Telepsychiatry - Day One

These are strange times.

For the past several years I have attended seminars on telepsychiatry. In Minnesota, we have an expert who has been doing it for a long time. He talks about the advantages of being an independent practitioner and using your own equipment rather than being a subcontractor. He has a definite method that includes seeing all of his patients in person at least once a year. His practice covers a large area that would otherwise probably not have a lot of psychiatric services. Over the years that I have been going to the seminars, I have thought about private practice and Telepsychiatry. I even looked at a storefront building at a shopping mall and fantasized about starting it up. But I am too close to retirement and there is a thing called tail coverage. That means if you carry malpractice insurance and retire you need to still pay the premium for two or three years into retirement in the event that you are sued.  That was a major deterrent and it seemed like I would just carry on in my current position until I decided to quit. And then the coronavirus and social isolation hit.

The transition to Telepsychiatry rapidly happened last Thursday. I was going about my day when my younger colleague told me that she was switching to Telepsychiatry this week. She encouraged me to get on board. Several people were critical to the effort and I was up to speed on the system by this weekend. I had to confirm that I had the computer power, bandwidth, and dropped frame rate consistent with software. I pulled up my schedule this morning and the main difference I was sitting at home looking at it on my big Mac Pro. I tested the camera and microphone. It produced a good image of me sitting in my home office and I was ready to go. What followed was a big glitch and some realizations about the visual aspects of psychiatry.

An initial series of emails let me know that the visual feed was not working. That essentially took out the software and as a replacement I was supposed to do telephone interviews. Hoping that they could get it up and running I moved the first patient new evaluation to the last slot in the daytime. There was some suggestion that only follow-ups should be seen as telephone interviews. I was concerned that patients would have to hold the telephone receiver for 45 to 60 minutes but was reassured that it would all happen over speakerphone. The locations were all secure and managed by our clinical administrator. When it became apparent that the visual feed would not occur I started doing new assessments and follow-ups strictly on the telephone.

In retrospect I found myself myself in an ironic position. For years I studied telephone switching both as a high-tech investor and as electronics hobbyist. I eventually got involved in communications theory. The engineering version of communications theory is highly technical and interesting but I have never been able to apply it to the clinical interview. The clinical interview is an exchange of information. There is always a certain noise level that varies significantly from person to person. That noise can occur strictly on the information being exchanged or various emotional levels that can add or subtract from the overall noise level. A good example would be a person who brings a lot of biases into the interview. As an example, I have had people slow the interview down or bring it to a halt just based on my physical appearance and how it was interpreted. Some of those people would be very explicit in telling me they could only work with a psychiatrist who had a certain religion, philosophical bent, or political affiliation. There was often speculation, that I did not meet the preferred categories. Interviews done without the visual channel, removed those factors.

I dictate all my valuations and follow-ups and have done that most of my career. Critical parts of what has become known as the Mental Status Exam are dependent visual assessment. A few examples of common bullet points include:

Appearance: I comment on whether the person appears to be alert, interactive, their overall grooming and hygiene, their eye contact and social demeanor. Where it applies I also comment on whether they appear to be intoxicated, distracted, potentially delirious, and in some situations whether they realize I am in the room with them.

Psychomotor: Hyperkinetic and hypokinetic movements and possible movement disorders need to be described. Psychomotor agitation and retardation as well as motor restlessness also need to be commented on. It is about a 40 foot walk to my office and the person’s gait also needs to be described.  Gait analysis is useful because of the association with dementias, neurological disorders, and medication side effects. It is also useful in assessing chronic pain patients. The commonest acute pain disorder I notice is gout due to its high prevalence in men of all ages. Specific movements require additional examination in some cases rating scales. For example if tardive dyskinesia is noted and AIMS (Abnormal Involuntary Movement Scale) can be done to determine a baseline score. There are additional rating scales for Parkinson’s, akathisia, tics, and dystonia.

Affect: Psychopathologists like Sims have pointed out the subtle differences between affect and mood. In his text for example he describes affect as “differentiated specific feelings directed toward objects”. Mood is described as “a more prolonged prevailing state or disposition”. He comments that both terms are used “more or less interchangeably”. Modern use is much more basic and it has to do with direct observation of the patient’s emotional expression, the specific context, and whether or not it may be consistent with an underlying phasic mood disturbance.  A common error I notice in many descriptions is that the time domain is omitted - people never seem to comment on the affective state over the course of the interview or the fact that the patient's affect appears to be completely normal - despite the assessment being done for a mood or anxiety disorder.

If you are interviewing people by telephone rather than Telepsychiatry, you don’t have access to any of those three critical domains as well as other parameters that might be important. For example, vital signs, focal physical examination, and the overall determination about whether or not a patient may be physically ill or critically ill just based on their appearance.  There is also a pattern matching aspect to psychiatric diagnosis. After psychiatrist has evaluated hundreds or thousands of patients, certain patterns are evident that can facilitate diagnosis. The most obvious one is delirium. It has always been a mystery to me why that diagnosis is so difficult for a lot of people to make. Once you have seen a few delirious people, the pattern seems obvious. Other findings are much more subtle. An example might be a patient appears to be in pain but also does not want to disclose the source of that pain. It could be a self-inflicted injury or injury from intimate partner violence. Those findings would be very difficult to pick up over a telephone interview.

A couple of examples come to mind when I think of critically ill patients who did not come to see me because they were critically ill. The first was a patient who looked the whitest I had ever seen a person. I asked him if he was physically ill and he denied it. I asked him about possible causes of blood loss and that was also denied. He did eventually allow me to order a complete blood count. I got the results back his hemoglobin was extremely low and when I called him - he did acknowledged some symptoms of G.I. blood loss and agreed to go to the emergency department. He was subsequently found to have a gastric ulcer. In another case I was talking with the patient appeared to be physically ill. He seemed to have some abdominal distress. He allowed for a limited exam of his abdomen and appeared to have right upper quadrant pain and tenderness. He was also referred to the emergency department and had acute cholecystitis and required surgery. Both of these scenarios depend on how the patient actually looks to the psychiatrist and that is why the visual presentation is so important.

Many people think that psychiatry is an exchange of words. A common myth these days is that these words allow people to be grouped into diagnoses based on other sentences and phrases. A discussion between two people is always much more than that. When a psychiatrist is in the room the discussion is between two people one of whom has memories of tens of thousands of important patterns and findings that mean something. A significant number of those patterns are visual rather than strictly verbal.

I have lost count about how many times a rapid visual diagnosis played a critical part in the diagnostic process. When I see a patient with serotonin syndrome or neuroleptic malignant syndrome or malignant catatonia - I am not running down the diagnostic criteria in my head. I am thinking that they are critically ill probably have a specific diagnosis - but I have to get them somewhere fast where they can receive the necessary supportive care while that diagnosis is clarified and treated. Most of that is a visual process based on what I have seen in the past. In most cases, the diagnosis occurs in seconds to minutes.

I thought the telephone interviews went well. My notetaking was as intense as ever. I am looking at an average of about six pages of handwritten notes that I base my dictations on. But I know the process can be much better. Telepsychiatry is superior to telephone psychiatry, and I hope to find out how close it is to a face-to-face interview.

Hopefully that visual feed will be there tomorrow.

George Dawson, MD, DFAPA

How To Survive Social Distancing If You Are An Exercise Fanatic

This is an interesting topic from a personal, practical, and consciousness level. I came by some of this knowledge the hard way and hope to pass that along to people who can benefit from it. I also hope to reach the people that are thinking right now “I can make the best of staying at home by only eating between 2 PM and 9 PM, increasing my resistance workouts, and doing more intervals or HIIT (high-intensity interval training)”.  You might be able to but there are some precautions along the way.

A couple of high points from my experience. About 10 years ago, I was out on the local speedskating track. I had just started warming up and noticed my heart rate monitor was at 160 bpm. I did not see that is being out of the ordinary and after another couple of laps my monitor started chirping away. The display read 240 bpm. There was also a warning light. I checked my carotid pulse and sure enough I was in atrial fibrillation. That began a 10-year saga of cardiac ultrasounds, stress tests, episodes of anticoagulation, cardioversion, and antiarrhythmic therapy. The ultimate diagnosis was lone atrial fibrillation. In other words, atrial fibrillation from no known structural cause. The likely cause was long periods of time of running my heart rate way beyond the maximum recommended heart rate for a guy my age.

Even before that I was out speedskating on the roads when I went down and ended up with a large abrasion over my left lateral thigh. My first thought was whether I should cover it with something. It was a clean abrasion that I had washed thoroughly and immediately and it looked good.  Over the next several days it no longer looked good and was clearly infected. In the emergency department was given an intramuscular injection of cephalexin with a number of capsules to take home.

Both of these scenarios highlight the fact that exercise related injury can lead to treatment in the ED (emergency department). During the time of a pandemic you do not want to end up in an emergency department. So the first lesson here is to avoid extremes and also high risk scenarios where you could end up with an abrasion, a cut, head trauma, fracture, a sprain, or any other sports injury that needs acute medical attention. I think there are practical ways around that but it also takes addressing the exercise fanatic mindset.

1.  Avoid the gym:

I can only speak for what happens in the men’s locker room but hygiene at the gyms I have been in is atrocious. It is the primary reason I stopped going to gyms even though my wife encourages me to go to her gym on a regular basis. There is also the problem of risky behavior. I got tired of seeing personal trainers trying to kill novices with some absurd exercise routine, the roid rage folks threatening one another, and having to intervene in order to prevent serious injury. You can only advise that teenager with a loaded barbell resting on his cervical spine that it is not a good idea so many times, before you get known as the old white guy who is a know-it-all.  Luckily many governors and mayors have shut these facilities down as a transmission risk.

2.  Maintenance not maxing out:

Most exercise fanatics collect a lot of data on their favorite exercise routines. You can certainly do it with smart phones and activity monitors these days but a lot of us also automatically keep track of reps, times, and maximums. For example on a day-to-day basis I can predict my maximum number of push-ups, pull-ups, back extensions, bicep curls, max power output on my ergometer, and max road speed on a bike. When you think like an exercise fanatic, you are always thinking about how to maximize those numbers. That also happens to be the periods of likely injury. I naturally hit a wall at about age 55. Up to that point I thought it was indestructible in terms of exercise tolerance. After that point, I questioned why I had been so foolish and not adhered to some basic rules like maximum heart rate.  First and foremost don’t push it like you are 20 when you are 40 or 50. Secondly, don’t push it to high age-appropriate levels when there emergency services are limited by a pandemic and you don't want to be an additional burden on that resource.

3. Avoid the typical Internet suggestions:

During this period of social isolation there are any number of exercise sites advising you on how to stay fit outside of the gym. They range from exercises that focus on specific body regions to replacing exercise equipment with everyday household items. Keep in mind that doing reps with a gallon of milk or a can of paint is not like using that Cybex machine at the gym. The biomechanics are completely different and even the grip can result in injury. Don’t take innovation too far when it comes to exercises that you are used to doing in a specific range of motion on well-designed equipment. Even mimicking that young aerobics instructor video and she does various leg extensions can be a problem. Start out with very few repetitions to make sure it is safe before you try the whole workout.  Even then there are exercise that are not appropriate for certain ages or injury patterns. Many athletes have learned this over a number of years from their physical therapist. Don't ever ignore the advice of a physical therapist. 

4. Stop immediately if you are hurt; don’t exercise until the pain is long gone.  If it doesn’t go you need an assessment.

Repetitive stress and overuse injuries are common with aging and you have to overcome the propaganda that you heard in high school or your early 20s that all you have to do is “shake it off” or that pain is somehow therapeutic. I first noticed significant knee pain when I had to carry a floor sander up three flights of stairs. It weighed about 250 pounds. I remember thinking as I went up that stairway: “It feels like my knees are going to blow out at any time”. I was about forty years old. By paying close attention to that feeling I have been able to preserve my knees for another 25 years. During that time they have served me well with thousands of miles of cycling and speedskating. I pay close attention to that joint stress perception when I am weightlifting or even doing push-ups or pull-ups. I plan to avoid any of those situations during the pandemic social isolation.

These are a few tips to avoid injury and needing medical care during a pandemic. To most people they are obvious. To exercise fanatics they may not be.  Being an exercise fanatic is an interesting conscious state. Reality testing is intact to a large extent. As an example I would never think that I could skate in the Olympics or cycle in the Tour de France. At the same time my personal goals were probably unrealistic for men my age and yet I reached many of them. The part of my reality testing that was not intact involved the basic denial of the aging human organism. For example, I recognized in a nick of time that my spine could probably not tolerate lifting large amounts of weight anymore. As we age, intervertebral discs degenerate and in many cases disappear. Osteophytes form. The old human spine is a lot less stable then the young human spine. That has implications for maximum load whether that load is a stack of weights or running.

I used to think that men were particularly prone to the exercise fanatic mindset but since then I have encountered many women with the same biases. A significant number of them continued to exercise when they were injured and ended up with permanent disabilities. Women may be more likely to be told that their exercise is “an addiction” because of the over exercising associated with an eating disorder diagnoses. They have that bias to live with that men generally do not.

Stay fit during this time by staying with what you know, taking it easy, and avoiding injury. If you are an exercise fanatic this is the wrong time to be pushing your limits - and you might ask yourself if there is ever a right time.  Even as a novice it is the wrong time to jump into a rigorous program because there is somebody selling it on the Internet and it looks good.

George Dawson, MD, DFAPA

The First Case Report - Implications For Coronavirus Conspiracy Theories

At the time of this writing I have encountered at least three coronavirus conspiracy theories.  The American version goes something like this. The current pandemic resulted from a leak from a Chinese bioweapons laboratory. The supplementary information generally talks about how these particular bioweapons labs are not very secure and leaks are common. The Chinese version has a human twist and it involves a visit to China by 300 US military athletes. The suggestion is that these athletes intentionally introduced the virus or inadvertently passed the virus to the Chinese population. There is an Iranian version - suggesting that the virus is basically an American bioweapon.  There are various embellishments. Prominent politicians are involved in restating these conspiracy theories. I have been reading about bioterrorism for the past 20 years and would dismiss these theories as being implausible from a technical perspective. From a political perspective, it makes perfect sense to me that politicians will always try to look for a way to deflect any responsibility. One of the most common ways to do that is to blame an adversary - especially one that might be unpopular with the majority of citizens.

The report of the first case of coronavirus in the US is a rare opportunity to end all the conspiracy theories with real evidence. I do realize that conspiracy theories are not generally refutable by facts.  This post is directed at those who can incorporate factual information into their worldview. There has been a lot written lately about distinguishing opinion from fact, including the results of a standardized international test suggesting that American students may have some deficits in this area.

Detailed case report in the New England Journal of Medicine is interesting from a number of perspectives.  The patient is a 35-year-old man walked into an urgent care in Snohomish County, Washington on January 19, 2020 the four-day history of cough and “objective fever”. He had returned from visiting relatives in Wuhan, China. His health history was basically unremarkable. Initial vital signs showed a temp of 37.2°C, BP of 134/87, and pulse was 110 bpm. Restaurant rate was 16 breaths per minute and O2 sat was 96% on room air.  Initial viral screen for influenza a and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and for common coronaviruses was negative. The CDC was contacted and samples were collected for 2019-nCoV. The virus was confirmed one day later.

The patient had been discharged home but after 2019-nCoV was confirmed he was admitted to an airborne isolation unit for observation. The clinical course is described in the figure below that is taken from the original paper (with permission). The symptom course before the admission date of January 20 is estimated on the diagram. I think it is instructive to note that cough preceded the development of a low-grade fever on day five of 37.9°C or 100.2°F. The patient also had fatigue nausea and vomiting before the development of fever.

Laboratory findings over the course of the illness are presented in the original article and six blood samples did not show any marked abnormalities. He had mild elevations of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase. Blood tests were done due to fevers and they showed no growth.  Chest x-ray on day 9 of the illness showed left lower lobe pneumonia that correlated with decreased O2 sat down to 90%. At that time he was put on supplemental oxygen. It is also treated with vancomycin and cefepime for presumed hospital acquired pneumonia. On day 10, based on his chest x-ray, the need for supplemental oxygen, and reports of the development of severe pneumonia is physicians decided to treat him with an investigational drug - remdesivir. By day 12 he was clinically improved and no longer needed supplemental oxygen. His oxygen saturations were normal on room air. As seen in the diagram, is always symptoms at the time were a cough and rhinorrhea.

Contrary to the conspiracy theories, this paper points out that the Chinese researchers shared the full genetic sequence of the 2019-nCoV in the National Institutes of Health GenBank Database and the Global Initiative on Sharing All Influenza Data (GISAID) database. 

The authors emphasize at the time of this writing that the full spectrum of clinical disease is undetermined. Transmission dynamics are also undetermined because the patient had not visited the seafood market in Wuhan or had any contacts with known cases in China. They list several complications noted in the Chinese population including acute respiratory distress syndrome, severe pneumonia, respiratory failure, and cardiac injury. There are several radiographs on Twitter suggestive of significant lung injury and at least one report of myocarditis in a significant subset of patients. The authors also point out that the patient is nonspecific symptoms prior to the onset of pneumonia were consistent with the number of common respiratory viruses. In differentiating this illness travel history, the decision by the patient to seek treatment, and a coordinated effort among public health officials led to the timely identification of the virus. I would add that this case report also shows the clear need for clinical expertise as the illness transforms from what appears to be a typical respiratory virus to pneumonia. The question that needs to be asked is whether that level of expertise is available everywhere in the country.

Addressing the threat of emerging infectious diseases requires a public health infrastructure and cooperation across many countries with their own political interests. Many those countries may have public health officials that are cooperating with one another, but politicians who may decide to use a pandemic for their own interests. With most countries engaged in significant quarantine efforts at this time, clear cooperation among world leaders in stopping this pandemic is urgently needed.

George Dawson, MD, DFAPA

References:

1: Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, Spitters C, Ericson K, Wilkerson S, Tural A, Diaz G, Cohn A, Fox L, Patel A, Gerber SI, Kim L, Tong S, Lu X, Lindstrom S, Pallansch MA, Weldon WC, Biggs HM, Uyeki TM, Pillai SK; Washington State 2019-nCoV Case Investigation Team. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020 Mar 5;382(10):929-936. doi: 10.1056/NEJMoa2001191. Epub 2020 Jan 31. PubMed PMID: 32004427.



Permission:

Figure 2 above is from the original article in reference 1 - with permission from the Massachusetts Medical Society.  License date is March 16, 2020 - license number is 4791120888948 for 12 months from the date of the license. 

The Pandemic Report From Beam Avenue

It was my day off yesterday but I have been looking at a “need maintenance” light for the past four days. I had to leave the house for car maintenance. Given the pandemic status this would be a whole new trip. Even though Minnesota does not have a lot of cases at this time, they are increasing and there is an identified COVID-19 case in a town 5 miles away and a neighbor four houses away with direct exposure to coronavirus in the workplace. My secondary goal during this trip was to take a look at social distancing and the other practical suggestions to contain the spread of this virus.

Beam Avenue is a busy thoroughfare that connects Highway 61 on the west and White Bear Avenue on the east. My Toyota dealer is on the west end of Beam Avenue and 1.5 miles away a popular shopping mall sits on the corner of Beam Avenue and White Bear Avenue. St. Johns Hospital is about half way down and the photo was shot from the sidewalk. Average vehicle traffic in this area is about 17 to 18,000 vehicles per day.

I don’t generally set up appointments for vehicle maintenance. I wait until the light goes off and then I typically drive in and wait. Even though the wait takes 1 to 2 hours, the accommodations for customers at this dealership are excellent. A comfortable waiting area, free cookies, and free coffee. This waiting area is generally very congested due to the high levels of work done at this dealership. It was going to be a challenge to see if social distancing was possible or not.

I pulled into the service area and was greeted by one of the service managers. He took me over to his desk and we started going through all the details. I told him I needed a new battery in my starter fob. He took it from me, pried open, installed the new battery, blew the dust out of both halves of the fob with his own breath, snapped it together, and handed it back to me. We talked about the purpose of this visit specifically oil change and tire rotation. He offered to sell me a new service plan but I told him I was thinking of trading in my current RAV4 for a new one. He asked me what my timeframe was and I told him:

“I want to see this coronavirus thing pans out.”  He smiled at that.

After deciding the course of action he told me it might take one to two hours and I headed into the customer waiting area. I have probably seen more customers there at other times but it was packed, everyone was eating cookies and drinking coffee, and there were few open seats. There are study carrels along one wall. That is where I typically sit and do computer work while I wait. I decided it was a bad idea because there is no expectation that these surfaces would be sanitized. The same would be true of the padded and more comfortable seating in the middle of the waiting area. Appropriate social distancing was not evident and in fact I counted 16 people in the service area that were probably within a 10 foot radius of me. I decided it was a good time for a walk.

Beam Avenue is not the ultimate walking course. There are numerous pedestrian crossings just to get to the main sidewalk on the north side. Several large businesses have entrances across that sidewalk. It was an opportunity to see how many motorists never stop or even slow down when making a right-hand turn at a red light or stop sign. Costco motorists seemed more prone to that maneuver. The problem with the walkway is the intensity of traffic and the associated noise and exhaust fumes. That might explain why during the entire 3 mile walk I did not encounter a single fellow pedestrian. The traffic at 3 o’clock on Friday afternoon was as intense as I have ever seen it.

I got to the mall and walked through the main entrance. All the entrances and exits to the mall had pneumatic sliding doors and that is clearly a plus in terms of virus transmission. As I walked further into the mall those benefits seem to diminish. I came across children who were swarming all over free plastic playground equipment. I also saw kids jammed into moving seats wearing some kind of virtual reality goggles that appeared to be simulating a Star Wars battle. I did not inspect all of this equipment but hand sanitizers were not apparent. The kids all looked like they were having fun - it is probably hard to think about social distancing when you are a parent of young children.

When I got to the food court I was surprised that the tables had been thinned out. It looked like there was about a 60% reduction in the total number. As a result there was roughly 10 to 12 feet between most of the tables-the suggested social distancing interval. The other notable change was that even with fewer tables, there was hardly anybody eating at the food court. There was one long line of what appeared to be high school students who had not been seated. There is also visible housekeeping staff with sanitation equipment and they appear to be interested primarily in the food court area.

The men’s room was disappointing. With all the emphasis on handwashing there should be an expectation that any facility will be adequate for that task. In the men’s room, 40% of the soap dispensers and 60% of the faucets were not working. One of the faucets was totally gone. There was a paper towel dispenser that was empty and two air hand dryers. I had time to discover that I needed to go from sink to sink but if there was any crowding - I am sure it would affect the number of people adequately washing their hands. I headed out the door and back to the Toyota dealer.

When I got back - social distancing remained a problem. The service manager met me in the cashier line and reviewed all of the billing. There are two cashiers with six people in two lines and we were all about 1 foot apart. Nobody was coughing or sneezing. I was able to pay and leave in about five minutes.

On the way home I had to pick up some milk and bread and stopped at one of the major grocery store chains in the Twin Cities. The parking lot was packed. I decided to shop without a cart and avoid any cart contamination. There were hundreds of people in the store many of them very old. The store was well-stocked and the only thing that was missing was the toilet paper and paper toweling. A woman in front of me laughed very loudly when she turned the corner and saw that there was about a 50-foot section of shelving completely empty where these paper items had been. I grabbed the milk and bread and headed to the self-checkout line. Six people in line again to get to the touchscreen checkout computer. I checked out got in my car and used a liberal amount of hand sanitizer. I had also used outdoor gloves to negotiate doorways at the car dealership.

On the final drive home, I was thinking about how social distancing was absent in most of the scenarios I encountered. Vehicle and foot traffic were heavy and there was plenty of congestion.  What will it take to get people to stay home and out of public spaces? Some commentators have said that inconsistent messaging is a big part of it. Declaring a pandemic a political hoax one day an actual public health emergency the next day doesn’t work. Today I read three different conspiracy theories on COVID-19 as a bio weapon that was either deliberately used by the United States or China or inadvertently escaped the Chinese bioweapons lab. None of those theories appears to be consistent with what really happened. I was watching a celebrity news program and saw a caller say that the only time he took the pandemic seriously was when he learned that Tom Hanks and Rita Wilson had contracted the virus.

I started to think about why I take it seriously. I worked on two different Avian Influenza Task Forces about 15 years ago. It was a significant effort. One of the main concerns was surge suppression or preventing emergency departments and other resources from being overwhelmed by people who thought they had the disease. There is actually a program called Psychological First Aid where mental health professionals train volunteers to counsel these people and direct them away from emergency departments. I was a trainer for this course. In our meetings there was always a vague discussion of what would actually happen in hospitals if they were overwhelmed by patients with avian influenza.  In some of those discussions we would see a PowerPoint slide of a pallet loaded with Tamiflu at some Air Force Base. We were reassured that in the event of a local epidemic- that medication would be made available. The specifics about negative pressure rooms, ventilators, workflow, and manpower requirements were never really discussed. The current strategy for coronavirus of slowing the infection rate by social distancing and quarantine was also not discussed. At some point it was apparent to me that if avian influenza pandemic occurred, we would be making it up as we went along. I had studied several of these epidemics and had concerns about surge suppression especially in a highly infectious situation.

There appear to be some common errors that are made along the way when considering that pandemics are not only possible but likely. The first one is analyzing the situation according to a particular political bias. This is a very common mistake these days even though it clearly doesn’t work. Contradictory information in addition to those political biases amplifies the problem. Independent of political bias, it takes the ability to imagine that a pandemic is possible. That approach can be historical, biological, medical or mathematical. Any one of those disciplines can provide the necessary knowledge base. There are concerns today that in the era of social media dynamics – every one is an expert at the rhetorical level. The signal of real expertise is lost in the noise of grabbing for celebrity and the associated benefits. Self-selection leads to all of the adherents of a common belief isolating themselves in one little area on the Internet. That leads to the expected cognitive biases but also the illusion that life can go on as a member of an isolated group with no role in greater society.  Pandemics directly confront that denial.

I did see some bright spots on Beam Avenue today, but not many.  Vehicle and foot traffic is heavy and social isolation is a problem in high congestion areas. If people are expected to wash their hands frequently – washrooms need frequent attention and repair. The focus on cancellation of mass sporting and entertainment events is useful, but day to day sources of possible contamination need attention – especially when there are clearly identified cases and exposures in the area.

People need to stay home unless travelling to congested areas is absolutely necessary.  It is the best way to prevent the severe measures being taken in some countries right now and get through this.

George Dawson, MD, DFAPA

The Best Advice I Got In Medical School

It has been a long time but when you get to be an old man you can obsess about what you currently know, what you used to know, and how you got here.  I got some life-changing advice as an undergrad but not much good advice in medical school or residency. I can say without a doubt, the best advice I got was:

“If you are sure you are going into psychiatry, take as many medical electives as you can. Don’t take any psychiatry electives because you will be doing that for the rest of your life.”

I did not have to think too much about it because I enjoyed most aspects of medical education and training. The only two negative rotations I had in my training were based primarily on the staffing patterns at the time and they were not major medical or surgical rotations. They also did not seem to be very interesting. Practically all of the medical and surgical residents I worked with were outstanding in many ways. I felt like an integral part of the team and I was happy to do the necessary work.

As a result of the advice I took endocrinology, cardiology, renal medicine, allergy and immunology, neurology, infectious disease, and neurosurgery in addition to the required general medicine rotations. I took a little flak from the Dean. There was some concern that there were not that many spaces available in medical electives. At one point it was suggested that I should limit myself to two or three medical electives. I prevailed and got what I wanted largely because the specific rotations were at a public hospital and the local VA hospital. 

One of the aspects of medical training that is not discussed enough is camaraderie. When you are a medical student, your role is often ill-defined. The role generally depends on the staff you are working with, the institution, and the general culture within the medical school. At the hospitals where I spent most of my time medical students were an integral part of the team. On day one – you are assigned patients and admissions. You were expected to report on patient progress and write progress notes. You learn communicate with everybody in the hierarchy ranging from the intern to the resident to the attending physician. You are supposed to learn how to research and study the specific problems that your patients had and in some cases do a special report. Examples would include a chart review I did on gram-negative meningitis at the VA medical center and presentation on anaphylaxis on my allergy rotation at Milwaukee County Hospital. Both of those studies went extremely well.

But camaraderie is more than knowing the chain of command, hospital systems, and how to get the work done. A key component is the educational quest that everyone is on. Doing rounds with five or six different people at all levels of training ranging from novice to world expert is experience that you don’t get in many places. Some of the results can be stunning. I did a consult on a patient with possible spontaneous bacterial peritonitis (SBP). I wrote up the consult form and prepared to present to the attending physician that afternoon. When he walked in the room from about 10 feet away, he asked everyone else on the team what the problem was with the patient’s leg. I had been focused on abdominal, systemic, and laboratory findings. Nobody could answer the question. The attending physician who happened to be an expert in streptococcal infections, pointed to a rosy rash on the patient’s left shin and suggested that it was a form of streptococcal cellulitis. He did the necessary tests to confirm that diagnosis at his lab.  One of the many processes that must be attended to in these rounds is the pattern matching aspects of diagnosis. It was vaguely implicit in my training and I realized only later when teaching a course in avoiding diagnostic errors - that these rounds are the place to ask experts: “What are you seeing that nobody else is?” All experts including psychiatrists recognize certain patterns and can make more rapid and more accurate diagnoses than people outside their specialty.

A lot of people reading this may have a hard time believing that what you learned in medical school is relevant to a specialty that you practice your entire life. After all - aren’t these specialties updated at some point and doesn’t your knowledge base become dated? It is surprising how the basic approach to the patient that is unique to each specialty does not change much. There is still relevant review of systems, specialty specific diagnoses, and laboratory testing. Working with specialists for even a month gives medical students and residents a clear idea of how to approach patient problems in a systematic manner. Even though there have been radical changes in some specialties like cardiology, most medical specialties change slowly at the mechanistic level typically with some pharmacological innovation. A clear example relevant to psychiatrists is the endocrinology of metabolic syndrome and diabetes mellitus. Over the course of my career that has resulted in increasingly complex pharmacotherapy ranging from insulin, metformin, and sulfonylureas to an additional five classes of drugs and more complicated insulin preparations.

A unifying concept that I learned on all those medicine specialty rotations is that it is important to still know about these mechanisms and medications even if your specialty involves another bodily system and you are prescribing an additional treatment. No matter what specialty service I was on there was never the idea that we could focus only on a specific bodily system and ignore the rest. On all of those rotations including neurosurgery, I was often the person focused on what was going on with the patient’s brain.

Learning medicine and neurosurgery on all of these rotations was quite exciting. I am much more likely to retain information if I am excited about it. I was excited right up until 11 PM on the last day of medical school.  I was doing renal medicine at the time and the senior resident was going to be a rheumatology fellow. We finished rounding about 6 PM and he noticed we had 4 or 5 additional consults. He was the kind of guy that you really like working with. He had a great sense of humor and was always engaging. He could even engage an introvert like me. I remember him saying: “Look I know - this is your last day but you could really help us out by doing some of these these consults. The new team is coming in tomorrow and I don’t want to leave all of these consults behind.” He threw in a couple of politically incorrect jokes for good measure and I headed off to do two consults. We came back and met with the attending physician who was considerably older than I am right now and finished them all by 11 PM. I really did not want to say goodbye to that team. But I headed off by foot across the golf course sized county hospital grounds to my apartment on 89^th St.

The knowledge gained in that fourth year of medical school was a springboard for the next 30 years. I continue to read about all those medical specialties and remember what happened in 1982. I continue to research all the medical problems and medicines that my patients are taking. I continue to wish at times that I was still on that renal medicine team back at Milwaukee County Hospital.

I didn’t get a lot of good advice in medical school but for all those reasons the advice about what to do in my fourth year was the best.

George Dawson, MD, DFAPA





Supplementary 1:

Second best piece of advice in med school was from the head of our Biochemistry class in the first year.  Our biochemistry class consisted of lectures and research seminars where we read and critiqued biochemistry research. At one of the first lectures, the department head stated:

"Subscribe to the New England Journal of Medicine and read it."

I have been reading it ever since and that was definitely a good idea.


Supplementary 2:

I did take one psychiatry elective in the last two years of med school - Infant Development and Psychotherapy.  It was taught by two psychiatrists who were very excited about the field Frank Johnson, MD and Jerry Dowling, MD - both Medical College of Wisconsin psychiatrists. We screened infants and very young children at risk especially if they had one or both parents with severe mental illness. We instructed parents on how to interact with their children in order to overcome behavioral difficulties associated with disruption of the infant or child and parental bond.  Every week we had a research seminar where we read relevant papers on the subject.  We had a very large clinic where we did evaluations and saw large groups of parents. It was a very positive experience and has implications to this day.  As far as I know there are no clinics in the US like the one we had in 1982.  It provided a valuable service to infants, young children, and their families.

1: Wesner D, Dowling J, Johnson F. What is maternal-infant intervention? The role of infant psychotherapy. Psychiatry. 1982 Nov;45(4):307-15. PubMed PMID: 7146225.

Medication Checklist-Current Version

I have posted past medication checklists on this blog in the link below will take you to the current version. I developed this over the last 10 years seeing outpatients who have been treated with various psychiatric medications over the previous 5 to 50 years. During a comprehensive evaluation a history of past psychiatric treatment including hospitalizations, past medications, past psychotherapy, and other biological therapies needs to be discussed. Ideally a patient will recall ineffective therapy from the past that can just be restarted. In my current practice setting that is relatively rare. People with chronic mood disorders, anxiety disorders, and insomnia ever happened men treated with multiple psychotherapies and medications. They are typically seeing me because those past therapies have not worked. It is up to me to come up with a newer and safe approach based on my past history.

There are varied responses to the question about what medications have been prescribed in the past. If it has been a long time since the last episode of treatment many people say they can’t recall the name of the medication at all. In some cases people admit that they never really studied the name of the medication, they just took it out of the bottle at the correct time. There are some people who will get a month-long prescription from a physician and never take a single pill. When people have been treated with multiple medications the responses are more varied like “I have taken all of them”, “I have taken all of the SSRIs”, or “I’ve taken all the SSRIs and SNRIs”. Closer examination often shows that many people take anywhere from 3 to 5 antidepressants over any 20-year span. There are people have taken the same antidepressant for 20 or 30 years and wanted it to be changed.

There are many other questions pertaining to best use of medications including diagnostic clarifications. The commonest problem I see is people misdiagnosed as having bipolar disorder and then not treated in a standard way for bipolar disorder. There are also people who have bipolar disorder who do not receive standard treatment. In this era of direct to consumer advertising, many people are treated with aripiprazole or brexpiprazole who would not have been treated with dopamine receptor blocking agents in the past. That opens up an entire new category of potential side effects and comorbidities.

All these reasons make the history of medication use extremely useful in a psychiatric evaluation.  Formal versions of medication history such as the Antidepressant History Treatment Form (ATHF) have been used in research for 20 years as a standard way to document whether or not a patient has received an adequate trial of an antidepressant (dose x duration). This form generally requires collecting a lot of collateral information especially with regard to the dose. Checklist approach I am using is focused on getting the general name and class of the medication. If I think additional information is required I will try to get the necessary collateral information. But generally I am looking for class effects, especially if it is apparent that the patient cannot tolerate a particular group of medications.

Over the years I have been using it this form has been useful. It is essentially like the memory testing paradigm where you proceed from spontaneous recall to categorical recall to list prompts. This is definitely a list prompt but for much larger universe. That is often why I direct people to focus on a particular section of the list. As an example if I am seeing a young person and they have only taken one or two antidepressants and cannot recall the names, I advise them that they can probably find it in the top half of the antidepressant column. The clinical problem can be managed to subsections of the list.

A disclaimer is in order. This list is for the purpose of discussion among clinicians and possible scientific use. It is not been validated from a psychometric perspective. It is not commercial or for-profit like everything else on this blog. There is no guarantee that it will cue accurate memories of past medications. Like everything in clinical psychiatry, collateral information-in this case from pharmacies is the gold standard. Apart from its clinical use, this list can also function to illustrate the universe of medications that are applied to psychiatric disorders. There can be useful for trainees and since this list is updated, anyone who wants to take a look at current FDA approved medications. The list is generally compiled for convenience. I wanted all the medications to be listed on a single sheet - front and back. I wanted the list to be easily readable even by geriatric patients. I wanted the list to be disposable - in many cases the patient wants to take it with them in order to do future research.

That brings me to the topic of research. Most medical centers have been are large electronic health records for about 20 years at this point. Those EHRs vary significantly in their research capabilities. The obvious study of a list like this would be to see how accurate patients can recall their medication history spontaneously and with this list or a something similar. Optimal membership on the form can also be debated. I eliminated tiagabine from the anticonvulsant section as a misadventure in the treatment of anxiety from about 20 years ago. I did that in order to make room for beta-blockers and orexin antagonists. A colleague pointed out that I don’t have the old amitriptyline-chlordiazepoxide or amitriptyline-perphenazine combination medications. I started practicing over 35 years ago it was extremely common to see those medications being prescribed and thankfully that does not happen anymore. Some of the older medications on the list are of historical interest but also because older patients may have taken them.

The list can be downloaded from the link below. Let me know what you think in the comments section. Please restrict those comments to the utility of this list.

George Dawson, MD, DFAPA

References:

1: Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62 Suppl 16:10-7. Review. PubMed PMID: 11480879. Full Text

Medication Checklist:

Download

Adventures In Vaccine Reactions

This area of erythema appeared on day 3 - only on the arm where the Pneumovax was placed

This post is about vaccinations for old people.  It is a mix of science and anecdotes because that is all there is out there right now. A lot of the information I elicited by posting my experience getting the Shingrix Zoster Vaccine and the Pneumovax 23 Vaccine. It illustrates the concept of biological heterogeneity that I post about on this blog. Many people can seem confused about that, particularly the idea that practically every biological system in the human body has significant heterogeneity and the immune system is no exception.

I don’t work on Fridays anymore so last Friday afternoon I headed down to a primary care clinic to get some problems checked out. The primary care doctor was clearly knowledgeable, reassured me that I had no major problems, and asked me if there is anything else that he could do for me. At that point the conversation went something like this:

Me:  “Well I keep being told every other visit that I need a second Pneumovax vaccination and I need the second Shingrix vaccination. Is it possible get those today?”

MD:  “That should not be a problem”

Me:  “Is there any problem with getting them on the same day?”

MD:  “No you can get them both on the same day.”

At that point he pulled up the EHR and verified that I had a Pneumococcal Conjugate Vaccine (PCV13) on 1/11/2016 and a Pneumococcal polysaccharide vaccine (PPSV23) on 9/8/2010 and a previous Shingrix vaccine on 10/30/2019. He explained the rationale for the second PPSV23 vaccination.

MD: “Did you have any reactions to the first vaccinations?”

Me:  “Just a little pain at the injection site but nothing major.”

The nurse came in the room and asked me if I wanted the shots in the same arm or different arms.  She gave me the Shingrix injection in the left arm and the PPSV23 injection the right arm. I noted the time was 2 PM.  I have a history of anaphylactic reactions and an anaphylactic reaction to a second dose of anti-rabies duck embryo vaccine when I was in the Peace Corps. I forgot to bring an EpiPen, but there is a coffee shop just down the street. I spent an uneventful 40 minutes there (to get through that window) and then headed home.

About six hours later I started to get more intense muscle pain in both arms that eventually extended into the back and down the back. A short time later I started to get a headache. By 9 o’clock that night I was taking acetaminophen for those symptoms. I also noted that I was feeling physically ill and fatigued. The next morning I did not feel any better and continued to take the acetaminophen and added naproxen.  By 1 o’clock the next day - nearly 24 hours after the injection I started to get intense chills. It took my temperature and it was normal. I had put on outdoor clothing and sat next to the fireplace. I was shaking. It reminded me of when I had malaria back in 1975. In those days I had a cheap sleeping bag and crawled into that but eventually crawled across the floor into a tub of hot - water dragging the sleeping bag with me.  I had better resources now. I developed some tachycardia and felt very physically ill until about the 60 hour mark. At that point the chills stopped and the tachycardia resolved.

In the meantime I had solicited a number of medical and nonmedical opinions. One of the best internists I know told me that he advises patients take Shingrix vaccination but that they should plan on being out of commission for 2 to 3 days. He also does not recommend any other vaccinations with it because of the severity of the reaction. Several other primary care physicians have given me similar advice. I posted my experience on a listserv for psychiatrists and my Facebook site and several people had similar experiences. The physical illness caused by the immunizations was intense enough to take sick leave from work.

When I left the doctor’s office I was given “Vaccine Information Statements” that were both CDC documents.  One was entitled “Pneumococcal PolysaccharideVaccine - What You Need to Know” and the other was “Recombinant Zoster (Shingles)Vaccine: What You Need to Know”.  For the shingles vaccine the risk of reaction to the vaccine was listed as mild to moderate arm pain in 80% of people and side effects that prevented 1 of 6 people from doing regular activities that included fatigue, muscle pain, headache, shivering, fever, stomach pain, and nausea. The side effects were supposed to resolve in 2 or 3 days. By comparison the pneumococcal vaccine states that “less than 1/100 people develop a fever, muscle aches, or more severe local reactions”.

At a theoretical level it is interesting to consider the differences between both vaccines. In order to generate an immunological response, vaccinations need to create inflammation at the injection site. That typically requires an adjuvant. Adjuvants like aluminum compounds result in local cell death that leads to release of IL-1 family cytokines and danger-/damage associated molecular patterns (DAMPS). That in turn leads to T cell response and immunity (3). 

The adjuvants for these vaccines are significantly different.  The PPSV23 adjuvant is a standard alum based.  The Shingrix adjuvant is an ASO1_B that is described as “ f 3-O-desacyl-4’-monophosphoryl lipid A (MPL) from Salmonella minnesota and QS-21, a saponin purified from plant extract Quillaja saponaria Molina, combined in a liposomal formulation. The liposomes are composed of dioleoyl phosphatidylcholine (DOPC) and cholesterol in phosphate-buffered saline solution containing disodium phosphate anhydrous, potassium dihydrogen phosphate, sodium chloride, and water for injection.” By comparison Zostavax the original shingles vaccine was live attenuated varicella-zoster virus without an adjuvant.  The Zostavax vaccination is much less effective, leading the CDC to recommend both doses of Shingrix, even if there is a significant non-allergic reaction to the first injection. 

Flu-like symptoms are an area great interest to me into a large extent they are cytokine mediated.  The top flow sheet at this post gives common cytokines that can cause flu like illness.  Given the complexity and sheer number of cytokines the scope of inflammatory cytokines triggering these reactions is not known.  Of the known cytokines from the Shingrix inflammatory reaction (4) it is likely that IFN- γ is a cause. The other interesting aspect of this response is that it is hypothalamically mediated.  The preoptic anterior hypothalamic area (POAH) has networks for heat production (shivering) and dissipation (vasodilation) (5) and both were affected in my situation. This area is described as being sensitive to a number of compounds including cytokines.  Other  cytokines may explain the associated flushing and sweating.

At the time this was posted I have been seen in the Urgency Room last night because my health plan was concerned about tachycardia and flushing.  The ED doc thought it was all a post vaccine reaction and did not do any further testing.  He said to come back if I got a rash, bloody urine, or a temp of 100.5.  I had the chills for about 8 hours at that point. I went to bed at midnight and woke up at 3AM sweating.  By 7AM, the tachycardia and flushed sensation and appearance were gone. Things were going well until this afternoon when I noticed the redness on the arm where I had received the Pneumovax (see photo).  I was seen in Urgent Care this time.  They had an alternate explanation for the inflammatory response, if the needle is withdrawn too quickly some of the vaccine and adjuvant gets deposited in subcutaneous tissue and leads to a broad inflammatory response.  They recommended an antibiotic (cephalexin) and prednisone just in case. I declined the prednisone and could not get the antibiotic filled anyway.  The pharmacy I use closes at 7PM and I got out of Urgent Care at 7:07.

What are the lessons from this adventure in vaccinations?  First off, as I have said repeatedly on this blog there are no guarantees in medicine. Everything is a probability statement.  In the case of Shingrix, I am taking a vaccination that may be 90% effective in preventing shingles but the trade off is that in clinical trials as many as 1 person out of 6 gets disabling side effects for at least 2-3 days. I have heard from some people where it lasts for 10 days.  Second, even though those are significant side effects shingles is potentially far, far worse. In the people I have treated, that includes months of disabling neuropathic pain, eye complications, facial nerve complications, and in some cases extensive testing just to find out what the problem was.  As an example, a 79 year old man had extensive testing for severe abdominal pain that was thought to be a malignancy that was ultimately diagnosed as shingles.  In the case of Pneumovax it is pneumonia, meningitis, sepsis and death. Case closed.  My memorable case there was an elderly patient who presented to the emergency department with "agitation".  As the intern on Neurology I was called to see her.  By the time I arrived she was unresponsive.  Upon examination she had pus running out of her ear and nuchal rigidity. A lumbar puncture showed pneumococcal meningitis.  She survived a complicated course including acute respiratory distress syndrome (ARDS) but became completely deaf from the meningitis. Third, it is probably reasonable to not get both vaccinations at once. The physicians writing to me at this point have all been affected by complications they have seen in their patients who got Shingrix and they have seen it as a vaccine that has more than the ordinary amount of adverse effects compared with typical adult vaccinations.  Finally, what about the issue of repeat Pneumovax vaccinations?  It only comes up in cases where a person has COPD or asthma (me) and gets a vaccination before the age of 65 on that basis. Clearly, the arm rash here seems to indicate more of an inflammatory response on the Pneumovax side than the Shingrix in my case. Was it because of a robust antibody response after the initial vaccination?  I don’t have the answer to that question but if there are any immunologists reading this post – I would be very interested in your comments.

That is it for now.  Hopefully I am heading into work tomorrow morning.


George Dawson, MD, DFAPA




References:

1.  SHINGRIX (Zoster Vaccine Recombinant, Adjuvanted), suspension for intramuscular injection.  FDA Package Insert   https://www.fda.gov/media/108597/download

2.  PNEUMOVAX® 23 (pneumococcal vaccine polyvalent) Sterile, Liquid Vaccine for Intramuscular or Subcutaneous Injection.  FDA Package Insert  https://www.fda.gov/media/80547/download

3.  Muñoz-Wolf N, Lavelle EC. A Guide to IL-1 family cytokines in adjuvanticity. FEBS J. 2018 Jul;285(13):2377-2401. doi: 10.1111/febs.14467. Epub 2018 May 3. Review. PubMed PMID: 29656546.

4. Cunningham AL, Heineman TC, Lal H, Godeaux O, Chlibek R, Hwang SJ, McElhaney
JE, Vesikari T, Andrews C, Choi WS, Esen M, Ikematsu H, Choma MK, Pauksens K, Ravault S, Salaun B, Schwarz TF, Smetana J, Abeele CV, Van den Steen P, Vastiau I, Weckx LY, Levin MJ; ZOE-50/70 Study Group. Immune Responses to a Recombinant Glycoprotein E Herpes Zoster Vaccine in Adults Aged 50 Years or Older. J Infect Dis. 2018 May 5;217(11):1750-1760. doi: 10.1093/infdis/jiy095. PubMed PMID:29529222.

5. Swaab DF. Autonomic Disorders in Handbook of Clinical Neurology, Vol. 80
(3rd Series Vol. 2) The Human Hypothalamus: Basic and Clinical Aspects, Part II,
2004, Elsevier, Amsterdam, pp351-370.



Supplementary 1:

Did not make it into work as expected on February 4. Went to see my primary care MD instead.  The erythema (redness) had not gone down and actually extended farther down the arm (I drew a line around it the night before).  No systemic symptoms but more redness.  Needed to know if the antibiotic needed to be changed and if prednisone was a good idea.

His conclusion - not an infection but inflammation from a reaction to the vaccine.  He has only seen a couple of reactions like this with Pneumovax and pointed out that it is given to immunocompromised people every ten years starting at a younger age.  He said to keep taking the cephalexin for a week but no prednisone: "I give prednisone to people with life threatening problems - not a red arm.  More medicine is not necessarily good medicine."

Work tomorrow. 

Supplementary 2:

New CDC Guidelines on Pneumococcal Vaccinations:



New Pneumococcal Vaccine Recommendations for Adults Aged ≥65 Years Old

PCV13. PCV13 vaccination is no longer routinely recommended for all adults aged ≥65 years.
Instead, shared clinical decision-making for PCV13 use is recommended for persons aged ≥65 years
who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have
not previously received PCV13 (Table 1).

CDC guidance for shared clinical decision-making. When patients and vaccine providers engage
in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for the specific individual aged ≥65 years, considerations may include the individual patient’s risk for exposure to PCV13 serotypes and the risk for pneumococcal disease for that person as a result of underlying medical conditions (Box).

If a decision to administer PCV13 is made, it should be administered before PPSV23 (5).
The recommended intervals between pneumococcal vaccines remain unchanged for adults without
an immunocompromising condition, CSF leak, or cochlear implant (≥1 year between
pneumococcal vaccines, regardless of the order in which they were received) (5). PCV13 and PPSV23 should not be coadministered.

ACIP continues to recommend PCV13 in series with PPSV23 for adults aged ≥19 years
(including those aged ≥65 years) with immunocompromising conditions, CSF leaks, or
cochlear implants (Table 1) (2).

PPSV23 for adults aged ≥65 years. ACIP continues to recommend that all adults aged ≥65 years
receive 1 dose of PPSV23. A single dose of PPSV23 is recommended for routine use among all adults aged ≥65 years (1). PPSV23 contains 12 serotypes in common with PCV13 and an additional
1 serotypes for which there are no indirect effects from PCV13 use in children. The additional
11 serotypes account for 32%–37% of IPD among adults aged ≥65 years (22). Adults aged ≥65 years
who received ≥1 dose of PPSV23 before age 65 years should receive 1 additional dose of PPSV23 at
age ≥65 years (2), at least 5 years after the previous PPSV23 dose (Table 1) (5).


Note:  In the above case of the vaccine reaction I received 1 dose of PPSV23 before the PCV13 and one dose after by a period of 4 years.  That is not consistent with the guideline but they  were not coadministered and there was a period of at least one year between injections (PPSV23 in 2010, PCV13 in 2016, and PPSV23 in 2020).