Community Acquired Pneumonia - and How To Avoid it

 

Disclaimer:  Like all posts on this blog this is intended for educational and commentary purposes and is not medical advice in any form.  All medical decisions need to be made in collaboration with your personal physician who knows your history.  For reasons stated below - vaccination information and recommendations are also less clear than they have ever been due largely to political influences that can also affect physicians.

 

This a strategic post about pneumonia.  By strategic I mean I hope to clarify what it is and how to prevent it.  This is not about diagnosing and treating it.  Most people reading this blog either don’t need to know that or know a lot more than me about it. Instead, I hope to address three things – misinformation about it, barriers in the modern healthcare system to acute care, and how to prevent it.

My focus will be on community acquired pneumonia (CAP).  It is a term I am very familiar with dating back 40 years to med school and my medical internship. As an intern I carried around my copy of Sanford’s antimicrobial therapy and the relevant section of Phantom Notes which was basically an outline of the leading Internal Medicine text at the time.  Thirty percent of the people I admitted to the hospital had some kind of pulmonary problem.  Depending on who you read chronic obstructive pulmonary disease (COPD) is as high as the third leading cause of death worldwide.  Exacerbations of COPD were very common reasons for hospital and ICU admission. 

CAP by definition is acquired in the community and not in a hospital setting.  It can be cause by a range of microorganisms and host factors.  It can also develop in people with no known risk factors. Conventional wisdom used to be that the lung was sterile territory but now we know that it contains a low biomass microbiome consisting of bacterial, viral, and fungal elements that are there via microaspiration of mouth contents.  Local physiological changes can occur to change the microbiome, or pathogens can be inhaled that establish primary infections (1).   Certain lung diseases like COPD and asthma can also lead to selective proliferation of elements of the microbiome. 

The ability of the lung to repair itself after injury or infection is controversial. Some research suggested that the lung was permanently changed by infection.  One example would be the association of asthma with previous rhinovirus infection. More recent work suggests there is room for optimism if the regenerative capacity of the lung can be activated (2).  

My motivation for this post was a clinical trial I read in the New England Journal of Medicine.  It was about treating CAP in East Africa.  The research question was whether adding glucocorticoids to antibiotic treatment as usual would improve outcomes.  That study quotes the mortality of CAP as 25-30%. The study was conducted in Kenya.  2,180 study patients were randomized to standard care versus glucocorticoids.  All patients were admitted to a hospital and CAP was defined as “the presence of at least two of the following signs and symptoms for less than 14 days: cough, fever, dyspnea, hemoptysis, chest pain, or crackles on chest examination.”  Imaging was not a criterion for study entrance because it was not available in many settings.  They were started on the protocol within 48 hours of admission. Glucocorticoids were provided for free as one of five glucocorticoids in bioequivalent doses for a total of 10 days (including after discharge) in addition to standard care (6 mg of dexamethasone, 160 mg of hydrocortisone, 30 mg of methylprednisolone, 50 mg of prednisolone, or 50 mg of prednisone).  Standard care was antibiotic therapy per World Health Organization (WHO) guidelines (beta lactam and macrolide antibiotics). Exclusion criteria are available in the paper.

30-day mortality was the primary endpoint in an intent-to-treat analysis.  To get to the treatment population a total of 46,224 patients were screened.  Of the 2,180 patients mortality was 530 (24.3%) at 30 days.  246 of 1089 (22.6%) were in the glucocorticoid group and 284 of 1091 (26.0%) in the glucocorticoid group.  That translates to a hazard ratio of 0.84.  The authors explain the limitations (comorbid illnesses – HIV, hypertension) and advantages (large N, lower media age) of their study.  That seems like a slight reduction in mortality for the intervention, but the authors point out that several other studies had better results up to a 50% reduction in mortality with glucocorticoids and it is a low tech readily available intervention.

In looking at the side effects of glucocorticoids   Pulmonary tuberculosis and hyperglycemia were the most common adverse effects in the glucocorticoid treated group.  Pulmonary tuberculosis and acute kidney injury were the most common adverse effects in the standard care group. 

The striking part of this study for me are the mortality figures. Although the researchers emphasized throughout their study that this was a pragmatic trial in a healthcare system with fewer resources – the estimated mortality for community acquired pneumonia in the United States is 6% at 30 days for hospitalized patients but that increases to 34% at 30 days for patients who do not initially improve initially (4).  There are treatment guidelines for primary care physicians about who can or cannot be treated on an ambulatory basis.  Age is a risk factor for increased incidence of pneumonia with the rate increasing from 248 (all adults) to 634 (ages 65 to 79) to 16,430 per 100,000 after the age of 80 (5).  Pre-existing COPD increases the risk of hospitalization 9-fold.

There are characteristic patterns of pneumonia by pathogen based on the immune response.  Bacterial infections elicit an infiltration of neutrophils into the alveolar space in a pattern of lobar or bronchopneumonia that results in an exudate of dead cells and phagocytes in the alveolar space.  Viral infections cause an interstitial pattern of inflammation with lymphocytic cell infiltrates.  Identification of the pathogen is largely done on a clinical basis due to difficulty identifying the pathogens.  Indirect methods can be used like determining acute and convalescent phase antibodies to specific viruses. Both types of infection compromise normal physiology and can lead to hypoxia and in the case of bacteria secondary infections - like meningitis.      

Recent sporadic and annual viral pandemics have created a confluence of factors at the hospital that are best avoided.  The first is the use of broad-spectrum antibiotics.  Since a significant portion of people admitted with viral pneumonia develop hospital acquired secondary bacterial infections – antibiotics are given prophylactically to prevent that complication.  Increasing exposure to increasingly potent antibiotics leads to multiple drug-resistant bacteria.  The best pathway is to avoid getting the respiratory infection in the first place. 

The absolute best way to avoid is vaccinations.  Vaccinations are currently available for influenza, COVID-19 (Sars-CoV-2), respiratory syncytial virus (RSV), and Streptococcus pneumoniae (pneumococcal pneumonia and meningitis).  They have all been tested and offer relative protection (rather than absolute) against serious illness, hospitalization, and death, especially for adults 65+ years of age.  Vaccinations have become a mixed bag of accessibility.  On the one hand you can get them from pharmacies and that is a recent development.  On the other hand we have an elected government that has appointed a well known antivaccination promoter as the head of Health and Human Services – Robert F. Kennedy, Jr.  So far there have been restrictions on the COVID vaccination to people who are 65+ or have an underlying health condition.  Since the administration is apparently making health decision based on politics and ideology many states and professional organizations are publishing their own guidelines.  As an example here is a list of respiratory virus vaccination guidelines from the American Academy of Family Practice (AAFP).  The CDC still has pneumococcal vaccination recommendations for children less than the age of 5 and adults over the age of 50.

The University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP) program has a good brief on the vaccine controversy and chaos introduced by the Trump administration and the lack of scientific origins at this link.

Apart from vaccinations risk factor modification should be considered.  If you were born and raised in American culture – it is important to realize that you have been socialized to expect to get sick in the wintertime.  I did not realize that until I was getting sick 2-3 times a year on the inpatient unit where I worked.  They were viral illnesses that took 2-3 weeks to recover from.  The building was made in an era where preservation of heat was the primary design goal.  There was minimal circulation of clean air or filtration.  My suggestions to improve the air quality were ignored.  The mini-epidemics were made worse by admitting people who were ill with respiratory viruses and not using any precautions to prevent the spread of those viruses.  The new personal time off (PTO) policies that make no distinction between vacation and sick days also lead to increased exposure to sick employees who would rather work sick than use PTO days for sick time.  Since the COVID pandemic even outpatient clinics ask questions every time they see you to minimize staff exposure to respiratory viruses.

Masks work.  They must be N95 masks and fit correctly but there is no doubt that they work.  These days it is common to see political arguments and in the extreme ridicule heaped on people who use them. Large scale uncontrolled studies are often cited as evidence that they are a weak intervention.  These studies are almost all self report with no measures of actual adherence to masking.  The best studies are done in a lab that look at filtering virus sized particles and there is no doubt they are equal to that test.  

Risk factor modification is probably important.  Cardiopulmonary diseases are significant risk factors for pneumonia – so maintaining the best possible treatment for those conditions is important.  Weight control and activity level are also important.  There is at least one study showing that 65+ year olds who maintain high activity levels have better immunity than those who do not.  The specific dose of exercise for that effect is unknown currently. 

Expert advice on vaccine allergies is an important point.  I have personal history of an anaphylactic reaction to anti-rabies duck embryo vaccine in 1975.  For the next 30 years I did not get a single vaccine against influenza because it was egg based.  I had innumerable episodes of viral illness that was probably influenza and decided to see an immunologist to see if I could be desensitized to eggs so I could get the flu vaccine.  When he confirmed that I could eat eggs without a problem he said that I would probably not have any problems with the vaccine.  He was correct and I have not missed an annual dose since.

Look for respiratory infection season onset and peaks.  They are typically available through your state public health department and the CDC. When I notice it – I change my routine to shop at nonpeak hours and wear a mask in stores.  In addition to protection from the airborne transmission route hand washing is also important.  Shopping carts, door handles, and other high traffic areas are unavoidable areas for direct contact transmission. That may include being in a public bathroom any time somebody flushes a toilet.  Keep in mind that there are number of circulating common cold viruses that include 4 coronaviruses that can make you very ill.

What about barriers to care in the current healthcare non-system in the US?  There are many since businesses have taken over health care in the past 40 years.  Healthcare is rationed by both businesses and governments with only a very grudging nod to quality. The most obvious example is avoidance of the emergency department if you need it.  Anyone with previous experience knows about waits in emergency departments and delays in care.  People avoid paramedics and ambulances out of fear they will be billed for that service.  If you expect that you are ill beyond a typical cold and have additional warning signs like shortness of breath – seek help immediately.  I have given that advice to many people and it is included in the final paragraph of this AMA information sheet.   Keep in mind that pneumococcal infection can also cause meningitis which is even a more significant emergency and those symptoms can include a severe headache and neck stiffness.  Maintain a low threshold for checking these symptoms out with your primary care physician’s office during working hours and their call line after hours. But if that is not available or able to give you an answer call 911 and get a paramedic there in person to advise you and advocate for you getting timely care.  Even in our fragmented healthcare system you do not have to go it alone.  

Finally – you must realize that the infectious disease space has been infiltrated by many people who do not belong there.  They have mixed agendas involving politics and health and wellness profits.  In some cases, they are just promoting themselves.  This varies from a kernel of truth rhetoric (eg. “most people who get this virus do not die”) to outright lies (eg. “this vaccine has never been adequately tested”).  There are many points in between such as “He died of pneumonia not COVID”.  In outrageous cases they have attacked and threatened public health officials.  It is important to recognize who these people are and why they must be ignored to preserve your interest and that is your personal health. 

I attached a list of the main respiratory pathogen vaccinations as a supplementary below. The indications are taken directly from the FDA approved package insert that is in turn based on clinical trials for efficacy and safety. There are significant differences between the FDA approved indications and eligibility as determined by various organizations. There are also links to those graphics in the appended material. Note that for the COVID vaccinations especially the eligibility can vary based on age, susceptibility status, and what has been referred to as mutual decision making. In my opinion this is basically slow walking vaccine denial in as eligibility. Essentially all medical decisions are based on informed consent as mutual decision making. I did not get a single influenza vaccine for 30 years because of mutual decision making that was based on inadequate information. I asked an Internist about what he would recommend in the cased of COVID-19 vaccinations and he said: “Definitely recommend for over 65. Recommend for patients with multiple comorbidities. Recommend for healthy young adults if they were healthcare workers, teachers or in an occupation with lots of exposure to the public.” Why are the eligibility criteria not that simple?  As far as I can tell the answer is politics.

That is my overall strategy to avoid pneumonia.  It is most important as you age into categories where your risk doubles (65+ yrs old) and increases 25-fold (80+ yrs old).  I use these strategies myself and have found them to be very effective.  And remember the overall strategy is to avoid the physical virus or bacteria if at all possible and failing that make sure your immune system is activated by a vaccination to attack it if you are infected.

 

George Dawson, MD, DFAPA

 

References:

1: Li, R., Li, J. & Zhou, X. Lung microbiome: new insights into the pathogenesis of respiratory diseases. Sig Transduct Target Ther 9, 19 (2024). https://doi.org/10.1038/s41392-023-01722-y 

2:  Ainsworth C. Lung, heal thyself. Nature. 2026 Jan 29;649:S9 – S11.

3:  Lucinde RK, Gathuri H, Mwaniki P, et al. A Pragmatic Trial of Glucocorticoids for Community-Acquired Pneumonia. N Engl J Med. 2025 Dec 4;393(22):2187-2197. doi: 10.1056/NEJMoa2507100. Epub 2025 Oct 29. PMID: 41159889; PMCID: PMC12659994.

4:  Peyrani P, Arnold FW, Bordon J, et al. Incidence and mortality of adults hospitalized with community-acquired pneumonia according to clinical course. Chest. 2020;157(1):34-41.    

5:  Jain S, Self WH, Wunderink RG, et al.; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427.

Graphic:

Pages from my trusty copy of Phantom Notes that I used on wards as a medical student.  I went back to check to see if community acquired pneumonia was a thing back then and it was not.  If you can read it they do discuss where it was acquired under Classification (D3).   According to PubMed that term was used just twice in 1981 - but became progressively more popular in the 1990s.

Note also that we have an expanded list of viral pathogens compared with 1981.

Phantom Notes Medicine 79-80 edition copyright Joe D. Glickman, Jr, MD All Rights Reserved.  

A Shocking Anecdote about Pneumococcus:

When I was an intern on neurology (1983) I was called down to the emergency department to assess a 70 year old woman for "agitation".   That was all they could tell me aside from the fact that her labs and exam were normal.  She was unresponsive, groaning softly and rolling from side to side on the bed.  I proceeded with my examination and found that she had a stiff neck and pus draining out of her left ear.  I called my two senior neurology residents and they came sprinting to the ED.  A quick gram stain of the pus showed gram positive cocci and we gave her 1 gram of IV chloramphenicol, did a lumbar puncture and transferred her to the Neurology ICU.  She subsequently developed ARDS and required transfer to the medical ICU for ventilatory support.  She was discharged a month later and was completely deaf as a result of pneumococcal meningitis.

Vaccines for Respiratory Tract Infections: Indications versus Eligibility:

 

Vaccine	Indication (From Package Insert)	Eligibility (From CDC)
Influenza	FLUARIX is a vaccine indicated for active immunization for the prevention of disease caused by influenza A subtype viruses and type B virus contained in the vaccine. FLUARIX is approved for use in persons aged 6 months and older. (1)  - Fluzone High-Dose is a vaccine indicated for active immunization for the prevention of disease caused by influenza A subtype viruses and type B virus contained in the vaccine. (1) Fluzone High-Dose is approved for use in persons 65 years of age and older. (1)	Annual all adults CDC Guidance
COVID	Moderna - SPIKEVAX is a vaccine indicated for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SPIKEVAX is approved for use in individuals who are: • 65 years of age and older, or • 6 months through 64 years of age with at least one underlying condition that puts them at risk of severe outcomes from COVID-19   Pfizer - COMIRNATY is a vaccine indicated for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). (1) COMIRNATY is approved for use in individuals who are:  65 years of age and older, or  5 years through 64 years of age with at least one underlying condition that puts them at high risk for severe outcomes from COVID-19. (1)	Adults should discuss with their health care provider to see if this vaccine is right for them. CDC Guidance
RSV	-Active immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months of age. (1.1) - Active immunization for the prevention of LRTD caused by RSV in individuals 60 years of age and older. (1.2) -Active immunization for the prevention of LRTD caused by RSV in individuals 18 through 59 years of age who are at increased risk for LRTD caused by RSV	Adults 75+ Adults 50-74 at increased risk CDC guidance
Pneumococcus	Pneumococcal Conjugate Vaccines (PCV)   PCV15 (Vaxneuvance): Protects against 15 types of pneumococcal bacteria.  is indicated for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 6 weeks of age and older.   PCV20 (Prevnar 20): Protects against 20 types of bacteria; it has largely replaced the older PCV13 (Prevnar 13). Prevnar 20 is a vaccine indicated for • active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 6 weeks of age and older. (1) • active immunization for the prevention of otitis media caused by S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F in individuals 6 weeks through 5 years of age. (1) • active immunization for the prevention of pneumonia caused by S. pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 18 years of age and older. (1) The indication for the prevention of pneumonia caused by S.pneumoniae serotypes 8, 10A, 11A, 12F, 15B, 22F, and 33F in individuals 18 years of age and older is approved under accelerated approval based on immune responses as measured by opsonophagocytic activity (OPA) assay.   PCV21 (Capvaxive): A newer vaccine approved in 2024 for adults, protecting against 21 types, including several strains not covered by other vaccines. CAPVAXIVE™ is a vaccine indicated for: • active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15B, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B in individuals 18 years of age and older. (1) • active immunization for the prevention of pneumonia caused by S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A,15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B in individuals 18 years of age and older. (1) The indication for the prevention of pneumonia caused by S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B is approved under accelerated approval based on immune responses as measured by opsonophagocytic activity (OPA).Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. (1) Pneumococcal Polysaccharide Vaccine (PPSV) PPSV23 (Pneumovax 23) PNEUMOVAX 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F,14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F). (1.1) PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged ≥2 years who are at increased risk for pneumococcal disease. (1.1, 14.1)	Adults aged 50 or older according to CDC

 

 *High risk for severe outcomes:  For the comprehensive list of underlying medical conditions that place a person at risk for severe outcomes from COVID-19 see this CDC document: https://www.cdc.gov/covid/hcp/clinical-care/underlying-conditions.html

 FDA Vaccine, Blood, and Biologics Web Page:  https://www.fda.gov/vaccines-blood-biologics

 FDA Vaccines Licensed for Use in the United States:  https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states

CDC Vaccine Schedule with graphic:  https://www.cdc.gov/vaccines/imz-schedules/adult-easyread.html

COVID recommendation:  “Adults should talk to their health care provider to decide if this vaccine is right for them”.

 AAFP Adult Vaccination Schedule with graphic:  https://www.aafp.org/dam/AAFP/documents/patient_care/immunizations/2025%20adult%20Schedule_NOV.pdf

COVID recommendation:  “1 – 2 or more (age >65) does of the updated 2025-2026 vaccine”.

 Minnesota Department of Health Adult Vaccination Schedule with graphic: https://www.health.state.mn.us/people/immunize/resprecs.pdf

COVID recommendation:  “All adults especially 65+ (2 doses)”.

 

 

Norovirus - Avoid It If You Can

 

Norovirus is an Increasing Problem

Norovirus is a non-enveloped single strand RNA virus.  One of the critical features of Norovirus is infectivity.  Infected individuals secrete the virus in feces, saliva, and oral mucus.  Virus can be detectable in the saliva for up to 2 weeks after infection even though most of the guidelines for food preparers suggests that they can go back to work 2-3 days after the acute illness has passed.  The infective dose for Norovirus is as little as 18 viral particles (1).  An infected person is excreting billions of these particles. For comparison, influenza virus requires a dose of about 1.95-3.0 x 10³ infectious particles, and most common respiratory viruses including SARS-CoV-2 are on par with Norovirus. 

The clinical syndrome develops rapidly after exposure resulting in abdominal cramping, vomiting and diarrhea.  It creates significant mortality and morbidity causing an estimated 213,000 deaths world-wide (2).  In the US 900 people die per year out of 21 million infections. Most of the fatalities occur in the elderly and immunocompromised. Rapid fluid loss and dehydration is most likely a causative factor especially in the case of pre-existing medical problems. There is a bias toward advising all people like they are healthy young adults and that this syndrome is a self-limited 2-3 day episode of stomach flu.

There is an asymptomatic carrier state with anywhere from 11.6-49.2% of measured populations carrying the virus. This also extends to 1-3.4% of food handlers.  Humans were previously the only known reservoir for this virus, but a recent review looked at modern data and concluded that it may be a reverse zoonosis with human to animal transmission in lab animals and the wild (3, 4). 

Outbreaks of the virus are getting more common especially in environments where there is close contact and contact with contaminated surfaces like schools, universities, elderly homes, and cruise ships.  In the US there are about 2,500 outbreaks per year and poor granularity in terms of geographic locations. In other words, unless a local news channel picks up the story of an outbreak – you probably will not know until you get there.  The distribution of outbreaks over the calendar year for the last 4 years is given at the top of this post.  Outbreaks tend to intensify in the winter months where there is more aggregation.   

The most common advice given to prevent Norovirus infection is hand washing and cleaning contaminated surfaces.  The virus remains physically stable in pH 3-7 condition and temperatures up to 60 degrees C (140 degrees Fahrenheit) but that conventional wisdom may not be enough.  The virus is aerosolized presumably by coughing, sneezing, and toilet flushing and has been detected in the air around hospitalized patients (8). The particles detected were in the droplet nuclei/aerosol range but that may be an artificial dichotomy (9).  The main point in this research is that the droplets detected contained sufficient virus to cause infection. Current CDC precautions for Norovirus do not include masking except where there is a risk of “splashes to the face during the care of patients, particularly among those who are vomiting.”  This is reminiscent of the reluctance to declare respiratory viruses including SARS-CoV-2 and influenza airborne. 

6.6% of the US population are immunosuppressed based on taking immunosuppressant drugs or having a health condition that affects immunity and that number is increasing (10).  Women are more likely to be affected than men. In addition to the immunocompromised - 39% of the population has at least one serious chronic illness any number of which can affect innate immunity (11).  In addition, many of these diseases or their management can end up compromised by severe acute gastroenteritis.  Common examples would be blood glucose management in diabetes mellitus and electrolyte and fluid management in hypertension, arrhythmias, and renal disease.  Since 42% of the population has 2 or more chronic conditions it is highly likely that recommended management of rehydration will need to be personalized to that patient.  

There are also nebulous recommendations about the quarantine necessary following an episode of this illness.  The CDC web site provides an example, in order:

“Most people with norovirus illness get better within 1 to 3 days; but they can still spread the virus for a few days after.”

“You can still spread norovirus for 2 weeks or more after you feel better.”

“Stay home when sick for 2 days (48 hours) after symptoms stop.”

Apparently, Norovirus has been detected in saliva for up to 2 weeks after infection – leading to this mixed recommendation. There is some additional information at a public health link – but not much more. This link has interesting information on clinical criteria without biological confirmation that a probable Norovirus outbreak is occurring. In a 2013 review, Norovirus was the second most common infection disease outbreak affecting psychiatric hospitals (13).  This review looks at infection control procedures that may be unique to psychiatry as well as those that address the difficult to destroy nature of the virus.  It is resistant to common hand sanitizers and the need for contact cleaning with hypochlorite while masked and gowned to prevent infection of staff.  The reference on the possible airborne nature of the virus also applies. A description of a psychiatric hospital with 4 previous Norovirus outbreaks and how that was stopped by a specific infection control program is also described (14).

That is currently the state-of-the-art on Norovirus. I have some additional information posted below.  The best defense at this point is to know that this is a highly infectious virus that is nothing to fool around with, especially if you are elderly, have chronic medical conditions, or are immunocompromised.  I don’t think it is my place to make specific rehydration recommendations because of the complexity I describe in the above paragraphs – but your personal physician certainly can.  No matter what you read – avoiding dehydration is the most important aspect.  Your physician can best describe how to do that given any other medical conditions. 

There are currently no vaccines or antiviral medications for Norovirus.  Vaccines are complicated by several factors discussed in this paper (15) that projected vaccine availability 5-10 years out from 2014.  Here we are 10 years out. Like the current SARS-CoV-2 vaccines early trials show a limited duration of immunity, but that can eliminate many cases in more vulnerable populations.

 

George Dawson, MD

 

Supplementary 1:

For 2025 – I decided to separate out my anecdotal experience from the published scientific data.   Readers of this blog know that my intent is generally to include it as additional relevant information and I have joked about trying to learn more about diseases by trying to get most of them.  That is no different with Norovirus.  The actual clinical syndrome I have seen many times dating back to my days as a Peace Corps volunteer travelling in East Africa.  It was referred to as “Traveler’s Diarrhea” and the theory was that it was caused by “enterotoxigenic E. Coli.”  Various remedies were suggested including Pepto Bismol (bismuth salicylate) or a prophylactic course of sulfamethoxazole/trimethoprim (SMX/TMP) – an antibiotic that I subsequently prescribed many times as an intern and resident.  

All Peace Corps volunteers were issued a medical kit and the two primary medications were a large bottle of Lomotil (diphenoxylate/atropine) and another large bottle of Benadryl (diphenhydramine).  So most acute diarrheal diseases were treated with Lomotil.  We also got IM cholera vaccines that interestingly were discontinued shortly after my Peace Corps tour because “they were more painful than protective.”  The only currently approved cholera vaccine is an oral vaccine.

My wife recently had a complicated course of appendicitis and there was concern about the possibility of an intraabdominal abscess.  As she recovered slowly from the surgery she had residual right upper quadrant pain and suddenly developed an acute illness again very similar to the appendicitis. I convinced her to go to free-standing emergency department where she was treated for nausea and rapidly given 1 liter of normal saline in less than 30 minutes. She was hypotensive and had a lot of vomiting and diarrhea in the hours before this assessment.  A CT scan of the abdomen was negative and a PCR test of a stool sample confirmed no C. difficile toxin and positive for Norovirus (see test panel below).

Returning home she recovered over the next two days – but I contracted it and am recovering on day 3.  I will post the symptom course in this note when I am fully recovered.  I will note that my wife has had 2 episodes of SARS-CoV-2 infections in the past 3 years and I did not get them from the airborne route but was masked and using a UV air cleaner at the time.  This time I was not masked – but I was using all of the CDC recommended contact precautions, the same UV air cleaner, and handwashing.       

Supplementary 2:

Sometimes it pays to be a hoarder. I found this book in my auxiliary library today.  It was sent to me by a friend who was attending Harvard Medical School when he heard I was definitely headed to Africa.  I regaled my Peace Corps colleagues with tales of possible infections in Africa. The most interesting section for this post is that it provides an anchor point for diarrheal disease classification in 1975. It lists invasive and enteropathogenic E. coli as the primary pathogens detectable by culture and bioassay or an assay set up to detect the toxin.  Epidemic viral gastroenteritis is attributed to Norwalk virus in the same book.  The name originated from immune electron microscopy of a viral particle identified as a causative agent in Norwalk, Ohio.  Episodic viral gastroenteritis at the time was attributed to rotavirus, duovirus, and orbivirus.

Supplementary 3:

I resumed working out on day #7 and have charted the symptoms using my invention of a malaise index.  Note that APAP here means acetaminophen that I take for symptoms that are generally caused by cytokines from the inflammatory response caused by viral and bacterial infections.  The index itself is included below the graphic of the course of the illness to explain what was rated.  For research purpose a Likert scale approach for every item would probably be used.  Even though the symptom descriptions are fairly basic - the underlying pathophysiology is not.  There are also some symptoms that I experienced that were not included like a sensory lack of taste for food. 

Supplementary 4: 

The Minnesota Department of Health came out with the following release on Norovirus today.  Apparently there have been 40 outbreaks in the state of Minnesota.  No specific locations are given and the general advice has the limitations I outlined in the above blog post.

All of the details can be found at this link.

Supplementary 5:

EPA Registered Products that will kill Norovirus:  Chlorox and Lysol products are the most recognizable names but there are many (386).  Note the necessary contact time in the table necessary to effectively eliminate the virus.

https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-norovirus-feline

References:

1:  Winder N, Gohar S, Muthana M. Norovirus: An Overview of Virology and Preventative Measures. Viruses. 2022 Dec 16;14(12):2811. doi: 10.3390/v14122811. PMID: 36560815; PMCID: PMC9781483.

2:  Pires SM, Fischer-Walker CL, Lanata CF, Devleesschauwer B, Hall AJ, Kirk MD, Duarte AS, Black RE, Angulo FJ. Aetiology-Specific Estimates of the Global and Regional Incidence and Mortality of Diarrhoeal Diseases Commonly Transmitted through Food. PLoS One. 2015 Dec 3;10(12):e0142927. doi: 10.1371/journal.pone.0142927. PMID: 26632843; PMCID: PMC4668836.

3:  Robilotti E, Deresinski S, Pinsky BA. Norovirus. Clin Microbiol Rev. 2015 Jan;28(1):134-64. doi: 10.1128/CMR.00075-14. PMID: 25567225; PMCID: PMC4284304.

4: Villabruna N, Koopmans MPG, de Graaf M. Animals as Reservoir for Human Norovirus. Viruses. 2019 May 25;11(5):478. doi: 10.3390/v11050478. PMID: 31130647; PMCID: PMC6563253.

5:  Karimzadeh S, Bhopal R, Nguyen Tien H. Review of infective dose, routes of transmission and outcome of COVID-19 caused by the SARS-COV-2: comparison with other respiratory viruses. Epidemiol Infect. 2021 Apr 14;149:e96. doi: 10.1017/S0950268821000790. Erratum in: Epidemiol Infect. 2021 May 14;149:e116. doi: 10.1017/S0950268821001084. PMID: 33849679; PMCID: PMC8082124.

6: CDC.  Norovirus Facts and Stats.  (accessed on 12/15/2024): https://www.cdc.gov/norovirus/data-research/index.html

8:  Alsved M, Fraenkel CJ, Bohgard M, Widell A, Söderlund-Strand A, Lanbeck P, Holmdahl T, Isaxon C, Gudmundsson A, Medstrand P, Böttiger B, Löndahl J. Sources of Airborne Norovirus in Hospital Outbreaks. Clin Infect Dis. 2020 May 6;70(10):2023-2028. doi: 10.1093/cid/ciz584. PMID: 31257413; PMCID: PMC7201413.

9:  Drossinos Y, Weber TP, Stilianakis NI. Droplets and aerosols: An artificial dichotomy in respiratory virus transmission. Health Sci Rep. 2021 May 7;4(2):e275. doi: 10.1002/hsr2.275. PMID: 33977157; PMCID: PMC8103093.

10:  Martinson ML, Lapham J. Prevalence of Immunosuppression Among US Adults. JAMA. 2024 Mar 12;331(10):880-882. doi: 10.1001/jama.2023.28019. PMID: 38358771; PMCID: PMC10870224.

11:  Benavidez GA, Zahnd WE, Hung P, Eberth JM. Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area. Prev Chronic Dis 2024;21:230267. DOI: http://dx.doi.org/10.5888/pcd21.230267

12:  Fukuta Y, Muder RR. Infections in psychiatric facilities, with an emphasis on outbreaks. Infect Control Hosp Epidemiol. 2013 Jan;34(1):80-8. doi: 10.1086/668774. Epub 2012 Nov 27. PMID: 23221197.

13: Tseng CY, Chen CH, Su SC, Wu FT, Chen CC, Hsieh GY, Hung CH, Fung CP. Characteristics of norovirus gastroenteritis outbreaks in a psychiatric centre. Epidemiol Infect. 2011 Feb;139(2):275-85. doi: 10.1017/S0950268810000634. Epub 2010 Mar 25. PMID: 20334730.

14:  Tseng CY, Chen CH, Su SC, Wu FT, Chen CC, Hsieh GY, Hung CH, Fung CP. Characteristics of norovirus gastroenteritis outbreaks in a psychiatric centre. Epidemiol Infect. 2011 Feb;139(2):275-85. doi: 10.1017/S0950268810000634. Epub 2010 Mar 25. PMID: 20334730.

15:  Gupta SS, Bharati K, Sur D, Khera A, Ganguly NK, Nair GB. Why is the oral cholera vaccine not considered an option for prevention of cholera in India? Analysis of possible reasons. Indian J Med Res. 2016 May;143(5):545-51. doi: 10.4103/0971-5916.187102. PMID: 27487997; PMCID: PMC4989827.

16:  Benenson AS (ed).  Control of communicable diseases in man – 12^th Edition. American Public Health Association. Washington, DC.  1975:  96-101, 125-129.

17:  CDC.  Confirmed norovirus outbreaks submitted by state.  Good source of data from CaliciNet updated every months.  Gives number of outbreaks per state in the past year and rough data on virus genotype.  https://www.cdc.gov/norovirus/php/reporting/calicinet-data.html

 

Stay Indoors - But Is That Enough?

 

Any casual reader of this blog might know that I was interested in indoor air quality including airborne viruses – long before it became fashionable. That had various origins including an undergrad focus on ecology, being raised by two heavy smokers, having to manage a coal fired stoker as a kid, working in a HEPA filtered clean room as a research assistant, and routinely getting viral respiratory infections in a hospital staff setting where we were all advised that hand washing was supposed to stop the mini-epidemics. And having asthma through all of that.

The indoor air quality issue has become complicated as our outdoor environment deteriorates. As an undergrad 50 years ago, we studied air pollution scenarios that affected large cities.  That included the concept of how smog was created by photochemical reactions but a lot of the specifics were not known.  More recently the entire Midwest and Northeastern US has been blanketed by wildfire smoke from Canada. Wildfire smoke is chemically complex.  In a lot of areas there are air quality alerts on one day due to wildfire smoke and ozone the next day. Those alerts are graduated to advise people with health conditions like asthma, emphysema, and heart disease on the lower end to limit outdoor activities or stay inside.  At high levels everyone gets the same advice.

The advice to stay inside assumes that your indoor air quality is better than the outdoor air quality that you are being warned about.  But is that a valid assumption?  How do you get measurements on everything and know the critical differences?  A good place to start is the outdoor air quality. The EPA has developed a nationwide network of sensors that detects particulates and ozone in the air and calculates the air quality index.  The AirNow app is available for your smart phone.  It gives you the outdoor reading, particulates, and ozone, as well as the break points from Good (0-50) to Hazardous (301-500). It will give you conservative advice about what to do about health and activity for those break points.

The CDC has a publication on indoor air quality in airports (1) where smoking was allowed. It provides some more intuitive markers of indoor quality. They found that the PM 2.5 (<2.5 micron particles per cubic meter) were 300+ in the smoking areas and 50+ in the areas adjacent to the smoking areas.  300+ levels are considered “very unhealthy”.  Anyone who has ever been in a smoke-filled room can probably sense that the atmosphere is not very good for your health either immediately of after leaving.  In Minnesota when the AQI was greater than 300 due to wildfire smoke – you could smell the wood fired smoke.

With an accurate assessment of the outdoor air – what about your indoor air quality?  I was fortunate enough to have purchased an air cleaner for my office with a PM 2.5 measure built into the machine. It usually reads in the 1-5 range but when the wildfire smoke arrived it was suddenly reading 40+ indoors. I had to figure out why that number was so high.  I had just replaced my furnace and it has a MERV13 filter that should provide some filtering efficiency.  The question mark was how my air exchanger fit into the mix.

My house is about 15 years old and like most modern houses it is considered airtight.  The concern by builders and contractors with modern homes is that they are so airtight that it leads to indoor air pollution from a number of sources including any combustion processes in the home and volatile compounds in the air from various sources like cleaning products.  As a result, air exchangers are installed to vent the indoor air and bring in fresh outdoor air.  These air exchangers are designed to reduce heat exchange and most do not have HEPA ( High Efficiency Particulate Air [filter])  filters.  They have a relatively primitive filtration system to remove mainly insects and very large particles. They can easily bring in outdoor smoke so it is a good idea to have it shut off on days where there is very high particulate matter.

The problem with my new system is that I was not sure that the air exchanger was off.  When my new furnace was installed the air exchanger was integrated into a touch panel with 30 different options and several ventilation settings.  I talked with 5 technicians (3 from the HVAC contractor, 1 from the air exchanger manufacturer, 1 from the smart thermostat manufacturer).  They all agreed shut off the air exchanger was a good idea but they gave me widely varying advice.  I decided to experiment myself over a period of 12 hours and generated the following graph (click to enlarge).

The first section shows the AQI outdoors versus indoors running the MERV 13 filter through the furnace.  There is no difference over that time period.  The next period I shut off the furnace filter and used a free-standing Space Gaard air cleaner with a MERV 8 (MERV = Minimum Efficiency Reporting Values) filter. Notice that during this time period the wind picked up outdoors, blew off some smoke and the PM 2.5 dropped from 160 to about 90.  At that time I talked with a 6^th technician and he gave me clear advice on how to shut off the air exchanger.  The last section is with the air exchanger off and all air circulating through the furnace filter MERV 13.  At that point the indoor AQ drops consistently despite a blip upwards in the outdoor PM 2.5 and continued to drop to 10.  To me that illustrates the importance of making sure the air exchanger if off when the outdoor AQ is poor and actively managing it to turn it one when the outdoor AQ is acceptable.

A related indoor AQ related to viral transmission is the carbon dioxide CO₂ levels.  Lower levels correlate with less people rebreathing air in the room and that decreases the risk of infection from airborne viruses. Outdoor CO₂ is roughly 400-420 ppm. My indoor measure is currently 570 without the air exchanger on.

There are currently PM 2.5 and CO₂ monitors available in most home stores and large online retailers.  What we really need is a more comprehensive single device that measures and records all of the parameters. I would suggest PM 2.5, PM 10, CO₂, Ozone, and Volatile Organic Compounds (VOC).  The closest I could come to that device was a gadget that required that I purchase a separate weather station and even then the bandwidth to multiple devices was limited.

Home HVAC system design could also use some innovation. Just based on my experience durability is a problem. Should an HVAC system last longer than 14 years?  Probably.  But the design itself does not seem very efficient.  I am not a certified HVAC tech by any means but it appears to me that the air exchanger introduces outdoor air into the system after the air filter so that any particulate matter in the outdoor air does not get at least one pass through the highest efficiency filter.

Outdoor air quality is a little discussed casualty of climate change. As the environment deteriorates, I expect that there will be increasing amounts of wildfire smoke and it will be chemically more complex. I currently wear an N95 mask outdoors during the alerts, but I can envision a time in the not-too-distant future where respirators that can also remove ozone and organic chemicals will also be necessary. Geography is no longer helpful in separating clean air from polluted air. Monitoring your personal indoor air quality and figuring out how to manage it will become the most critical part of home management. I have posted a few things that you can do right now and I am always interested in other ideas about how to address this problem.  Please post any of those ideas in the comments section.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Centers for Disease Control and Prevention (CDC). Indoor air quality at nine large-hub airports with and without designated smoking areas--United States, October-November 2012. MMWR Morb Mortal Wkly Rep. 2012 Nov 23;61(46):948-51. PMID: 23169316.

2:  CDC Health Alert Advisory.   Wildfire Smoke Exposure Poses Threat to At-Risk Populations.  Link

Update 07/06/2023: 

One week after turning off my air exchanger - the PM 2.5 in my house is down to 6 or essentially normal.  I talked with my air conditioning tech who also services the air exchanger and he agreed with the approach.

Image Credit:

Canadian Wildfire Smoke in Minneapolis

Chad Davis from Minneapolis, United States, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

file URL:  https://upload.wikimedia.org/wikipedia/commons/c/c0/Canadian_Wildfire_Smoke_in_Minneapolis_%2852907984452%29.jpg

page URL:

https://commons.wikimedia.org/wiki/File:Canadian_Wildfire_Smoke_in_Minneapolis_(52907984452).jpg

The Tomorrow River

 

The Tomorrow River is a small Wisconsin stream that crosses US Highway 10 three or four times between Fremont and Waupaca.  It eventually runs into a creek and becomes the Waupaca River.  I crossed all those tributaries twice on a trip last weekend. It gave me the usual opportunity to free associate to my past life. Two memories came immediately to mind – both from about 1977.  I was freshly out of the Peace Corps and trying to establish myself in a job as a research assistant cloning trees at an Institute in the area. That involved a lot of travel down Highway 51 to Highway 10 and I did not have a car.

One day I was travelling on a Greyhound bus heading to my apartment.  That was the first time I caught the Tomorrow River sign, as I looked up from a letter I was writing to my friend Glenn. I had a good experience in the Peace Corps entirely due to the Americans I met in my group.  They were bright, excitable, and energetic. We had gatherings where we listened to music, ate pizza, and played basketball.  We had long discussions into the night about what was important, what art meant, literature, music, math, science, and the meaning our work as high school teachers in the Peace Corps. We read the hipster literature of our time – Kerouac, Pirsig, Kesey, Brautigan, Wolfe, and others.  There were animated discussions and arguments.  All of that probably influenced the letter I was writing and then I saw the sign. The letter took on a surrealistic quality that Glenn appreciated in a letter he sent back to me.  As I visualized that decades old experience – it was a good feeling. I still feel a connection to my Peace Corps friends even though it has been decades and we rarely see one another or communicate.  I know that when I do – we will pick things up the way they have always been.

Between the second or third Tomorrow River sign there is an uphill curve in the road that bends to the left when you are traveling east. It is a long half mile bend. Later that same year just after Thanksgiving – I was getting a ride to my apartment from my friend Walt.  We went to the same high school and college. He was two years younger than me. Walt’s personality was completely the opposite of me. He was spontaneous, outgoing, and engaging. He could joke about anything.  I was the lab assistant in his organic chemistry section and one day his condenser hose broke loose and started spraying water just over the top of a freshly cut pile of sodium metal. I was able to grab the hose and redirect it.  Luckily there was no contact with the sodium, but after that point he started referring to himself and his lab partner as Captain Sodium.  On that day he was dropping me off and heading to his graduate program in endocrinology in Chicago.  The weather was not cooperating.  On that bend – the traffic that was usually travelling at 65-70 mph was at a dead stop in an ice storm and backed up for miles.  We both got out for a better view and realized it was impossible to stand on the road. Even  maintaining your balance, you eventually slid from the highest to the lowest part of the road and were forced to crawl back across the lane of oncoming traffic. We got back in the car and spent a long time joking about his bright reddish orange Dodge sports car and all of the trash talk he got from people in our home town about that car.  When he walked into a local bar he would hear: "Here comes the Fire Chief!"  We eventually completed the trip and I would see him from time to time over the next decades as he completed his PhD, then medical school, then residency in anesthesiology.  He became one of the top anesthesiologists in the country. And then several years ago, I got the news that he had died suddenly after a brief illness.  He was at the top of his game at the time – a department head and national expert in neurosurgical anesthesia.  I felt badly about not seeing him and not congratulating him on all of his success. I always feel badly when people don’t make it to retirement and a lot worse if I know them.  

Even before I went into the Peace Corps, I spent a lot of time navigating these roads with my friend Al.  We did that mostly in a 20-year-old Volkswagen beetle with a defective gasoline heater. When you tried to turn the heater on it might blow the hood open. Al was a mathematical genius and had accumulated almost enough math credits for a major when he was in high school - all self-taught by reading the texts. He decided to go to medical school and that led him to spend an additional 2 years as an undergrad taking the prerequisite courses.  Somewhere along the line driven by my insomnia and his sense of adventure, we ended up driving long distances to other towns at night to see movies or bands that we knew would never come farther north to our college town.  When you drive on roads in Wisconsin, Minnesota, and Michigan unusual things can happen.  When the pitch-black night is underlit by the snow cover – anything can happen. One night at about 2 AM we were on a road running parallel to Hwy 51 north when suddenly – an old model Chevrolet was airborne about 50 feet in front of us.  By airborne I mean it crashed over the top of a 5- or 6-foot snowbank at a high rate of speed and crossed our highway in a perpendicular path.   It landed on the other side of the road clipping the top of that snowbank first.  Turning around it was obvious that this was a planned attempt to launch the car from a parking lot outside of a bar to the other side of the road.  A few seconds later would have resulted in our Volkswagen being T-boned. That night we were able to turn up the radio and keep going.

These are the kinds of associations I have when I am driving these roads.  The paragraphs seem flat compared to the images in my head. I can envision my friends, our youth, images of what happened, the associated emotions, and the thoughts I have stacked on these events over the past 40-50 years. People I knew then often in a casual way.  People who I wanted to know better. People who – if I had interacted with them differently – would have drastically altered the course of my life and the people who did alter the course of my life. People who I wish would call me or send me an email.  People who I regularly think about and dream about.  But then I tell myself – “This is your own weird perspective on life – most people don’t think like this.”  Generally, that is good to know but at the same time – people do reach out from the past. They seem to realize that we are not the same people we used to be – but the common experience means something.  In many cases, it means a lot.  At my 50^th high school reunion, I was sitting outside of the main room when a classmate approached me and asked if she could sit down. I have known her for over 50 years and yet, that conversation was the longest I had ever spoken with her. It was longer than all of the conversations I ever had with her combined.  It was probably the best experience of the reunion.

I should probably clarify that I have no regrets and consider myself to be very fortunate.  All of these thoughts about the past don't cause regret - but there is often that feeling that you get when you go back to your home town for the first time. You see things in a different light.  You realize that you can't go back to the way things used to be. These thoughts have continuity with the present and the future.

At some point in the drive, I do a memory check.  I use the autobiographical memory test format and think of famous movie stars, visualize their image, and try to match names.  So far – so good.

I fantasize - primarily generative fantasies. I first encountered that term in the writings of the late Ethel Persons, MD.  She was an American psychoanalyst I found when I started to research fantasies in the 1990s.  She seemed to be one of the few psychiatrists writing about it. Generative fantasies are primarily problem solving fantasies that are more stimulating than coming up with lists in your head or your software. As I type that I am reminded of another road trip (east of Duluth on Hwy 2) when my wife asked me: "Do you ever have fantasies?' I told her I was fantasizing right at that time and she was very interested in the content. "I was thinking about what it would be like to win the men's 500M in the Olympics." She knew immediately that I was thinking about speedskating. I took up speedskating during residency and got quite good at it in my 40s. I was never an elite speedskater by any means, but I had the movements down, could endure the pain, and skated a lot of laps.  Part of learning the movement had to do with fantasies and thinking about the skaters I was seeing in the Olympics and racing against and remembering any advice I had received. I always have plenty of these thought patterns that seem focused on a hypothetical future.

 As a student of consciousness, I always wonder about how all of these thoughts are generated and (as a psychiatrist) what they might mean. Twenty years ago, I did a presentation on what I called the bus theory of the human brain. In computers, a bus is any system that connects components and allows data transfer between those components.  I decided that there was not enough emphasis on white matter and studied those tracts, their fiber content, and tried to calculate the bandwidth of those fiber tracts. At about the same time, I was wrapping up a course that I taught for many years on dementia diagnosis and cortical localization that was more of a behavioral neurology approach to the problem.  I tried to think of all of the recent papers I had pulled on hippocampal connectivity and recent papers on the neurochemistry of the hippocampus.  I thought about a paper I recently read on entropy and consciousness and whether thermodynamics could be a granular explanation for conscious states.  I am still a skeptic.

My wife wakes up.  We are driving home from her high school class reunion. There is a significant celebrity in her class and he sent a video when he could not make the reunion. The audio-visual equipment did not work, but we could see his projected image. We start to talk about the events of the night and what some of them might mean.  We talk about the A-V problems and the celebrity who clearly has become a projective test for everyone in her class. We talk about how good it will be to get back home and what we will need to do to reestablish the routine.

Thinking is a big part of life for me and life is very good…..

 

George Dawson, MD, DFAPA  

 

Photo credit for this one goes to my wife.  That is a Tomorrow River sign shot alongside Highway 10 last weekend.

References:

1:  Osanai H, Nair IR, Kitamura T. Dissecting cell-type-specific pathways in medial entorhinal cortical-hippocampal network for episodic memory. J Neurochem. 2023 May 30. doi: 10.1111/jnc.15850. Epub ahead of print. PMID: 37248771.