Category: health care

Ready for Another Step Counting Recommendation?

Remember my post about the step counter and my workout update pointing out the possibly bogus 10,000 step recommendation?

Well, get ready for another recommendation which lowers the bar somewhat, based on your sedentary index.

There’s a new study which says, essentially:

“Conclusions: Any amount of daily steps above the referent 2200 steps/day was associated with lower mortality and incident CVD risk, for low and high sedentary time. Accruing 9000–10 500 steps/day was associated with the lowest mortality risk independent of sedentary time. For a roughly equivalent number of steps/day, the risk of incident CVD was lower for low sedentary time compared with high sedentary time.”

Reference:

Ahmadi MN, Rezende LFM, Ferrari G, et al. Do the associations of daily steps with mortality and incident cardiovascular disease differ by sedentary time levels? A device-based cohort study. British Journal of Sports Medicine 2024;58:261-268.

I figure I’m in the low sedentary category. This is somewhat reassuring to me because so far, my step counter averages (over 3 days) about 2500 steps during my usual daily exercise periods. Of course, this doesn’t count trips to the bathroom. I guess I can relax now.

New Compound MM-120 Related to LSD Gets FDA Nod

I saw the story in Psychiatric Times about the compound MM-120, which the FDA recently granted breakthrough designation. MM-120 is related to LSD. Breakthrough designation is defined by the FDA as, “…a process designed to expedite the development and review of drugs that are intended to treat a serious condition and preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over available therapy on a clinically significant endpoint(s).”

The compound is made by the company MindMed. This is not to be confused with mind meld, a Star Trek thing related to Vulcans like Spock who can do this telepathic touch thing. The MindMed organization made MM-120 to help treat people who suffer from Generalized Anxiety Disorder. Their study shows the drug could be used as a standalone treatment for the disorder.

According to one story about it published in the December issue of Drug Discovery and Development, it’s not likely MM-120 will be stocked in pharmacies next to the antihistamines and decongestants. The authors believe it would be more likely included in a Risk Evaluation and Mitigation Strategies (REMS) program.

This brings back nightmares about the Clozapine REMS program, which many psychiatrists found almost impossible to enroll in several years ago because of glitches in the web-based application. In fact, the FDA was still not happy with it a couple of years ago, to the extent they had to “temporarily exercise enforcement discretion” over aspects of the program.

Anway, the article goes on to say that the drug has a pretty good safety profile, although concede that the study found the higher dose of MM-120 led to “…perhaps some more challenging experiences….” There were no incidents of suicidal or self-injurious behavior.

I wonder what the “challenging experiences” were, exactly. After all, MM-120 is basically LSD, which was invented in 1938 by the Swiss chemist, Albert Hofmann. He was doing research into crop fungus. He thought it could be used to treat mental illness, even after he accidentally ingested some of it and hallucinated a future in which a guy named Timothy Leary would advise everyone to “turn on, tune in, drop out.”

That whole fungus research issue reminds me of the still unsettled question of how a whole town in France got higher than a kite (leading to some deaths) back in 1951. Ergot poisoning was the initial theory, although later somebody believed it might have been perpetrated as a secret LSD experiment by the CIA. I think the mystery is still unsolved.

However, there is also the history of MK-Ultra, which apparently actually was a classified CIA project running during the Cold War which involved giving LSD to certain unlucky subjects, some of whom didn’t know they were getting it—with disastrous results in some cases.

Just to let you know, I don’t suspect there is some conspiracy between extraterrestrials and the pentagon to get the world population so confused on LSD that we start believing all those crop circles are being created by two guys using a board and a rope. Forget what Agent Mulder says.

Do You Really Need to Walk 10,000 Steps a Day?

Since we got this little step counter, I’ve been paying more attention to how I exercise. The step counter will even track steps when I juggle—probably because I drop balls often enough to chase after them a lot.

And then I ran across the 10,000 steps as a benchmark for walking to keep healthy. I get about 3,000 steps during a typical 30-minute exercise session, which I do at least 5 days a week. Most people probably know that the CDC recommends that older adults spend 150 minutes as week (5 days a week for about 30 minutes a day) of moderate-intensity exercise.

That includes walking, jogging, wrestling Bigfoot, things like that. Muscle strengthening and balance are also important.

The 10,000-step thing (or 4,000-6,000 steps for older adults) puzzled me a little. The 10,000-step goal has an interesting story behind it. It turns out that around the time of the 1964 Tokyo Olympic games, that 10,000 steps goal had no scientific basis and was a marketing gimmick for selling the early pedometers.

In fact, if you really use your imagination, you might see how the Japanese character for 10,000 looks a little like a man walking—a stick man. The meter was called a Manpo-kei which literally translates to 10,000 steps.

Just walking 10,000 steps a day as a health goal probably doesn’t have a lot of scientific support. But you can increase the intensity of walking to get more benefit, such as walking up stairs or using a step platform, which I use nowadays. As a consultation-liaison psychiatrist, I walked all over an 8-floor hospital. I would usually use the stairs, often well over 20 flights pretty much every day.

I think the other way to make walking a more vigorous exercise is to develop and practice the well-known technique of silly walking, documented in the Ministry of Silly Walks documentary.

Monty Python

Jim Updates His Workout and Adds a Step Counter!

Since we added the step platform, I’ve been wondering how to count steps when I use it because for some reason my smartphone step counter won’t count steps when I try to use it on the platform.

Sena got a handy step counter and it works! It works if you have it in your pocket or wear it on neck with a lanyard.

I usually practice juggling patterns as a warm up to exercising. I’m still working on the shower pattern. Progress is slow.

My exercise routine takes a half hour. Following that I sit for mindfulness meditation for 30 minutes. We are still using our anti-Peloton exercise bike. I do one leg stands for a minute on each leg. I still do floor yoga, body weight squats, planks, and dumbbells. I still count my own steps on the platform: 50 steps alternating right and left leg four times (200 steps). The counter number varies between 170-200 or so.

As a review, a recently published study found that climbing 5 flights of stairs (approximately 50 steps) was associated with a lower risk of ASCVD types independent of disease susceptibility (Song et al, see reference below). There was a threshold effect of stair climbing in the study, meaning the benefit was lost if you went over a certain number of “floors.” Going over 15 or 20 didn’t gain much for subjects. A flight was 10 stair steps.

Step up!

Reference:

Song Z, Wan L, Wang W, Li Y, Zhao Y, Zhuang Z, Dong X, Xiao W, Huang N, Xu M, Clarke R, Qi L, Huang T, Daily stair climbing, disease susceptibility, and risk of atherosclerotic cardiovascular disease: A prospective cohort study, Atherosclerosis (2023)

FDA Advisory Committee to Meet in May 2024 to Discuss Updating Covid-19 Vaccine

The FDA Vaccines and Related Biological Products Advisory Committee (VRBPAC) will meet on May 16, 2024 to make recommendations on Covid-19 strain selections for the fall vaccine of 2024-2025.

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)

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.