Author: James Amos

I'm a retired consult-liaison psychiatrist. I navigated the path in a phased retirement program through the hospital where I was employed. I was fully retired as of June 30, 2020. This blog chronicles my journey.

Juggling Update!

Well, we’re using our new safety glasses retainers and they work out fine. We’re a little off the beam on the 2-person 6 ball pass juggle for some reason. Some days are diamonds, some days are stones, I guess.

Our mistakes are funny. We just make too many.

I’m still working on the shower juggle pattern. I might be making slow progress. It feels easier to do if I use the large plastic balls or the new smaller balls with a tough leather shell. They’re decorated with stars to give you confidence.

I think if they’re round and hold their shape better if they’re made of harder material, they might fly better.

I think it would also help if I threw them more accurately.

Moderate Respiratory Illness Activity in Iowa

The CDC tracks respiratory illness and there is moderate activity in Iowa according the data tracker.

The weekly snapshot as of December 1, 2023 shows highlights including:

  • “COVID-19 test positivity (percentage of tests conducted that were positive), emergency department visits, and hospitalizations have increased nationally. A group of Omicron variants (XBB and its sublineages) are the predominant lineages detected in the U.S., with HV.1 being most common. The prevalence of another lineage, BA.2.86, is projected to account for 5-15% of currently circulating variants. CDC continues to monitor HV.1, BA.2.86, and all other lineages.
  • National test positivity, emergency department visits, and hospitalizations for influenza continue to increase.
  • RSV emergency department visits and hospitalizations continue to increase across the country. RSV-associated hospitalization rates remain elevated among young children and are increasing among older adults; of note, only 14.8% of adults 60+ report having received an RSV vaccine.
  • National vaccination coverage for COVID-19, influenza, and RSV vaccines increased less than one percentage point for children and adults, where indicated, compared to the previous week and remains low for both groups.
  • CDC has been monitoring increases in respiratory illness reported recently among children, including potential elevated rates of pediatric pneumonia in parts of the United States. These reported increases do not appear to be due to a new virus or other pathogen but to several viral or bacterial causes that we expect to see during the respiratory illness season. CDC will continue to work closely with our state and local public health partners to maintain strong situational awareness and will provide updates, as needed.”

Update on CDC Recommendation for Adult RSV Vaccination

I just checked to see if the Iowa Board of Pharmacy rules had changed about the recommendation that a physician and patient shared decision-making discussion should help clarify whether and why a prescription would be necessary to enable a patient over the age of 60 years to get the Respiratory Syncytial Virus (RSV) vaccine.

I found out that nothing has changed the position of the Iowa Board of Pharmacy on this issue, despite the CDC published list which now includes the RSV vaccine (which seemed to be the main issue against allowing pharmacists to administer the vaccine independently). I finally found the CDC Adult Immunization Schedule by Age web page. The section shows a table of vaccines recommendations broken down by age. Below the table is a list of the CDC recommended vaccines. Under the RSV category there is a Special Situation section with guidance for those over the age of 60 regarding those most likely to benefit from the RSV vaccine:

  • “Age 60 years or older: Based on shared clinical decision-making, 1 dose RSV vaccine (Arexvy® or Abrysvo™). Persons most likely to benefit from vaccination are those considered to be at increased risk for severe RSV disease.** For additional information on shared clinical decision-making for RSV in older adults, see www.cdc.gov/vaccines/vpd/rsv/downloads/provider-job-aid-for-older-adults-508.pdf.

For further guidance, see www.cdc.gov/mmwr/volumes/72/wr/mm7229a4.htm

**Note: Adults age 60 years or older who are at increased risk for severe RSV disease include those with chronic medical conditions such as lung diseases (e.g., chronic obstructive pulmonary disease, asthma), cardiovascular diseases (e.g., congestive heart failure, coronary artery disease), neurologic or neuromuscular conditions, kidney disorders, liver disorders, hematologic disorders, diabetes mellitus, and moderate or severe immune compromise (either attributable to a medical condition or receipt of immunosuppressive medications or treatment); those who are considered to be frail; those of advanced age; those who reside in nursing homes or other long-term care facilities; and those with other underlying medical conditions or factors that a health care provider determines might increase the risk of severe respiratory disease.”

While the rationale for the recommendation is clear, it’s interesting that Iowa is one of only 4 states in which pharmacists cannot administer the RSV vaccine independently (meaning a physician prescription is necessary). The RSV vaccine is in the CDC published vaccination schedule, which looks like it would satisfy the Iowa Code Section 155A.46 according to the Iowa Board of Pharmacy.

I still wonder whether it’s the shared decision-making discussion or the Iowa Code that’s the main reason a physician prescription is necessary to get the RSV vaccine.

It isn’t that I want the RSV vaccine. In fact, based on what I’ve read on the CDC Immunization Schedule, I don’t think I need it because I’m pretty healthy for a geezer. I just don’t understand why only 4 states require a physician prescription. Does that mean the pharmacists in the rest of the country are confident they can have a shared decision-making discussion with patients about the indication for the RSV vaccine?

Why You Might Have Noticed My Blog Was Missing in Action Recently

A couple of days ago, I tried switching my blog to a new theme. A theme is a kind of digital uniform for the blog. It’s a set of files and pictures that work together to display your blog content.

Every once in a while, I get an urge to change the theme. WordPress has a lot of themes, some free, some for a price.Usually, I can just put on a new theme like a new suit of clothes, pinch it a little and I’m done.

Not this time. I struggled with the new theme for hours. I thought it had features it didn’t have, partly because the initial description was a little misleading. I finally just went back to the old one, which was a lucky break.

While the theme construction was going on, some of you might have dropped by and noticed that my blog was either missing in action or severely crippled, with many essential parts missing. Sorry about that.

While the theme was out, some links evidently changed, mainly because certain web sites either dropped out or were modified. The changes were in the main menu at the top of the page (just to let you know, the new theme really didn’t have a menu per se). The menu looks like it lost weight. The blogs by Drs. Moffic and Pies got included in the main link for Psychiatric Times, which makes sense. One web site evidently no longer exists.

It’ll be a while before I mess around with my blog theme again, maybe until WordPress again tells me that I have to change it if they decide to discontinue it.

CDC Update on Covid-19 Variant BA.2.86

I saw a news item headline which mentioned Covid-19 Variant. BA.2.86. The CDC website tracking respiratory variants has a definitive update as of November 27, 2023:

“What to know about BA.2.86

  • The virus that causes COVID-19 is constantly changing over time. Sometimes these changes allow new variants to spread more quickly or effectively. If that occurs, the new variant may become more common relative to other variants that are circulating.
  • Since CDC’s first post on BA.2.86 in August 2023, the proportion of infections caused by BA.2.86 has slowly increased. In the CDC Nowcast posted Nov. 27, 2023, BA.2.86 is projected to account for 5-15% of currently circulating variants.
  • CDC projects BA.2.86 and its offshoots like JN.1 will continue to increase as a proportion of SARS-CoV-2 genomic sequences.
  • At this time, BA.2.86 does not appear to be driving increases in infections or hospitalizations in the United States.
  • CDC contributed to and agrees with the World Health Organization’s recent risk assessment about BA.2.86 suggesting that the public health risk posed by this variant is low compared with other circulating variants, based on available limited evidence.
  • Updated COVID-19 vaccines are expected to increase protection against BA.2.86, as they do for other variants.
  • As mentioned in previous updates, COVID-19 tests and treatments are expected to be effective against this variant, including its offshoot JN.1.
  • It is not possible at this time to know whether BA.2.86 infection produces different symptoms from other variants. In general, symptoms of COVID-19 tend to be similar across variants. The types of symptoms and how severe they are usually depend more on a person’s immunity than which variant causes the infection.
  • Regardless of what variants happen, CDC will continue to track them, working closely with partners around the world to understand how they are spreading and how they respond to vaccines and treatments.”

A Study Shows Mindfulness Is Non-Inferior to SSRI for Anxiety Disorders And What the Heck Does That Mean?

I ran across this study showing Mindfulness Based Stress Reduction (MBSR) is “noninferior” to escitalopram in the treatment of adults with anxiety disorders.

I passed my Biostatistics course in medical school—barely. I have been practicing MBSR daily (for the most part) since 2014 when I really needed to address my struggle with burnout. I’m probably a worrier but I doubt I have a clinically significant anxiety disorder. I’m admittedly biased in favor of MBSR. Otherwise, I wouldn’t still be practicing it after about 10 years.

On the other hand, I don’t have a great handle on the statistical concept of noninferiority in clinical studies. I found a little YouTube presentation on it and I think I’m a little more comfortable with it now. I said “a little bit.” I’m not taking questions.

Reference:

Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. 2023;80(1):13–21. doi:10.1001/jamapsychiatry.2022.3679

When Should Psychiatrists Retire?

In answer to the question in the title, I’ll confess right away I don’t know the answer. The impetus for my writing this post is the Medscape article about an 84-year-old physician who was forced to take a cognitive test required by her employer as a way of gauging her ability to continue working as a doctor. She’s suing her employer on the grounds that requiring the cognitive test violated the American with Disabilities Act (ADA), the Age Discrimination in Employment Act, and two other laws in her state.

I didn’t retire based on any cognitive test. I recall my blog post “Gauging My Readiness for Retirement,” which I posted in 2019 prior to my actual retirement. In it I say:

I spent 4 years in medical school, 4 years in residency, and have worked for more than 23 years as a psychiatrist, mostly as a general hospital consultant. Nothing used to jazz me as much as running around the hospital, seeing patients in nearly all specialties, evaluating and helping treat many fascinating neuropsychiatric syndromes, teaching medical students and residents, and I even wrote a book.

On the other hand, I don’t want to hang on too long. When people ask me why I’m retiring so early (“You’re so young!”), I just tell them most physicians retire at my age, around 65. I also say that I want to leave at the top of my game—and not nudged out because I’m faltering.

In it, I mention a blog post written by a physician blogger, Dr. James Allen. The title is “When Physicians Reach Their ‘Use By Date.’ At the time I didn’t make a link to his post because the web site was not listed as secure.

Since that time, the web site has become secure, and you can read the post here. Dr. Allen lists anecdotes about physicians who ran close to or past their “use by” date.

Dr. Allen’s point is that we often don’t realize when we are past our “use by” date. That applies to a lot of professions, not just medicine.

There’s been a shortage of psychiatrists for a long time and it’s not getting better, the last I heard. All in all, I’m OK with the timing of my retirement.

I note for the record that I have not seen any mention in the news that the Rolling Stones have ever been required to take a cognitive test to continue working. I also want to point out that they are around 80 years old and their 2024 tour is sponsored by the AARP, the organization formerly known as the American Association of Retired Persons. I heard that the Rolling Stones new song, “Angry” is up for a Grammy.

I doubt anyone is angry about the obvious fact they’re not even thinking about retiring.

Early Snowbird Gets the Berry

We got our first snowfall that stuck around yesterday. We didn’t have to shovel because it melted off our sidewalk and driveway shortly past noon.

On the other hand, the snow drew the birds out for the berries in the trees. Cedar Waxwings and other small birds feasted in the early morning. Whether they got the winterberries low to the ground or the ones high up in the trees—they got them.

It snowed the better part of the morning. It caught some Iowa drivers off guard. There were pictures in the news of cars rolled over on their roofs in the ditches.

But the birds made out like bandits.

Music Credit for YouTube Video:

Eternal Hope by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/

Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1100238

Artist: http://incompetech.com/

Now is the Time for Kauai Coffee and Beignets!

Remember that Beignet mix and rolling pin Sena got back in May? She got around to making them yesterday. The use by date was November 1, 1892! No, sorry, actually it was November 1, 2023.

The day started out pretty cold and it even snowed. Birds and squirrels acted like they never saw snow before.

Anyway, we also tried Kauai Coffee for the first time in our Keurig machine. The pods look really different, but they worked. The flavors are subtle but they go well with Beignets. We’re not sure why they looked more like fried green tomatoes when they were done.

Beignets are delicious. Have plenty of powdered sugar on hand!