Category: health care

Shout Out to the European Delirium Association

I just want to give an enthusiastic shout out to the European Delirium Association (EDA). I rediscovered the website. It’s updated and an extremely helpful organization in the study of delirium. It provides excellent education about the disorder.

I met one of the past presidents of the EDA, Alasdair MacLullich back in the early 2010s. In fact, while I was staffing the University of Iowa Hospital consultation-liaison service, he was generous enough to send us one of the pieces of technology which was designed to test for delirium: The Edinburgh Delirium Test Box or Delbox.

I wrote a blog post years ago about the EDA. At that time, the group published a newsletter called the Annals of Delirium. Here’s an excerpt from one of the issues in 2010:

Delirium has a long way to go before it gets the attention it deserves, before it is present in the public consciousness in the way cancer is, or even HIV. Bearing in mind the prevalence of delirium and the impact it has on patients and families we may believe it is only a matter of time, but I believe that the process is going far too slowly. Some countries are doing better than others and some areas of medicine are making greater inroads, which can only benefit us all in the long run. In the UK, however, if you search for delirium on the BBC website you are directed to the music page and the group Delirium Tremens.

I remember thinking that the anecdote reminded me of how that sounded a lot like the way things were going in the United States at that time.

And the EDA announcement about the new delirium organization in the U.S. that was just getting it’s start around that time, in 2011—the American Delirium Society (ADS).

There are educational videos about delirium on the EDA website and I’m excited to learn more about them.

Further, there was a sort of word search game I rediscovered that was made by the EDA. Some of the words are on the diagonal. Give it a shot! I finished it, but it was very challenging. If you need the key, please comment.

Gratitude to Pastor Robert Stone

I came across a couple of items that prompted my renewed gratitude. One of them was an article in Bloomberg on the web, “US Medical Schools Grapple With First Admissions Since End of Affirmative Action” by Richard Abbey, Ilena Peng, and Marie Patino, published on December 14, 2023. It’s about how hard it is for black students to get into and graduate from medical school. Just getting to college is a major hurdle.

The other item is an obituary of one of the most important persons in my life, Pastor Robert Leroy Stone. He authorized scholarships for two years of my undergraduate college education, which were at Huston-Tillotson College (now Huston-Tillotson University, one of the HBCUs) in Austin, Texas. That was back in the 1970s, ancient history now. The issue of Affirmative Action was widely discussed during that time.

As usual, I’m dumbfounded by how often I miss the passing of the critically important people who made my success in life possible. And there is this astonishing connection which followed me even to Iowa City—but of which I was unaware. After he retired, Pastor Stone moved from Mason City to Iowa City in November of 2001. At that time, I had graduated from The University of Iowa College of Medicine, finished my residency in psychiatry in 1996, and was on staff in University of Iowa Dept of Psychiatry. I never knew he was so close. He died in 2002.

Pastor Stone was a Board Member and Chair of the Mason City YMCA, where I lived for a while. He was also a Member of the Board of Chemical Dependency Services of North Iowa as well as the Mental Health Center of North Iowa.

Although I didn’t graduate from Huston-Tillotson College, I was able to transfer credit to Iowa State University. And from there I went to medical school at The University of Iowa.

I’ve read other stories about how hard it is for Black students to get into and finish medical school. My path was indirect and not easy, but Pastor Stone made it possible. And for that, I am grateful.

CDC Issues Health Alert Network Announcement Recommending Vaccinations for Seasonal Respiratory Illnesses

The CDC recently issued a Health Alert Network (HAN) announcement urging physicians to recommend that patients get their influenza, Covid-19, and RSV vaccines.

Time for Another Blast from the Past

I found an interesting blog post from my previous blog, The Practical Psychosomaticist. I wrote it in 2011 and it’s about the patient experience of delirium. I was delirious briefly after a colonoscopy many years ago. I don’t remember much about it. But from what Sena tells me about it, it was similar to other delirium episodes I’ve seen in the hospitalized medically ill. Thankfully, it was not severe.

“Recalling the Experience of Delirium: The Delirium Experience Questionnaire (DEQ)

Have you ever been delirious and recalled the experience? Many patients do and they usually are frightened by the experience which can be marked by delusions and hallucinations that are remembered as fragments of a harrowing nightmare. This has been studied by Breitbart, et al using an instrument they developed called the Delirium Experience Questionnaire (DEQ). In the article there’s a description of the scale:

The DEQ is a face-valid, brief instrument that was developedby the investigators specifically for this survey study andassesses recall of the delirium experience and the degree ofdistress related to the delirium episode in patients, spouses/caregivers,and nurses. The DEQ asks six questions of patients who haverecovered from an episode of delirium including: 1) Do you rememberbeing confused? Yes or No; 2) If no, are you distressed thatyou can’t remember? Yes or No; 3) How distressed? 0–4numerical rating scale (NRS) with 0 = not at all and 4 = extremely;4) If you do remember being confused, was the experience distressing?Yes or No; 5) How distressing? 0–4 NRS; and 6) Can youdescribe the experience? This final question allowed for a qualitativeassessment of the delirium experience through the verbatim transcriptionof patients’ description of the experience (not reported inthis paper). In addition, spouse/caregivers and nurses wereeach asked a single question: 1) Spouse/caregiver: How distressedwere you during the patient’s delirium? 0–4 NRS; 2) Nurse:Your patient was confused, did you find it distressing? 0–4NRS. The DEQ was administered on resolution of delirium[1].

54% of patients recalled their delirium experience. Perceptual disturbances were among the best predictors of recall. Delusions were the most significant predictor of distress. Patients with hypoactive delirium were just as distressed as those with hyperactive delirium. Mean distress levels for patients were rated at around 3 by patients and their nurses and close to 4 by family members.

In another more recent and similar study using the DEQ, the numbers were even more sobering. 74% of patients recalled being delirious and 81% reported the experience as distressing with a median distress level of 3[2].

In my work as a consultant, I’ve interviewed many patients who are delirious and their relatives and friends, who suffer as well from the experience of watching someone they love suffer from delirium. It’s very difficult to watch this kind of mental torture caused by medical disorders and medications.

The 6th question of the DEQ often produced accounts that sound terrifying. The point of the article was that the subjective report of delirium sufferers confirms that the distress levels are very high indeed and remind us of the major reason for developing systematic methods of preventing it or detecting it early and managing the syndrome—reducing suffering.”

1.            Breitbart, W., C. Gibson, and A. Tremblay, The Delirium Experience: Delirium Recall and Delirium-Related Distress in Hospitalized Patients With Cancer, Their Spouses/Caregivers, and Their Nurses. Psychosomatics, 2002. 43(3): p. 183-194.

2.            Bruera, E., et al., Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer, 2009. 115(9): p. 2004-12.

CDC Weekly Update on Viral Respiratory Illness

As of December 8, 2023, the CDC reports:

  • “National test positivity, emergency department visits, and hospitalizations for influenza continue to increase. Influenza A(H1N1) is the predominant influenza virus circulating although influenza A(H3N2) and influenza B viruses are also being reported.
  • RSV-associated hospitalization rates remain elevated among young children and are increasing among older adults; of note, only 15.9% of adults 60+ report having received an RSV vaccine.
  • National vaccination coverage for COVID-19, influenza, and RSV vaccines increased slightly for children and adults compared to the previous week and remains low for both groups.”

However, the overall respiratory illness rates have gone from “moderate” to “low” in Iowa.

What’s Up with Intranasal Covid-19 Vaccines?

I saw the JAMA article on intranasal vaccines research for Covid-19. It starts off pretty supportive of the principle. However, at the bottom of the article, the outlook looks pretty stable for injectable vaccines for at least a good long while.

It’s an interesting read. Skip to the Many Questions section:

How these experimental mucosal vaccines stack up against mRNA vaccines, considered the standard of care, remains to be seen, Beigel noted. The NIAID intends to conduct phase 2 trials that would compare mucosal and mRNA vaccines head-to-head, “so you’d know for certain what you’re trading off,” he said.

Ideally, a mucosal vaccine would generate as good a systemic immune response as an mRNA vaccine as well as a robust mucosal immune response. But an excellent mucosal immune response might make up for a bit of a decline in the systemic immune response, Beigel explained. Perhaps a vaccine inhaled through the mouth and into the lungs could provide the best of both worlds—strong mucosal and systemic immunity—but there are no data yet to support that theory, he said.

“Everyone knows we need a better vaccine and would really like it if we could get something that interrupts transmission and stops even mild disease,” Beigel said. “Whether that’s attainable or not, we don’t know.”

I’m not knocking the concept by suggesting you read the Conflict of Interest Disclosures.

Reference:

Rubin R. Up the Nose and Down the Windpipe May Be the Path to New and Improved COVID-19 Vaccines. JAMA. Published online December 06, 2023. doi:10.1001/jama.2023.0644

This is National Influenza Vaccination Week!

This is National Influenza Vaccination Week (Dec. 4-8, 2023) and the CDC word is:

“National Influenza Vaccination Week (NIVW) is a critical opportunity to remind everyone 6 months and older that there’s still time to protect themselves and their loved ones from flu this flu season by getting their annual flu vaccine if they have not already. CDC data shows that flu vaccination coverage was lower last season, especially among certain higher risk groups, such as pregnant people and children. When you get a flu vaccine, you reduce your risk of illness, and flu-related hospitalization if you do get sick. This week is meant to remind people that there is still time to benefit from the first and most important action in preventing flu illness and potentially serious flu complications: get a flu vaccine today. Check out CDC’s NIVW toolkit for more shareable resources and content.”

It’s also big news that a recent CDC co-authored study showed strong evidence for flu vaccine effectiveness. Among the university medical centers participating in the study was the University of Iowa Hospitals.

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?

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.”