Random Connections

Today, I read Dr. George Dawson’s blog post, “How I ended up in a high-risk pancreatic cancer risk screening clinic.” As usual I was impressed with his erudition, scientific literacy, and rigorous objectivity, even as it pertained to a deadly disease which runs in his family genetic history. I couldn’t help admiring his courage.

And, whether this is a random connection or not, this somehow led to my remembering Dr. George Winokur, a giant in the scientific study (including genetics) of psychiatric diseases, especially mood disorders. He died of pancreatic cancer shortly after he was diagnosed with it in the spring of 1996.

Dr. Winokur was chair of the University of Iowa Department of Psychiatry from 1971 to 1990. He remained on faculty, actively involved in research and teaching up until the day of his death in October of 1996.

I was a resident in psychiatry at University of Iowa from 1992-1996 and I have a clear recollection of meeting with Dr. Winokur in his office during my last year, when I was preparing for job interviews. I knew he had been diagnosed with pancreatic cancer.

He had been actively recruiting me to accept a position in the department and did so even as we spoke briefly. I remember noticing that he gripped an electrical conduit on the wall next to his desk so tightly that I wondered if he were in pain.

He was the main reason I stayed in Iowa. He had a great sense of humor. All of us residents loved him. There was even a list of his “commandments” all new residents received when they began their residencies at Iowa.

Winokur’s 10 Commandments

  1. Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
  2. Thou shalt not accept recompense for patient care in this center outside thy salary.
  3. Thou shalt be on time for conferences and meetings.
  4. Thou shalt act toward the staff attending with courtesy.
  5. Thou shalt write progress notes even if no progress has been made.
  6. Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
  7. Thou shalt not moonlight without permission under threat of excommunication.
  8. Data is thy God. No graven images will be accepted in its place.
  9. Thou shalt speak thy mind.
  10. Thou shalt comport thyself with modesty, not omniscience.

I never got the impression that George Winokur recruited me because I was black, although it was pretty obvious to me that I would be the first black University of Iowa psychiatry department faculty member. He had too much class to make that an issue.

I’ve known a few classy psychiatrists. Maybe the connection is not so random.

More On Taming the Juggling Balls

I’ve been juggling for about 5 months now and reflecting on my progress. I think I’m doing OK for a geezer. Sena would call me a hot dog although I would still call it ugly juggling by any standard.

What’s striking, at least to me, is the little bit of science I can find on the web about juggling. I hear the term “muscle memory” when it comes to learning juggling. Actually, there’s some truth to that. There are different kinds of memory. For example, most of us know about declarative memory, which about memorizing facts, because we use it to prepare for exams. Those of us who went to medical school remember the agony of taking tests for the basic sciences.

But so-called muscle memory, or the memory for learning new skills like juggling, takes place in the brain. There was a study published in 2009 which found changes in both gray and white matter of subjects before and after learning to juggle (Scholz J, Klein MC, Behrens TE, Johansen-Berg H. Training induces changes in white-matter architecture. Nat Neurosci. 2009;12(11):1370-1371. doi:10.1038/nn.2412).

The study about correlation of the inability to stand on one leg for 10 seconds with higher mortality in older patients, which I relate to the ability to do the under the leg juggling trick, was published last year (Araujo CG, de Souza e Silva CG, Laukkanen JA, et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. British Journal of Sports Medicine 2022; 56:975-980.)

I talk a lot about juggling as though I’m a teacher. I’m not a juggling instructor by any means. You can find better juggling teachers on the web. But my approach to talking about juggling in terms of it being a hobby for me is really not different from how I talked about consultation-liaison psychiatry before and after I retired. I’m still a teacher—just evolving in retirement.

However, you can find much better resources for learning how to juggle at the following websites:

https://www.renegadejuggling.com/

Have fun!

Xylazine More About Death Than the Walking Dead

The recent news stories about xylazine-adulterated fentanyl (also known as Tranq) describe it as turning users into zombies because it causes skin necrosis. This can lead to abscesses which may require amputations.

Even more important, it can kill users. Xylazine, which is an animal tranquilizer (hence the name “Tranq”) is said to be available for free in some locations. It has been reported in the eastern states, including Pennsylvania and the availability has been moving steadily westward across the country. The Iowa Office of Drug Control website has posted information about it.

Connecting xylazine to zombies may be a way to get people to pay closer attention to this dangerous substance. That’s ironic because it doesn’t make users just look like the walking dead—it causes death. Xylazine-laced fentanyl overdoses can’t be completely reversed by naloxone because xylazine is not an opioid.

Dr. George Dawson wrote an excellent blog post describing the scientific details about xylazine and its deadly effects in April of 2022.

Those who make this drug know exactly what they’re doing. It’s one thing to sell it on the street, which itself is a terrible thing to do. But if it’s true that it is available for free in some places, then something other than the profit motive is at work.

Thoughts on Regrets

I’ve been thinking about Dr. Moffic’s article on regret, posted on February 16, 2023 in Psychiatric Times.

I’ve dwelt on it long enough that I feel compelled to inject humor into the subject. It’s one of my many defenses.

There’s a quote from Men in Black 3 involving a short telephone conversation between Agent K and Agent J:

Agent K: Do you know the most destructive force in the universe?

Agent J: Sugar?

Agent K: Regret.

You could probably sense that joke coming. Whenever there is talk of regrets, I always recall maybe one or two remarkable episodes which led to lifelong regret. Because regret is pretty corrosive, as noted by Agent K, I need something to counter it.

My trouble is that I have many regrets. Am I so different in that regard?

Sometime in mid-career, a very important leader told me, frankly and calmly, “You’ll never be a scientist.”

Well, by then it was far too late for me to change life course. It was true; I’ve always been the rodeo clown, never the matador.

On the other hand, I know one thing I’ve never regretted and that’s my retirement. At least I think I haven’t regretted it. I have this recurring dream. It’s not every night, but often enough to make me wonder what I should do about it.

In the dream, I’m late for an exam or class and I fear I’m going to flunk. I look for the building where the exam is going to be held. I can never find it. Hallways appear and look vaguely familiar, but as I wander about looking for the bookstore or classroom or exam room, I feel like I’m in a maze, climbing stairs, almost like an Escher drawing.

That reminds me. Incidentally, several years ago, one of the medical students rotating on the psychiatry consult service drew a picture entitled “The Practical Psychosomaticist” which contained images of stairs running in different directions similar to an Escher drawing (see the featured image). It was really just her expression of how I got around the hospital. I avoided elevators and always took the stairs.

Anyway, I’m carrying several notebooks and loose papers keep falling out. I get lost in this jumble of halls and stairways, never finding my destination.

The dream is probably just me telling myself I’m failing at something in my waking life. It’s not like I need a dream to notify me.

This is a long way of saying I have many regrets, and that I may not know exactly how many. Some of them are less important than others. Take the “I’ll never be a scientist” theme. I’m not terribly broken up about it.

After all, rodeo clowns do pretty important things.

Dare to Discover at University of Iowa!

There’s been enough bad news. How about some good news? Have a look at the Dare to Discover campaign at The University of Iowa. It shines a light on young researchers who dream big. And that’s great for all of us!

Jim Learns About Induction Cooktops

I’m learning about induction cooktops. I know I’m way late in the game. The house we bought a little over two and a half years ago came with an induction cooktop. It’s the first one we ever had; we always used gas or electric stoves.

The main topic here are the noises including clicking noises we heard when using the induction cooktop. I say “we” but I should say Sena because I am allergic to kitchens.

I had to search the internet about induction cooktops. I found out way more than I wanted to know about them. I guess I can summarize that in a few lines:

Induction cooktops:

  • They work using electricity, not gas. They generate energy from an electromagnetic field below the glass cooktop surface which transfers energy to the magnetic cookware, which causes them to heat up.
  • They’re more energy efficient than gas.
  • The electro magnetic field (EMF) they emit have not been shown to increase the risk for cancer.
  • Although some chefs say hard anodized cookware won’t work on induction cooktops, they will if the bottom of the cookware has a ferromagnetic surface (meaning it has iron in it).
  • You can tell most of the time if a pan will work on induction cookware by holding a magnet up to the bottom of it and checking to see if the magnet sticks. If the magnet sticks, you’re good to go.

I finally checked that last point about magnetism by suddenly realizing that we had a magnet. It happens to be the magnetized lid for the space holding a deck of cards and pegs on our large cribbage board. It stuck to the bottom of one of our new KitchenAid hard anodized pans.

The old pans we had clicked a lot and there are reasons for the variety of noises you can hear. Most of the websites I noticed which describe this problem also have videos about which don’t have audio. Many of the websites say that some clicking is normal. Others will make an effort to identify the cause for the noises.

Our new cookware doesn’t make any noise at all. And they heat up very quickly. You don’t need to crank up the heat and can keep the power level pretty low.

The sound of screaming is probably from the extraterrestrial you’re trying to fry. Don’t do that.

FDA VRBPAC Discussion Topics Today

The FDA VRBPAC 178th annual meeting on future Covid-19 vaccine regimens includes two main discussion topics:

“Future periodic vaccination campaigns:
Simplification of COVID-19 vaccine use:

  • Immunization schedule: Please discuss and provide input on simplifying
    the immunization schedule to authorize or approve a two-dose series in
    certain young children, and in older adults and persons with compromised
    immunity, and only one dose in all other individuals.
    Periodic update to COVID-19 vaccines:
  • Vaccine composition: Please discuss and provide input on the
    consideration of periodic updates to COVID-19 vaccine composition,
    including to the currently authorized or approved vaccines to be available
    for use in the U.S. in the fall of 2023.”

Among the members attending the web conference is University of Iowa Professor Stanley Perlman, MD, PhD, Departments of Microbiology and
Immunology, Professor of Pediatrics, Mark Stinski Chair in Virology.

The meeting is today from 8:30 AM to 5:30 PM ET.

Update: Dr. Stanley Perlman MD, PhD from the University of Iowa will be the acting voting chairman of today’s meeting.

Update: Dr. Jerry Weir gave a clarifying and practical bird’s eye view of the issue at hand which began at 2:30 PM on the live play today (the meeting is being recorded). The questions and comments for Dr. Weir by Offit, Levy, and Chatterjee were also helpful to hear.

Update: Voting Question is:

“VRBPAC Voting question
Simplification of current COVID-19 vaccine use:

  • Vaccine composition: Does the committee recommend harmonizing the
    vaccine strain composition of primary series and booster doses in the U.S.
    to a single composition, e.g., the composition for all vaccines administered
    currently would be a bivalent vaccine (Original plus Omicron BA.4/BA.5)?”

Voting Result: Unanimously upvoted.

Reminder: FDA Advisory Committee Meeting Thursday January 26, 2023 on Future of Covid-19 Vaccination Regimens

Remember, the 178th Annual Meeting of the FDA Advisory Committee on the future of Covid-19 Vaccination Regimens is this Thursday from 8:30 AM-5:30 ET.

The details so far include the voting question:

“Simplification of current COVID-19 vaccine use:

  • Vaccine composition: Does the committee recommend harmonizing the
    vaccine strain composition of primary series and booster doses in the U.S.
    to a single composition, e.g., the composition for all vaccines administered
    currently would be a bivalent vaccine (Original plus Omicron BA.4/BA.5)?”

FDA Advisory Committee Meeting to Discuss Future Covid-19 Vaccine Regimens

The FDA 178th Meeting of the Vaccine and Related Biological Products Advisory Committee will meet in open session January 26, 2023 to discuss future Covid-19 vaccination regimens. The meeting will run between 8:30 AM-5:30 PM ET.

CDC Identifies Preliminary Covid-19 Vaccine Safety Signal

The CDC announced that a prelimary Covid-19 Vaccine Safety signal has been identified in a recent update on their website:

“Following the availability and use of the updated (bivalent) COVID-19 vaccines, CDC’s Vaccine Safety Datalink (VSD), a near real-time surveillance system, met the statistical criteria to prompt additional investigation into whether there was a safety concern for ischemic stroke in people ages 65 and older who received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent. Rapid-response investigation of the signal in the VSD raised a question of whether people 65 and older who have received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent were more likely to have an ischemic stroke in the 21 days following vaccination compared with days 22-42 following vaccination.

This preliminary signal has not been identified with the Moderna COVID-19 Vaccine, Bivalent. There also may be other confounding factors contributing to the signal identified in the VSD that merit further investigation. Furthermore, it is important to note that, to date, no other safety systems have shown a similar signal and multiple subsequent analyses have not validated this signal:

  • A large study of updated (bivalent) vaccines (from Pfizer-BioNTech and Moderna) using the Centers for Medicare and Medicaid Services database revealed no increased risk of ischemic stroke
  • A preliminary study using the Veterans Affairs database did not indicate an increased risk of ischemic stroke following an updated (bivalent) vaccine
  • The Vaccine Adverse Event Reporting System (VAERS) managed by CDC and FDA has not seen an increase in reporting of ischemic strokes following the updated (bivalent) vaccine
  • Pfizer-BioNTech’s global safety database has not indicated a signal for ischemic stroke with the updated (bivalent) vaccine
  • Other countries have not observed an increased risk for ischemic stroke with updated (bivalent) vaccines”

The CDC says it’s “very unlikely  that the signal in VSD represents a true clinical risk…” The data and additional analyses will be discussed at the January 26, 2023 meeting of the FDA’s Vaccines and Related Biological Products Advisory Committee.

No changes are recommended to the current Covid-19 vaccination practice:

“CDC continues to recommend that everyone ages 6 months of age and older stay up-to-date with COVID-19 vaccination; this includes individuals who are currently eligible to receive an updated (bivalent) vaccine. Staying up-to-date with vaccines is the most effective tool we have for reducing death, hospitalization, and severe disease from COVID-19, as has now been demonstrated in multiple studies conducted in the United States and other countries:

  • Data have shown an updated COVID-19 vaccine reduces the risk of hospitalization from COVID-19 by nearly 3-fold compared to those who were previously vaccinated but have not yet received the updated vaccine.
  • Data have shown that the updated COVID-19 vaccine also reduces the risk of death from COVID-19 by nearly 19-fold compared to those who are unvaccinated.
  • Other preliminary data from outside the U.S. have demonstrated more than 80% protection against severe disease and death from the bivalent vaccine compared to those who have not received the bivalent vaccine.

Overall safety data for the bivalent COVID-19 vaccines are available here.

Once again, no change is recommended in COVID-19 vaccination practice, which can be found here.”

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