Americans. Nearly 60 percent thought their skins were thicker, and 12 percent thought their nerve endings were less sensitive than those of white people.

    The medical students and residents who endorsed false beliefs like these were more likely to rate the pain of a black patient as less severe than that of an otherwise identical white patient and less likely to recommend treating black patients’ pain.

    Other studies show that physicians, white ones in particular, implicitly prefer white patients, falsely viewing them as more intelligent and more likely to follow professional advice.

    In 2013, the American Medical Association — the largest medical association in the United States — published a review of the relationship between pain and ethnicity in its Journal of Ethics. It concluded that variations in treatment stem in part from racial misconceptions about heightened pain tolerance among African-Americans and from the (false) notion that blacks and Hispanics are more likely than whites to abuse drugs.

    In turn, nonwhite patients receive less pain treatment, just as there are discrepancies in how they are treated for heart diseasecancerdiabeteskidney disease, among many other illnesses.

    Dr. Oliver said the bias problem in medicine was “not intractable — I’m actually hopeful that we can change the way people think.”

    He is African-American and said he was old enough to remember when racism was commonly overt and direct. “It’s primarily unconscious biases today,” he said, but he didn’t want to minimize those biases either. “They can lead to death.”

    It’s a bias that is overwhelmingly harmful to minority patients, even as it may have spared some from the worst outcomes of the early opioid epidemic.

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