Rather Fight Than Switch?

I wonder how many baby boomers remember those TV cigarette commercials featuring an actor holding a smoke, sporting a black eye and saying “I’d rather fight than switch.” I guess they ran those ads from the 1960s to 1981.

I think of those commercials when I read the news. There are a couple of Iowa news items about a University of Northern Iowa (UNI) professor requiring his students to wear masks or suffer the consequences to their lab grades. He’s suffering the consequences because he’s going up against policies of the state Regents and UNI, which prohibit mask mandates. He’s doing it to protect others from COVID-19 infection. It sounds like he’d rather fight than switch.

The Governor of Iowa has signed into law a ban on applying mask mandates. However, Iowa City Mayor Bruce Teague has just extended “until further notice” a city-wide mask mandate that started August 18 and was set to expire today. Iowa Attorney General Tom Miller has been studying the situation for weeks and has apparently made no decision, despite the Governor’s office saying the mandate is “illegal” and “unenforceable.” I guess Mayor Teague would rather fight than switch.

There has been an executive order by President Biden to mandate COVID-19 vaccines for the many hospitals which have over a certain number of employees and are paid by Medicare and Medicaid. Headlines indicate there are many who would rather quit their jobs than get the jabs, which would not make patient care any easier. I guess they would rather fight than switch.

A man in Germany recently walked into a convenience store to buy beer and when the clerk asked him to put on a mask, the man left angry, came back wearing a mask and shot the clerk dead. I guess he’ll do the rest of his fighting in prison.

There a few songs about fighting and switching. I don’t remember Ruby Johnson’s version of “I’d Rather Fight Than Switch.” There was another version done by a group called The Tomboys, a group of female vocalists I’ve never heard of who were also performing in the 1960s. It looks like country star George Jones did a reversal of it with “I’d Rather Switch Than Fight.”

I wonder how things would be if people would start saying “I’d Rather Talk Than Fight.”

COVID Conspiracy Theories

A few days ago, I read the news story about COVID-19 antivaxx vigilantes interfering with the medical care of patients hospitalized with COVID-19. The writer interviewed Dr. Wes Ely, MD, MPH. He’s an intensive care unit (ICU) specialist at Vanderbilt University.

I first corresponded with Dr. Ely by email about 10 years ago when I wrote a blog called “The Practical Psychosomaticist.” I sort of poked fun of him in one of my posts about the chapter on psychiatrists and delirium in one of his books, Delirium in Critical Care, which he co-authored with another intensivist, Dr. Valerie Page, and published in 2011.

I can’t really tell the anecdote the way I usually told it to residents and medical students because of copyright rules but the antipsychotic drug haloperidol is mentioned. I made fun of the very short section “Psychiatrists and Delirium” in Chapter 9 (“Treatment of delirium in critical care”). It’s only a couple of paragraphs long and comically gives short shrift to the psychiatrist’s role in managing delirium. That’s ironic because I have always thought the general hospital psychiatric consultant’s role was very limited in that setting.

Maybe you should buy that book and, while you’re at it, buy the other one he recently published this month, Every Deep-Drawn Breath. My wife just ordered it on Amazon. It’s reasonably priced but in order to qualify for free shipping, she had to buy something else. It turned out to be Whift Toilet Scents Drops by LUXE Bidet, Lemon Peel (travel size, not that we’re traveling anywhere in this pandemic). Be sure to get the Lemon Peel.

In the email Dr. Ely sent to me and many others about the book, he said, “Every penny I receive through sales of this book is being donated into a fund created to help COVID and other ICU survivors and family members lead the fullest lives possible after critical illness. This isn’t purely a COVID book, but stories of COVID and Long COVID are woven throughout. I have also shared instances of social justice issues that pervade our medical system, issues that you and I encounter daily in caring for our community members who are most vulnerable.”

Anyway, the Anti-Vaxx vigilantes have played a big role in filling up the Vanderbilt ICU and many others by posting conspiracy theories about the COVID-19 vaccines on social media, which for some reason are hard to control. They persuade patients and their families that doctors are trying to kill them with the treatments that are safe and effective. Instead, they recommend ineffective and potentially harmful interventions such as Ivermectin, inhaling hydrogen peroxide, and gargling iodine.

There are different opinions about conspiracy theories and those who believe in them. Some psychiatrists say that conspiracy theories are not always delusional. One psychiatrist wrote a short piece in Current Psychiatry, Joseph Pierre, MD, “Conspiracy theory or delusion? 3 questions to tell them apart.”  Current Psychiatry. 2021 September;20(9):44,60 | doi:10.12788/cp.0170:

What is the evidence for the belief? Can you find explanations for it or is it bizarre and idiosyncratic?

Is the belief self-referential? In other words, is it all about the believer?

Is there overlap? There can be elements of both.

The gist of this is that the more self-referential the conspiracy theory, the more like it is to be delusional.

Another article which expands on this idea is on Medscape: Ronald Pies and Joseph Pierre, “Believing in Conspiracy Theories is Not Delusional”—Medscape-Feb 04, 2021. According to them, delusions are fixed, false beliefs (something all psychiatrists learn early in residency) and usually self-referential. Conspiracy theories are frequently, but not necessarily, false, usually not self-referential, and based on evidence one can find in the world—often the internet. Conspiracy theories have blossomed during the COVID-19 pandemic. One of them is that it’s a government hoax. An important difference between the current pandemic and the flu pandemic of 1918 is the world wide web which makes it easier for many people to share the conspiracy theories.

Pies and Pierre describe a composite vignette of someone who has a conspiracy theory featuring many false beliefs about the COVID-19 vaccines ability to change one’s DNA, thinks that research results about the vaccines are faked, mistrusts experts, has no substance abuse or psychiatric history and no mental status exam abnormalities. He exhibits exposure to misinformation, biased information processing, and mistrusts authorities.

They would say he has no well-defined psychiatric illness and antipsychotic treatment (such as haloperidol) would not be helpful. However, similar to the approach with frankly delusional patients, they would argue against trying to talk the person out of his false beliefs. Instead, if the person can be engaged at all, the focus should be on trying to establish trust and respect, clarifying differences in the information sources available, and allowing time for the person to process the information. It would be more helpful to avoid confrontation and arguments, instead pointing out inconsistencies in the information the person has and contrasting it with facts. Countering misinformation with accurate information could be helpful.

There are two major routes to anti-vaccination beliefs of the severity under discussion here. One is the problem of conspiracy theories out there. The other is the florid delirium that can happen to patients admitted to ICUs with severe COVID-19 disease. The former may not be a classifiable mental illness per se, but the latter definitely is.

Haloperidol is not the main solution for either problem.

Jab Who?

I just read a news item saying that the Blank Park Zoo in Des Moines, Iowa is administering COVID-19 vaccine to the animals there. I wondered how that would go, especially with large animals. I figured the zoo staff would be using dart guns. Talk about vaccine hesitance.

Then I saw a YouTube showing animals at the Louisville Zoo in Kentucky getting their shots. Apparently, they can get sick from COVID-19 infection. There were a few disparaging comments from viewers. Would 70 zoos vaccinate their animals if it weren’t safe and effective?

The animals didn’t seem to mind it. In fact, they were probably more cooperative than some humans. Of course, they got treats. But we give gift cards, beer, lottery prizes, turkey-flavored candy corn—which don’t really work. About 25% of Iowans don’t plan to get the vaccine according to a Des Moines Register news story.

Will the animals get boosters?

Featured image credit: Jim & Sena Amos at Henry Vilas Zoo in Madison, WI in 2009.

Proof of Simulated Reality—Or Cool Camera Trick?

I watch the History Channel TV show “The Proof is Out There” hosted by Tony Harris. Early this year (I think January), an episode featured a snapshot showing a woman who’s mirror reflection didn’t match her facial expression. It was striking. The question was whether this proved we live in a simulated reality (think of the film “The Matrix”). At that time, I think Tony and his panel of analysts (including a digital imaging expert) called the photo unexplained but stopped short of declaring it proof we’re all living in a simulation.

A couple nights ago, on an episode of the new season, Tony had to admit he and his colleagues got it wrong—because the snapshot can be created using the smartphone camera panorama mode. Somebody submitted a couple of photographs duplicating the effect of the one submitted in January along with an explanation of how to make them.

Sena and I checked this out. When I googled the term “panorama mirror trick,” I got several hits with step-by-step instructions and several YouTube presentations. Depending on what search terms you use, I could find internet references going back several years.

We played with the camera. It took a little practice, but we got the hang of it quickly. These are rough instructions:

Mirror trick:

Open the camera app and swipe to panorama mode.

Subject stands adjacent to the mirror, at an angle partly facing it and partly turned toward the camera operator.

Camera operator taps the shutter button while panning from one direction toward the subject and moving past, keeping the arrow centered on the straight horizontal line.

When camera operator has panned just past subject and before reaching the mirror, stop moving the camera and have the subject change position. This should take only a moment or so. If the camera is still moving, you’ll get a lot of motion artifact.

After subject has assumed the new posture, start panning again toward the mirror and a bit beyond, then tap the shutter button to end the shot.

You should get an image with the subject in one posture and the subject’s mirror reflection in a completely different posture.

Doppelganger trick:

I call this the doppelganger trick because the maneuver creates an image with two different images of the same subject in two different spots, creating a twinning or doppelganger effect.  

Set up is the same as for the mirror trick but have the subject stand in one spot to the left of the camera operator and strike a pose.

Camera operator starts panning to the right, then stops briefly.

Subject zips behind the camera operator on the left side and takes up a new position on the opposite side.

Camera operator restarts the pan right and completes the shot after moving past the subject.

Doppelganger

It may take a few tries, but when you get it right, the result looks startling. It’s fun.

Now here’s a question for Tony Harris. Do Doppelgangers exist?

CDC Statement on COVID-19 Vaccine Boosters

The CDC published a media statement this morning that outlines the amended Advisory Committee on Immunization Practices (ACIP) recommendations for COVID-19 vaccine boosters. Late last night, CDC Director Rochelle Walensky restored the recommendation that ACIP voted down yesterday: “People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks.” This is consistent with the FDA regulatory recommendations made on Wednesday.

Now, to my understanding, at least in Iowa, according to University of Iowa Hospitals & Clinics (UIHC) and others, it’s up to the Iowa Department of Public Health (IDPH) to green-light the booster rollouts locally.

ACIP Meeting on COVID-19 Vaccine Boosters: Day Two

It must have been after 8:00 PM last night that the FDA posted the COVID-19 Booster EUA authorization. The ACIP took that ball and ran with it all day long. Today was the second day of the ACIP meeting and the committee covered a lot of ground and ran over the schedule by more than an hour by the time voting on recommendations ended.

In a nutshell:

The committee voted unanimously to give boosters for people 65 and over as well as nursing home residents. Most of them voted to give boosters to those 50-64 with medical conditions that raise the risk for severe COVID-19 infection. A smaller majority voted to give boosters to those 18-49 with based on individual benefit and risk given underlying medical conditions. The committee voted down a proposal to give boosters to those 18-64 who would be at elevated risk of infection because of occupational or other setting, including health care workers, prison guards, and people who live or work in homeless shelters.

Nobody was happy about not giving an option to “mix and match” vaccines. If you got Pfizer in the initial series, you got Pfizer. But if you got Moderna or J&J—you couldn’t get Pfizer. More data is coming about heterologous vaccine dosing, but it’s not immediately available. On the other hand, the 6-month mark for getting the booster is anything but a hard line. You could wait months longer and still retain adequate vaccine effectiveness.

I thought it was interesting that, according to a survey in unpublished data, about a third of unvaccinated respondents said that offering a booster would make them even less willing to get vaccinated at all. See slides 52 and 53 in the presentation “Evidence to Recommendation Framework: Pfizer -BioNTech COVID-19 Booster Dose” by Dr. Sara Oliver. Despite that, several members of the committee stressed the critical importance of continuing to attempt vaccinating them.

There’s going to be a lot of flux in the next several weeks as more data is obtained. These recommendations are subject to updates and there will likely be several more meetings ahead, according to attendees.

I know that in Iowa, a lot of people are counting on the Iowa Department of Public Health (IDPH) to give the word on when to roll out the boosters. The University of Iowa Hospitals & Clinics and Story County officials have said that. I have not seen boosters even mentioned on the IDPH website, though. I inquired about what their plans are for the booster rollout this morning on their website contact form. I expect it may be a while before I get a reply, if I get one at all. They’re incredibly busy.

I heard one expert say that in his community, they were offering the vaccine to people in a way that emphasized the individual’s benefit only. I think that’s certainly one way to “sell” it. Altruism has a place here, though. I get regular email messages from Hektoen International, hekint.org.

They almost always contain some essay or quote that’s thought-provoking and inspiring. Here’s one I got this morning that included a public domain photograph of Bertrand Russell as well as his thoughts on the receding ego:

Bertrand Russell on life from Hektoen International hekint.org

Make your interests gradually wider and more impersonal, until bit by bit the walls of the ego recede, and your life becomes increasingly merged in the universal life. An individual human existence should be like a river — small at first, narrowly contained within its banks, and rushing passionately past rocks and over waterfalls. Gradually the river grows wider, the banks recede, the waters flow more quietly, and in the end, without any visible break, they become merged in the sea, and painlessly lose their individual being.

“How to Grow Old,” from Portraits from Memory and Other Essays by Bertrand Russell

Bertrand Russell by Fotograaf Onbekend / Anefo. 1957. Nationaal Archief. Public Domain. Via Wikimedia.

ACIP Meeting on COVID-19 Vaccine Boosters: Day One

This was the first day of the Advisory Council on Immunization Practices (ACIP) on COVID-19 vaccine boosters. I was struck by how organized it was. I was also struck by the statement by one presenter that they’re still waiting for a final decision from the FDA on the issue. I thought they made that last Friday. The decision has not yet been posted, though and I think it has to be published on the FDA website before it’s gospel.

In fact, ACIP is wondering if tomorrow’s meeting should be postponed if the FDA decision has not been made by then. Tomorrow is when ACIP plans to vote on what they decide about the who and how of the booster shots. Would they really leave it up in the air like that?

The only thing I see about boosters on the FDA website after the September 17th meeting is a podcast on September 20th that FDA Commissioner, Dr. Janet Woodcock did on a show called “In the Bubble with Andy Slavitt.” I thought it was a good general introduction to the booster issue. The interview also included questions about Pfizer’s latest study of their COVID-19 vaccine in children, ages 5-11 years of age. I thought there were too many commercials. There was supposed to be another broadcast about boosters on the show today, but I was too busy watching the ACIP meeting. I’m pretty sure I’m getting most of what I need from that, but I might check out the Andy Slavitt show “Toolkit: Answering Your Booster Questions.”

I know one thing; I heard the best lecture about the basic immunology of the boosters this morning. See the slides from the presentation “Adaptive immunity and SARS-CoV-2” by Dr. Dr. Natalie Thornburg, PhD. I still have cold sweats every time I think of the first basic immunology lecture we got in medical school. That was ages ago. The poor lecturer at some point during her talk happened to look up at us and she abruptly stopped talking. She looked dismayed by what must have been the totally lost look on our faces. She was demoralized and there was this—pause. She looked like all the air was sucked out of her. I thought for a moment she was too demoralized to go on.

I don’t remember how I got through the immunology exam. I do know I still have flunking nightmares of being a student at some level of college or medical school. In the dream, I’m usually trying to find a lecture hall, riffling through a key set of notes and books, all of which are incredibly jumbled up. I’m always hopelessly late and I have this sense of despair about ever graduating.

But today’s presentations were brilliant, fascinating, and helped clarify at least some issues in the complexity, not the least of which is deciding what the main goal of the boosters should be. Should it be preventing severe disease, hospitalization, and death, or preventing infection altogether?

I learned that not only are nursing home residents at high risk for getting COVID-19 but that it’s actually the level of community transmission that drives infection rates in residents (see presentation “Modeling the potential impact of booster doses in nursing home residents” by Dr. R. Slayton). Which brings up the issue of transmissibility of the virus, which is very high. Would the boosters cut the transmissibility? It’s unclear.

The boosters seem to be very safe and effective for pregnant people, yet only about 30% of them get vaccinated—cut that percentage in half for African American women. See the lectures with the word “pregnancy” in the title.

Dr. Sara Oliver’s “Work Group Summary” was enlightening and disturbing. The safety and immunogenicity date are reassuring but limited. But getting more data takes more time. What are the next steps for the ACIP? They are awaiting regulatory action from the FDA. I get a sense that we need a lot more beyond Dr. Janet Woodcock’s word on that. As she said in the “In the Bubble” interview with Andy Slavitt— “We need to get this right.” I think that means they need to take whatever time it takes to do that.

Will ACIP meet tomorrow? Will they vote? Don’t ask me; I still have flunking nightmares.

CDC Advisory Committee on Immunization Practices Meeting This Week on COVID-19 Vaccine Boosters

The CDC Advisory Committee on Immunization Practices (ACIP) will meet this week, Sept 22 and Sept 23 to discuss COVID-19 vaccine boosters. The agenda is posted although slides are not and the topic headings do not so far indicate a clear plan to vote on any specific booster recommendations. Recall on the August 30, 2021 ACIP meeting, Dr. Sara Oliver alluded to the probability of a vote on boosters (slide 49) in the presentation, “Framework for booster doses of COVID-19 vaccines.”

The University of Iowa Hospitals & Clinics (UIHC) today announced what its plan would be for boosters after the ACIP committee makes its own recommendation for boosters. The Iowa Department of Public Health must also give its approval. It looks like the guidance would be for UIHC employees only for the time being. Since more information about the ACIP recommendations for boosters will be posted on The Loop, you can access that directly. I will also be posting a link in the main menu on my blog site for now.

More COVID-19 Vaccine Booster Sausages This Week?

I saw a nice summary by Stat News of last Friday’s FDA Advisory Committee meeting on Pfizer’s COVID-19 vaccine booster. They indicate the Advisory Committee on Immunization Practices (ACIP) are meeting this coming Wednesday and Thursday to fine-tune the FDA recommendations, which was a messy affair. I have been checking the ACIP web site frequently but so far, I’ve not seen any agenda or slide sets for September 22 and 23. Is that a signal that watching their meeting will be even more like watching sausages being made?

Just as an aside on the quote attributed to Otto Von Bismarck I mentioned in my post on Friday—it’s probably apocryphal.

Laws are like sausages; better not to see them being made.”

Otto Von Bismarck or maybe John Godfrey Saxe

I glanced around the web and ran across several articles which cast doubt on whether the big sausage duel ever took place. It’s kind of a shame because it had the medical science angle. Supposedly the scientist Rudolf Virchow who was studying the parasite responsible for causing trichinosis had responded to Bismarck’s challenge to a duel by proposing they each eat one of two sausages as weapons. Bismarck and Virchow would choose a sausage to eat, one of which was loaded with trichinella or one that was not. They couldn’t tell by looking at the sausages which was which. I first learned about this duel on the Travel Channel show (episode entitled “Sausage Duel”), which I think set the context as nasty factories churning out Trichinella laden sausages because of horrifyingly unsanitary practices. The show cast Virchow and Bismarck as opponents over that issue specifically. Bismarck conceded and that led to the factories cleaning up their act. Scientists triumph over politicians!

That probably never happened, according to more than one writer. So maybe I should choose another quote. One by a lawyer statesman might be a partial fit:

If Columbus had an advisory committee, he would probably still be at the dock.

Arthur Joseph Goldberg

Another that I like just because I’m a Dave Barry fan:

“If you had to identify, in one word, the reason why the human race has not achieved, and will never achieve, its full potential, that word would be ‘meeting.’”—Dave Barry.

If you had to identify, in one word, the reason why the human race has not achieved, and will never achieve, its full potential, that word would be “meeting”.

Dave Barry

Some sources on the web say Barry’s quote was in one of his many books I used to own: Dave Barry Turns 50. It’s in a list: “25 Things I Have Learned in 50 Years.” I didn’t check with Barry’s web site to verify the quote. You can find some of them on line. Many of those items are on the order of booger jokes, of which I happen to be a fan. This quote also happens to be highlighted on the website called mycommittee, which ironically advertises committee management software which promises to make them more productive. The home page shows a sample software document entitled “Decisions regarding response to Covid-19.”

Hmm. Maybe the advisory committees could use this.

ADDENDUM: Whoa! ACIP just posted this Wednesday’s draft agenda. More materials will surely follow.

Watching Sausages, Laws, and FDA Advisory Committee Decisions Being Made

Sena and I watched the FDA Advisory Committee live streamed meeting yesterday on whether or not Pfizer’s COVID-19 vaccine booster should be given full licensure. You know, there’s a much-discussed question about who actually made the following quote:

“Laws are like sausages; better not to see them being made.”—often attributed to Otto Von Bismarck although it’s been attributed to others.

You can view the arguments about who said it at this link. The point is I think it should also apply to FDA meeting decisions. Our overall impression is that it was a messy process. We watched the entire daylong proceeding. The bottom line was that the committee revised the original question and reframed the approval from full licensure to Emergency Use Authorization (EUA):

The FDA approved the EUA for the booster based on the “totality” of the available evidence instead of just the originally specified Clinical Trial C4591001 (because of the small number of subjects including only a dozen in the older age group; the data from Israel was also fair game) and restricted the population to those age 65 and older (instead of the original 16 years and older). They further specified further that the booster should target those at increased risk for severe disease—which is to be understood to include health care professionals and others at risk for high occupational exposure.

One of the voting members disclosed candidly that his wife had already received a booster shot at a pharmacy well in advance of the meeting (technically off-label) and that he planned to do the same—after they unanimously approved the booster after the question was reframed. Sena and I both thought this was an extraordinary statement coming from an FDA advisory committee member.

The original question was voted down with only 2 of 18 members voting in favor. Dr. Stanley Perlman of The University of Iowa voted no on the original question and voted yes on the revised question. For many days now, the news has been reporting that a large number of people have been getting a booster shot despite the lack of FDA approval.

Dr. Arnold “Arnie” Conto M.D., the Acting Chair of the committee, after being asked to read the original question, slipped by indicating the age as “16 months” instead of “16 years.” He was instrumental in holding the committee members to staying on time for each phase of the meeting.

Dr. Conto: “Do the safety and effectiveness data from clinical trial C4591001 support approval of a Comirnaty booster dose administered at least 6 months after completion of the primary series for use in individuals 16 months of age and older?”

“I see someone has his hand raised. Do you have a question?”

Dr. X: Lips clearly moving but no sound.

Moderator: “Please unmute your mike” (Everyone was guilty of this oversight repeatedly throughout the day. One participant actually started speaking audibly and then leaned over and switched off his mike, possibly not to break the trend).

Dr. X: “Oh my, sorry about that. Arnie, we’re not sure on that part about “16 months and older.”

Dr. Monto: Oh yeah, I meant “at least 16 days and younger.”

Dr. X: Lips moving but no sound.

Moderator: “Unmute, please!”

Dr. X: “Oops, sorry! OK, Arnie. Does anyone know whether we’re supposed to vote on the time machine today, or will that be for the Advisory Committee on Immunization Practices?”

Christopher Lloyd: “I got that covered! Dang, I mislaid the keys to the DeLorean.”

We listened to those making short presentations at the open public hearing. They were each given about 3 minutes to make their statements. Some were in favor of the vaccine booster, others were not. Safety concerns were prominent, especially for giving vaccine boosters to children.

In fact, the committee seemed very ready to change the focus of the booster to place less specific emphasis on children. We imagine that’s part of the reason why the age range was adjusted away from specifying those 16 years and older (although they’ve probably been getting the primary series, even before the August approval of the Pfizer vaccine). One of the committee members asked, after the change of the age from “16 years” to “65 years” (but also specifying those at “high risk for severe disease”) whether that still meant a 16-year-old could get the booster. The answer was “yes.”

That made sense since children can have medical illnesses that increase their risk of serious complications from COVID-19 infection. But some committee members wondered about the 65 years of age cutoff, probably because they were not 65 years old. This and other speculations about how to specify the vulnerable population led to scrambling to get the meeting over because this was a question which the ACIP could clarify—and because it was getting very close to the end of the day.

We still don’t know when the ACIP is going to meet about the booster. They’ve added something for September 22 and 23, but I don’t find an agenda for it yet. Maybe they’ll have sausages for lunch.

%d bloggers like this: