FDA Authorizes Bivalent Covid-19 Vaccine Booster Dose Today

The FDA announced the EUA authorization this morning of the Moderna and Pfizer-BioNTech Bivalent Omicron Covid-19 Vaccine Booster Dose.

CDC-ACIP meeting starts tomorrow for evaluation of the booster doses.

Psychiatric Polypharmacy: An Opportunity to Teach with CPCP

Dr. H. Steven Moffic discussed the issue with psychiatric polypharmacy in his August 29, 2022 entry on Psychiatric Views on the Daily News. The patient who had been getting 10 psychotropic drugs was found to have a medical problem ultimately, which led to simplification of the complex regimen.

This is a great opportunity to again mention the value of what was a regular part of the teaching component of the University of Iowa Hospital Consultation-Liaison Psychiatry service, at least until my retirement. This was the Clinical Problems in Consultation Psychiatry (CPCP) seminar. Once a week or so, when I was staffing the service, I and the trainees, which included medical students, and psychiatry residents as well as Pharmacy, Neurology, and/or Family Medicine residents.

Whenever we encountered a difficult and interesting case, which was almost every rotation, the trainees did a literature search to bone up on the clinical issue and gave a short presentation about it before consultation rounds. Often the case had both medical and psychiatric features.

I looked through my collection of student presentations and found one that might fit Dr. Moffic’s example in a general way. Medical problems can often look like psychiatric problems, which can include thyroid and other diseases. A very important one is autoimmune encephalitis, one example of which is anti-N-methyl-d-aspartate (NMDA) receptor encephalitis. There is an excellent summary of it in the August issue of Current Psychiatry entitled Is it psychosis, or an autoimmune encephalitis? (Current Psychiatry. 2022 August;21(8):31-38,44 | doi: 10.12788/cp.0273).

Several years ago, three medical students tag-teamed this topic and delivered a top-notch CPCP seminar summarizing the pertinent points. I hope the CPCP is still part of the educational curriculum.

CDC ACIP Meeting for September 1-2 on Bivalent Omicron Covid-19 Vaccine Boosters

The CDC ACIP have an agenda posted indicating that the advisory committee will discuss Covid-19 Bivalent Omicron vaccine candidates on September 1-2, 2022. A vote is scheduled on September 1, 2022.

On the Other Hand Thoughts on HBCUs

Historically Black Colleges and Universities (HBCU) are in the news lately. It reminds me of the short time I spent at Huston-Tillotson College. It was renamed Huston-Tillotson University (H-TU) in 2005. I was there in the mid-1970s.

A new President and CEO was just named this month, Dr. Melva K. Williams. And H-TU was recently added to the National Register of Historic Places last month. It has been renovated and modernized. Pictures show a well-kept campus pretty much as I remember it over 40 years ago. I didn’t graduate from H-TU, but instead transferred credits to Iowa State University where I graduated in 1985.

My favorite teacher was Dr. Jenny Lind Porter-Scott, who was white, taught English Literature. Another very influential teacher was Reverend Hector Grant who was black. He taught philosophy and religion. He was instrumental in recruiting me to matriculate at H-TU. He helped me to process my loss on the debating team when the question was whether or not the death penalty played any role in the reduction of crime.

My opponent won the debate mainly because he talked so much, I couldn’t get a word in edgewise. I can’t remember which side of the question I argued, but I thought I could have done better if he had just shut up for a few minutes and let me speak. Reverend Grant used the word “bombastic” in describing the approach my opponent used. On the other hand, he also gently pointed out that sometimes this can be how debates are won.

There’s this “On the other hand” tactic in debating and in reflective thought that my debating opponent managed to repeatedly deflect.

I don’t know what ever happened to Reverend Grant. We spoke on the telephone years ago. He sounded much older and a hint of frailty was in his voice.

I could find only a photo on eBay of a man who closely resembles the teacher I knew and the name on the picture is Reverend Hector Grant. The only other artifact is a funeral program for someone I never knew, which lists Reverend Hector Grant as being the pastor and some of the pallbearers were members of one of the Huston-Tillotson College fraternities.

I think it’s unusual for people to disappear like that, especially nowadays when we have the world wide web. Reverend Hector Grant was an important influence for me. He was one of the few black men of professional stature I encountered in my early life.

On the other hand, contrast that with Reverend Glen Bandel, another clergyman who was a white man and another important influence starting in my early childhood. Reverend Bandel persuaded me to be baptized at Christ’s Church in Mason City, Iowa. He radiated mercy, generosity, and kindness. He died in June of this year. I can find out more about him on the web just from his obituary than I can ever find on Reverend Grant, who apparently disappeared from the face of the earth.

Both of these men were leaders for whom skin color didn’t matter when it came to treating others with respect and civility.

My path in life was largely paved by these two clergymen. Reverend Bandel sat up with our family one night when my mother was very sick. His family took me and my little brother into their home when she was in the hospital.

On the other hand, Reverend Grant was instrumental in guiding me to an HBCU where I saw more black people in a couple of years than I ever saw in my entire life. The First Congregational Church in Mason City was instrumental in making that possible because they helped fund the drive to support H-TU (one of six small HBCUs) by the national 17/76 Achievement Fund of the United Church of Christ.

The news is replete with stories, some of them tragic, about how Greek fraternities haze their pledges. On the other hand, H-TU was pretty rough on pledges too. Upper classmen would make the pledges roll down the steep hills around the campus. They looked exhausted, wearing towels around their necks, running in place when they weren’t running somewhere in the Texas heat.

One H-TU professor said that H-TU was “small enough to know you, but big enough to grow you.” Although I can’t remember ever seeing him on campus because he was traveling most of the time, I at least knew the name of the President was John Q. Taylor (1965-1988). On the other hand, when I transferred credit to Iowa State University, I never knew the name of the President of the university.

Habari Gani is Swahili for “What’s the news?” or as it translated in the context I’m about to set, “What’s going on?” Habari Gani was the name for the annually published book of poetry by the H-TU students. Dr. Porter supported the project. I submitted a poem for the 1975 edition, which didn’t make the cut. When I transferred to Iowa State University, I left without getting a copy.

On the other hand, years later, I got a digital copy of that edition. I tracked it down to the H-TU library in 2016. The librarian was gracious.

Habari Gani has always been a reminder of the reason why I went to H-TU in the first place. I grew up in Iowa and was always the only black student in school. I grew up in mostly white neighborhoods.

On the other hand, when I finally got to H-TU, one of the students asked me, “Why do you talk so hard?” That referred to my Northern accent, which was not the only cultural factor that made social life challenging.

Once I tried to play a pickup game of basketball in the gymnasium. I’m the clumsiest person for any sport you’ll ever see. I was terrible. But the other players didn’t give me a bad time about it. They softly encouraged me. This was in stark contrast to the time I played a pickup game with all white men years before in Iowa. When I heard one of them yell, “Don’t worry about the nigger!” I just sat down on the bleachers.

On the other hand, when I was a kid and our family was hit by hardship, Reverend Bandel was the kindest person on earth to us—it didn’t matter that he was white. And my 2nd grade teacher, who was black (the only black teacher I ever had before going to H-TU), slapped me in the face so hard it made my ears ring—because I was rambunctious and accidentally bumped into her. It’s far too easy to polarize people as good or bad based on the color of their skin, especially when you’re young and impressionable.

It takes practice and experience to learn how to say and think, “On the other hand….”

Thoughts on Doctors Going On Strike

I read Dr. H. Steven Moffic’s two articles in Psychiatric Times about the strike by mental health workers at Northern California Kaiser Permanente (August 16 and 26, 2022). So far, no psychiatrists have joined the strike.

However, this piqued my interest in whether psychiatrists or general physicians have ever gone on strike. I have a distant memory of house staff voicing alarm about a plan by University of Iowa Hospital & Clinics to reduce health care insurance cost support many years ago. It led to a big meeting being called by hospital administration to discuss the issue openly with the residents. The decision was to table the issue at least temporarily.

It’s important to point out that the residents didn’t have to strike. I don’t recall that it ever came up. But I think hospital leadership was impressed by the big crowd of physician trainees asking a lot of pointed questions about why they were not involved in any of the discussions leading to the abrupt announcement that support for defraying the cost of house staff health insurance was about to end.

That’s relatively recent history. But I did find an article on MedPage Today written by Milton Packer, MD (published May 18 2022) about what was called the only successful strike by interns and residents in 1975 in New York. I don’t know if it included psychiatric residents; they weren’t specifically mentioned.

In 1957, the Committee of Interns and Residents (CIR) in New York City and voted to unionize to improve appalling working conditions. They won the collective bargaining agreement, the first ever to occur in the U.S. because they went on strike, which hamstrung many of the city’s hospitals. Medical faculty had to pitch in to provide patient care.

After 4 days, the hospitals agreed to the residents’ demands. However, the very next year, the National Labor Relations Board ruled that residents were classifiable as “students,” not employees, which meant they weren’t eligible to engage in collective bargaining. This led to a reversal of the gains made by the strike.

Residents who are unionized voted to strike at three large hospitals in California in June of this year. They reached a tentative contract deal at that time. The news story didn’t mention whether there were any psychiatrists in the union.

There has never been a union of residents at The University of Iowa Hospitals & Clinics. I was a medical student and resident and faculty member for 32 years. I saw changes in call schedules and work loads that were the norm for the exhausting schedules that led to horrors like the Libby Zion case in New York.

Even as a faculty member on our Medical-Psychiatry inpatient unit, the workload was often grueling. I co-attended the unit for years and during the months I was scheduled to work there I shared every other night call with an internist for screening admissions. I was sometimes scheduled for several months at a time because it was difficult to find other psychiatrists willing to tackle the job.

If residents had wanted to unionize and voted to strike then, my internist colleague and I probably could have filled in for them.

But I would never have considered going on strike myself. It would have been next to impossible to find any other psychiatrist to fill in for me. And if other psychiatrists had gone on strike? We might have won a better deal—but only by hurting the patients and families who needed us.

I suspect my attitude is what underlies the impressions shared in Robert G. Harmon’s article, “Intern and Resident Organizations in the United States: 1934-1977,” in the 1978 issue of the Milbank Quarterly.

The house-staff choice of unionization as a formal process has disturbed some health professional leaders. One has pointed out that for a house officer to don another hat, that of striking union member, in addition to those of student, teacher, administrator, investigator, physician, and employee, may be a regrettable complexity that will further erode public confidence in physicians (Hunter, 1976). Others have seriously questioned the ethics and morality of physician strikes (Rosner, 1975). -Milbank Memorial Fund Quarterly/Health and Society, Vol. 56, No. 4, 1978.

When I graduated from medical school, I believed in the cultural view of the physician as a professional. My first allegiance was to the patient and family. I paid dearly for holding that stance. Sena reminds me of the times my head nearly dropped into my soup when I was post call. And I did struggle with burnout.

But I retired because I thought it was time to do so. I don’t think of it as a permanent strike. I hope things turn out all right.

59th Anniversary of MLK’s “I Have a Dream” Speech on August 28, 1963

Sena reminded me that today is the 59th Anniversary of Reverend Martin Luther King Jr’s “I Have a Dream” speech in Washington, D.C. After she reminded me about it, I found this anniversary mentioned in only a few headlines on the web.

But that’s no excuse. It doesn’t matter that I was just a small child on August 28, 1963. And when I hear the speech, it still makes the hair on the back of my neck stand up.

FDA Removes N95 Respirators from Shortage List

I think it’s ironic that about the same time a PLOs One study and news articles came out announcing a new method using 8-inch rubber bands for improving the fit of the surgical mask to approximate that of the N95 respirator, the FDA removed the N95 respirator from the medical device shortage list. This is relevant to help protect people from infection with Covid-19 because even vaccinated older people are getting hospitalized with the Omicron variant of the virus.

I’m not saying that the new rubber band method to tighten the fit of the surgical mask is not an improvement. It might come in handy when there is another shortage of N95 respirators.

The method mainly targets health care professionals. It would be difficult to persuade everyone in the community to adopt the technique. It’s tough enough to get people to wear masks even in crowded buildings in high transmission areas.

This is despite the CDC study showing that the elderly population continue to be at high risk for hospitalization from Covid-19 despite being vaccinated with the initial series and one or more boosters.

I think it’s hard to achieve a good fit even with the N95 respirators. The free ones distributed by the Federal government early this year were not widely available and fit poorly because the straps were elastic (similar to rubber bands, only flimsier) and loosened quickly, even after using only 2 or 3 times. At least the ones I got did. Prior to retiring, I was never able to pass a Fit test at the hospital using that type of mask.

I think my surgical masks fit better than the N95 respirators, especially after using the knot and tuck method to get a tighter seal.

Now the newer rubber band method to get a better seal uses two large 8-inch rubber bands to make the mid-face portion of the mask fit closer to your face. It looks a little easier to do than the earlier 3 rubber band technique developed a couple of years ago. That one was even tested at the University of Iowa Hospitals and Clinics by emergency room health care professionals, resulting in a small published study (the “double eights mask brace”).

All of the rubber band mask braces techniques were a response to the shortage of N95 respirators. What’s interesting to me is that, as the authors of the PLOs One study point out, there is a fair amount of variability in how well the N95 mask fits. Differences in the shape of a person’s face can account for some of this.

And there’s no shortage of N95 respirators—for now, at least according to the FDA.

If a non-health care professional wanted to use a rubber band brace, it would take some practice to get a good seal. There’s a bit of a learning curve even for a pro.

I think it would be difficult to persuade the average person to get the rubber bands and the surgical mask out of a pocket or a purse and fiddle around to achieve a good fit if you’re just going to run into Wal Mart—where I could not find that the big 8-inch rubber bands are even in stock. They’re pretty much a “3-day shipping” kind of item and could cost as much as $20 a bag.

CDC Study of High-Contact & Surface Contamination in Household of Persons with Monkeypox Virus Infection

The CDC study, “High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus Infection-Utah June 2022″ was published as an early release on August 19, 2022 in the MMWR. See the link below for the full article.

Pfeiffer JA, Collingwood A, Rider LE, et al. High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus Infection — Utah, June 2022. MMWR Morb Mortal Wkly Rep. ePub: 19 August 2022. DOI: http://dx.doi.org/10.15585/mmwr.mm7134e1.

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