James Amos

Fake Snakes Saga Slithers On

The fake snake saga continues with not much change in scaring off birds, evidently. Bird poop calling cards are still being left.

I repositioned them and we’re hoping for the best.

This reminds me that the other night I was awakened by what I was pretty sure was an owl and dogs raising a ruckus at each other. I thought there was either one or two dogs trying to imitate the owl.

I don’t think it was the other way around. There is an owl that barks like a dog, but I believe it’s found only in Australia. I think it barks because it can’t stop eating vegemite, which makes it think it’s a dog.

Snakes don’t make noises generally, other than hissing sounds unless they’ve been abducted by extraterrestrials. The ETs conduct genetic experiments on them and that’s how they came up with the reptilians—who bark like owls.

The Good and the Not So Good About Mental Health Treatment

Sometimes I write “depressing” blog posts. On the other hand, I have both good and bad news today.

I found out that, according to the Treatment Advocacy Center, Iowa’s state psychiatric hospital bed availability is dismal according to 2023 figures. That’s actually not new. Although we rate last in the nation for this, we still get a Grade B overall. I’ll have more to say later about it. You can check your own state’s grade on the web site’s map graphic.

And a recently published article about antidepressant prescribing for young people is sort of depressing, there are ways to address the likelihood that adolescent females are being prescribed antidepressants more often than adolescent males.

I tend to agree with the author of another article on adopting a more nuanced perspective on what is often called “depression” in young people. Not everybody who is distressed is depressed.

Even if we are depressed, there are healthy activities we can engage in to heal. We don’t all necessarily need antidepressants. That’s the point of a recent systematic review and meta-analysis on the role of exercise for managing depression. Exercise is effective either by itself or in addition to psychotherapy and antidepressant.

Iowa actually seems to be putting a lot of hard work in mental health outreach, such as Your Life Iowa. It’s funded by the Iowa Dept of Health and Human Services under the Division of Behavioral Health.

I’d say that’s pretty positive, overall.

Thoughts on a Study of Sitting with Your Patients

I saw this interesting article on a study about the effect of chair placement on physicians’ behavior when in a patient’s room, specifically whether it altered the length of time a doctor spends with a patient or the level of satisfaction patients had with the interaction. In this study, it didn’t lengthen the time, but seemed to strengthen patient satisfaction with interaction with the physician. It’s a concept I recognize because I took this one level up—I carried my chair with me on hospital rounds in my role as a consultation-liaison psychiatrist.

I got a gift of a 3-legged camp stool from a colleague who ran the palliative care service at University of Iowa hospital. Other members of the palliative team had been using them as well.

Patients got a big kick out of a doctor who carried his chair around with him and actually sat down to talk with them. The way the camp stool folds up apparently made it look like nunchucks to some patients, so I got jokes about that occasionally. It really helped build rapport.

The only drawback with the camp stool was that my one of my legs would go numb the longer I sat on it, and could lead to a challenge getting up from it gracefully because it was partly a balancing act. Even so, I often spent much more than 10-15 minutes with patients.

Once, the stool actually broke and I dropped unceremoniously on my butt while evaluating a patient for catatonia—who proved not to be catatonic by the apparent facial expression of mirth as I fell on the floor. In that sense, the chair actually became a part of the evaluation—accidentally.

Thomas Hackett knew all about this. He was a famous consultation-liaison psychiatrist and a past president of the Academy of Consultation-Liaison Psychiatry (ACLP). One of his quotes from an early edition of the Massachusetts General Hospital Handbook of General Hospital Psychiatry fits perfectly in this context:

“As a matter of courtesy, I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if that is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”— Hackett, T. P., MD (1978). Beginnings: liaison psychiatry in a general hospital. Massachusetts General Hospital: Handbook of general hospital psychiatry. T. P. Hackett, MD and N. H. Cassem, MD. St. Louis, Missouri, The C.V. Mosby Company: 1-14.

Reference: Effect of chair placement on physicians’ behavior and patients’ satisfaction: randomized deception trial BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2023-076309 (Published 15 December 2023)

African American Women in Iowa History

In light of March being Women in History Month (as well as Iowa History Month), I’d like to share some history stories about an African American librarian from Mason City, Iowa named Esther J. Walls. In 2020 during the Covid-19 pandemic, there was an essay about her, “Esther J. Walls: The Role of a Black Leader.” Her life story as a librarian, traveler, and educator is fascinating.

I looked through the list of women elected to the Iowa Women’s Hall of Fame and couldn’t find her name. However, I recognized Deborah Ann Turner’s name on the list. She was the first African American woman to be certified by the American Board of Obstetrics and Gynecology in gynecologic oncology. She was also from Mason City, Iowa. Her life story and list of accomplishments is also impressive.

I identify with both of them because they were born and raised in my hometown, Mason City, Iowa. Esther J. Walls was employed at the Mason City Public Library, my favorite haunt because my love of reading and writing began in early childhood.

An archived news item about Esther J. Walls entitled “A Mason City woman’s globe-trotting career” highlights her travels and her sense of humor.

Well, The Times They Are A’Changing at the CDC

We just found out that the CDC is, in fact, changing their recommendations on isolation precautions and other guidance for respiratory illness. It turns out the 5 day isolation rule for a positive Covid 19 test is going away. The Respiratory Virus Guidance page has changed as of today.

Sena found out about it from an article in the Wall Street Journal. The rules for health care personnel are not the same as they are for the public. I guess the times theye are a’changing.

CDC ACIP Meeting on the RSV Vaccine and Some Dad Jokes

We watched the section of the CDC ACIP meeting about RSV vaccines on February 29, 2024. There was a lot of discussion on the safety of the vaccine. It looks like it will still have a requirement that you have a shared clinical decision-making meeting with your physician. I think that still implies you’d need a prescription. However, there are only a handful of states which would require a prescription from your doctor. Iowa is one of them.

That made the comment by one of the committee participants thought provoking. I believe she got the RSV vaccine from a pharmacist, who asked no questions. There was no shared clinical decision-making discussion with that pharmacist.

But there was a discussion during the meeting with a pharmacist who was in the room. She made it clear that pharmacists had plenty of training (“20 hours” along with additional learning) and could handle the shared clinical decision-making piece with patients.

Sena and I have had all of our vaccines including the Covid-19 shots administered by pharmacy techs. I hardly know what the pharmacists look like because they are a blur, managing the drive-up window and all other customers. It’s clear that a large proportion of vaccines are available at most pharmacies and the techs give the shots. They are pleasant and happy to apply the Band-Aid.

You can’t even telephone the pharmacy and talk to a live person. Sometimes you’ll get a recording which replies to most of your questions with “Sorry, I didn’t get that. Did you say you want a vaccine or a cheeseburger with fries?” Scheduling vaccine appointments are generally done on line. Scheduling a visit with the pharmacist is probably not easier than scheduling one with your doctor, who might confuse you with “the colonoscopy” in room 5.

I’ve looked at the health care professional section on the CDC website pertaining to the age and medical conditions necessary to qualify for getting the RSV vaccine. I’m pretty sure I’m in the right age category, although I stopped keeping track after the evolution of asparagus. I don’t have any chronic medical conditions, unless you count dad jokes. I exercise, juggle, take only a multivitamin a day, meditate, and regularly leap tall buildings in a single bound. I’m pretty sure I don’t need the RSV vaccine, but what do I know? I’m a retired psychiatrist.

It looks like the risk of getting Guillain-Barre Syndrome (pronounced “GBS”) is not zero and may or may not be associated with the RSV vaccine. It’s pretty clear that 2 of the 3 major manufacturers of the vaccine who attended the meeting were pretty sensitive to any hints their product might have anything to do with GBS and might challenge you to a no holds barred thumb wrestling match if you say otherwise.

We think there’s a long way to go before everybody’s clear on who gets the RSV vaccine and when, and also where. But you can’t get it at the pharmacy drive up window.

CDC ACIP Meeting on Covid 19 Vaccine Additional Dose

The CDC ACIP meeting on February 28, 2024 on the proposal of a Spring booster of the Covid 19 vaccine was interesting and confusing. Initially right after the morning presentations, we were a little confused about whether the committee was targeting only those who got the vaccine booster last fall or everybody. That didn’t make much sense given the concern about low overall uptake of the vaccine.

The presenters also mentioned that getting the Spring Covid booster would be part of a shared clinical decision-making discussion with your doctor, similar to that recommended for the RSV vaccine. That was bewildering because we think that’s part of the reason some people might skip the RSV vaccine, given the news reports last year pointing out you had to have a prescription from a medical provider in some states to get it.

I was pretty interested in learning more about T-cell immunity given the concern about waning which of immunity from vaccines over a few months, which I think was based on neutralizing antibodies from B cells. I thought the CDC web site link to an article about the T-cell immune response suggested that cell mediated immune responses might mean that our immunity might not be waning that quickly. However, one of the presentations, “Evidence to Recommendation” showed a slide indicating that your T-cell immunity gets weaker with age (ref. de Candia P, Prattichizzo F, Garavelli S, Matarese G. T Cells: Warriors of SARS-CoV-2 Infection. Trends Immunol. 2021 Jan;42(1):18-30. doi: 10.1016/j.it.2020.11.002. Epub 2020 Nov 13. PMID: 33277181; PMCID: PMC7664351.)

I’ve read other articles, one of them on the CDC website, which says you may have more durable immunity provided by T-cells, but if I read it carefully, the authors hedge and say that T-cell adaptive immunity may not be as strong when you’re older. (Moss, P. The T cell immune response against SARS-CoV-2. Nat Immunol 23, 186–193 (2022). https://doi.org/10.1038/s41590-021-01122-w).

Later in the afternoon, the committee voted that those who are 65 years old and older should get the spring dose. There was no further discussion of limiting it to only those who got the Covid vaccine in the fall of 2023. There was also no discussion of the shared clinical decision-making detail. The committee upvoted the resolution with a majority.

And yet, the voting question did say: ACIP recommends that persons greater than or equal to 65 years of age “should” (which was changed from “may”) receive an additional dose of 2023-2024 Formula COVID-19 vaccine. The “additional dose” means in addition to the vaccine (monovalent XBB.1.5) given last fall. That’s a relatively select group, when you take the subset of those who are 65 and older.

However, the slides in the “Evidence to Recommendation” had recommended there should be shared clinical decision-making, meaning that you should discuss getting the vaccine with your doctor. However, according to the STAT NEWS article summary of this meeting, substituting the word “should” for “may” would make the conversation with a doctor unnecessary.

Finally, there was no discussion at all of changing the 5-day isolation precaution for those testing positive for Covid-19. If the committee were planning to drop that, as many news agencies recently reported, I would think they’d have discussed it at length at the meeting.

The CDC Director will have to sign off on the additional Covid-19 shot before it’s official.

2/29/2024 Update: CDC Director endorsed the additional dose yesterday.

Flight of Ideas on Junior Bald Eagles

A couple of days ago the temperature was in the mid-seventies, which is pretty balmy for February. We took the opportunity to get out for a walk on the Terry Trueblood Trail. It’s coincidental, but we did the same thing on the exact same date last February. It’s under the same condition for the most part—escaping from the bad news on the web. The difference was the temperature; it was only in the fifties last year.

The remarkable thing last February was that another trail walker claimed to have seen 16 bald eagles. I’ll have to say that we doubted it, at first. But shortly after that, we caught sight of half a dozen. There were also the quilted hearts we saw, connected to the “I Found a Quilted Heart” project, the goal of which is to make you happy.

This time, although we didn’t find any quilted hearts, we saw a young bald eagle in flight. It was a little hard to tell what it was at first. Bald eagles don’t look bald when they’re in the juvenile stage. I had to look it up. Juveniles look pretty mottled. I wondered if its parents were the bald eagle pair, which we saw at Trueblood in December of 2023. Probably not, given that nesting begins in January, incubation lasts over a month and the eaglets take their first flight over two months later, according to the Iowa Dept of Natural Resources. But it’s fun to think about.

This junior bald eagle looked a little clumsy, both in the air and near the water’s edge. It looked like it might have caught a little fish. It seemed like it was trying to learn how things work in the world and how it’s supposed to fit in.

Instinct takes care of most of that for a bald eagle. Humans have a lot of figuring out to do. We ran into somebody on the trail who told us a great deal about local history. Over time, a lot of things have changed in Iowa City. That goes for the world, too. Much of the time, the changes don’t always seem to make life better, at least according to older people who talk about them.

But the seasons come and go. Bald eagles lay eggs. Eaglets fledge. They don’t gaze up at the moon. Humans do look up at the moon, and occasionally fly there. It’s hard to know why.

There are plenty of earthly mysteries. We saw small black handprints on the Trueblood sidewalk, not far from the shelter. I can’t figure out why they would be there, and what’s more, I can’t find out anything on the internet that explains it. So much for the internet. I supposed I could take a chance and ask Artificial Intelligence (AI) about it, but I’m not confident it wouldn’t just make something up.

We also found a little badge on the ground. It was labeled National Museum USAF Junior Flight Crew. This time, when I checked the internet, I found out there is a lot of information about it on the internet—but none of it helped me understand why it would be on the ground along the Terry Trueblood Trail. You can find a very long article on the internet about how items from the National Museum USAF might not have been handled the way they should have been. You can buy one for about $20 or so on eBay, if you’re interested.

I think it’s more interesting to see how the junior bald eagles learn their way around the world. They earn their wings the old-fashioned way.

Rubber Snake Trick for Pesky Birds So Far

So far, the rubber snakes are not scaring off the birds. We have the telltale evidence for their continued visits to our porch.

It’s only a couple of days. We moved them around to see if that fools the birds into thinking the snakes are real.

Hot Mic in the NASA Control Room

By now, everybody probably knows about the Intuitive Machine lunar landing of the Odysseus space craft recently, broadcast from NASA. I happened to have a direct audio hookup to the control room during the hot mic episode which somehow didn’t get broadcast last week.

Sam: OK, how’s Odysseus doing?

Doug: Uh, we slightly overshot the planned landing.

Sam: What? How did that happen?

Doug: Not sure, but I heard a crunching noise.

Sam: Crunching? There’s no crunching allowed on this mission!

Doug: It’s OK, we can hit the gas and put it down in a different spot a little further away.

Sam: How far?

Doug: Not much, about 1,000 miles give or take. Almost there; applying disc brakes—now.

Sam: What is Odysseus’ position now?

Doug: Well, it looks like it sort of fell over on its side. But it’s transmitting images.

Sam: Great! What’s coming across?

Doug: Kind of fuzzy. Wait a sec, just need to adjust the rabbit ears here. What’s that?