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Measles outbreaks Switzerland (measles death) Italy Romania 31Mar2017 ECDC; WHO Regional Office for Europe The European Centre for Disease Prevention and Control (ECDC) update concerning ongoing measles outbreaks reported in EU/EEA countries weekly Communicable Disease Threats Report 31Mar2017. The largest current measles outbreaks in Europe are taking place in Romania and Italy. In addition, Switzerland reports its first measles death since 2009 in a vaccinated man.

Romania

Between 1 January 2016 and 24 March 2017, Romania reported 3,911 cases of measles, including 17 deaths. Cases are either laboratory confirmed or have an epidemiological link to a laboratory-confirmed case. Infants and young children are the most affected population.

Thirty-seven of the 42 districts are reporting cases, with Caras Severin being the most affected district with 853 cases. Vaccination activities are ongoing in order to cover communities with suboptimal vaccination coverage.

On 28 March 2017, the World Health Organization (WHO) posted a press release on the measles outbreaks across Europe. According to reported data, the three measles genotypes circulating in Romania since January 2016 have never been recorded in the country before, instead they have been reported in other locations in 2015, including several other European countries. Comprehensive laboratory and epidemiological data are needed before the origin of infection and the routes of transmission can be determined.

Italy

Since the beginning of 2017 and as of 26 March 2017, Italy reported 1,010 cases of measles, with 113 cases among healthcare workers. Nineteen of the 21 regions in Italy report cases. The majority of cases (86%) are from Piedmont, Lombardy, Lazio, Tuscany and Abruzzo. The majority of cases are above the age of 15 years, and 90% of the cases were not vaccinated. At least one complication was reported; 41% of the cases were hospitalised.

Switzerland

Since the beginning of 2017 and as of 21 March 2017, Switzerland has reported 52 cases of measles. In February 2017, a vaccinated man died of measles in Switzerland. He was undergoing strong immunosupressive treatment for leukaemia,

which explains why the measles vaccination did not protect him. This is the first measles death in Switzerland since 2009.

WHO update

The press release by WHO European Region on 28 March 2017 noted that over 500 measles cases were reported for January 2017 in the region. It said that measles continues to spread within and among European countries, with the potential to cause large outbreaks wherever immunization coverage has dropped below the necessary threshold of 95%.

Two-thirds of the Region’s 53 countries have interrupted endemic transmission of measles; however, 14 remain endemic, according to the Regional Verification Commission for Measles and Rubella Elimination (RVC).

There were 559 measles cases reported in the Region for January 2017. Of these, 474 cases were reported in 7 of the 14 endemic countries (France, Germany, Italy, Poland, Romania, Switzerland and Ukraine). Preliminary information for February indicates that the number of new infections is sharply rising. In all of these countries, estimated national immunization coverage with the second dose of measles-containing vaccine is less than the 95% threshold.

The WHO Regional Office for Europe is working closely with the national health authorities of countries at risk and in the midst of large measles outbreaks to plan and implement appropriate response measures. These include enhancing surveillance and identifying and immunizing those at heightened risk of infection, especially susceptible persons who may be or come in contact with infected persons, as well as engaging communities to encourage vaccination for all those who need it.

Infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016 I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

How difficult it is to change even the slightest tiniest bit and its all because of fear. Yet once you risk it, your entire world shifts. Mark Andrus

DVD As Good As It Gets

Stroke = vascular dementia, punctate lacunar strokes, Silent Strokes, increasing ventricular CSF cerebrospinal fluid to brain volume ratio.

Strokes double ages 35-44yrs in US. Stroke Rates Increasing in Under 50s Sue Hughes 23Nov2016

Alcohol Boosts Stroke Risk More Than Do Hypertension, Diabetes

Cerebrovascular Accident (CVA) = stroke Magnetic Resonance Imaging

While stroke rates have been declining for some time in the western world, new research suggests that this trend may be set to reverse, with a worrying increase in stroke rates occurring in the younger age group [less than age 50]. A new study November 23 in the Journal of the American Heart Association shows stroke rates continuing to decline in people aged 55 years and older, but in those aged under 55 years the incidence of stroke appears to be increasing.

"There appears to be a golden generation — the baby boomers born between 1945 and 1954, who have the lowest risk of stroke," lead author, Joel N. Swerdel, MS, MPH, Rutgers University School of Public Health, New Brunswick, New Jersey, commented to Medscape Medical News. "In people born from 1955 onwards, the stroke rate is rising again."

The study — which analyzed a database of all hospital discharges in New Jersey from 1994 to 2014 — found that between 1995–1999 and 2010–2014, the rate of strokes doubled in those aged 40 to 44 years and more than doubled in people 35 to 39 years.

Commenting on the findings for Medscape Medical News, Ralph L. Sacco, MD, professor Olemberg Chair of Neurology, Miller School of Medicine, University of Miami, and president-elect, American Academy of Neurology "This is an interesting set of data that suggests an alarming trend for rising stroke rates among younger adults."

The data confirm what has also been observed in other cohorts, he added. "Although stroke rates have been declining, the decline may be levelling off in older adults and actually increasing in younger adults."

The researchers suggest the trends are all to do with lifestyle factors.

"People born between 1945 and 1954 seem to have benefitted from better living standards and healthcare than those before them, and this would have been the first generation with the knowledge that smoking kills," Swerdel said. "But they have also escaped the sugar revolution and the obesity and diabetes epidemics which are affecting those born later. The influx of heavily sugar-laden food didn't really start until the mid-60s, so those born in the 40 and 50s were not brought up on sugar-coated cereals and the like. This likely explains the increase in obesity and diabetes that occurred in later years."

A 'Wake-Up Call' for the Younger Generation

He stressed that younger people need to take heed of these new data. "This is a wake-up call. People in their 30s and 40s have time and the opportunity to improve their lifestyle and take medications to control risk factors to head off these effects."

Dr Sacco agreed that lifestyle factors are the culprit. "We have definitely improved the control of smoking, blood pressure and cholesterol, but obesity, physical inactivity, poor diet, and diabetes are still on the rise. These conditions could be having a detrimental effect on stroke rates in younger adults."

He added: "The American Heart Association/American Stroke Association has made improving the cardiovascular health of all Americans across all age groups a major strategic priority for 2020. We need to get younger people more focused on healthy habits, such as regular exercise, following the AHA [American Heart Association] diet, and losing weight before it is too late. It is never too early to start thinking about improving heart and brain health."

For the study, the researchers obtained data on stroke and ST-segment elevation myocardial infarction (STEMI) [myocardial infarction = heart attack] for the years 1995–2014 from the Myocardial Infarction Data Acquisition System, a database of hospital discharges in New Jersey. Rates by age for the time periods 1994–1999, 2000–2004, 2005–2009, and 2010–2014 were obtained by using census estimates as denominators for each age group and period.

Results showed the rate of stroke more than doubled in patients aged 35 to 39 years from 1995–1999 to 2010–2014 (rate ratio [RR], 2.47; P < .0001). For the same time period, comparison stroke rates doubled in the age group 40 to 44 years (RR, 2.01; P < .0001) and showed a 23% increase in those aged 50 to 54 years (RR, 1.23; P = .001).

In contrast, strokes rates in those older than 55 years decreased during these time periods.

Those born from 1945 to 1954 had lower age-adjusted rates of stroke than those born both in the prior 20 years and in the following 20 years.

STEMI [heart attack] rates, however, showed a different pattern, decreasing in all age groups and in each successive birth cohort, although the reduction did appear to be flattening out.

"STEMI rates have dropped like a rock over last 20 years, but this fall is getting slower in the younger age groups," Swerdel commented. "This has also been seen in other US-wide data and has been attributed to the increase in diabetes we are seeing recently."

Dr Sacco said it was surprising that STEMI did not follow the same pattern as stroke, but he noted that the two conditions may be affected differently by different risk factors, with cholesterol control having a greater impact on for myocardial infarction [MI = heart attack] than for stroke [vascular dementia].

Study coauthor John B. Kostis, MD, professor of cardiology, medicine and pharmacology, Rutgers Robert Wood Johnson Medical School, New Brunswick, agreed. "Stroke may be more affected by blood pressure than STEMI, while STEMI is more affected by LDL [low-density lipoprotein] cholesterol. But we didn't have data on these risk factors in this study — just reasons for admissions to hospital."

Dr Kostis pointed out that while cardiovascular and cerebrovascular diseases have been declining in the West, they are growing in newly developed countries such as Russia, India, and Asia. "We had thought we had dealt with this in the US, but it appears that it might be coming back again."

He added: "The message is clear. We have to start taking care of ourselves early in life and continue this throughout life. Don't smoke, look after your weight, partake in exercise, take medicines for blood pressure and cholesterol if they are high. Start all these things early in life."

Quoting Latin "Dum spiro spero — While I breathe, I hope," Dr Kostis said of their findings, "Yes, this is a red flag but we can do something

J Am Heart Assoc 23Nov2016

Ischemic Stroke Rate Increases in Young Adults: Evidence for a

Generational Effect? Joel N. Swerdel et al the Myocardial Infarction [MI = heart attack] Data Acquisition System (MIDAS 29) Study Group, Javier Cabrera, John Pantazopoulos and Davit Sargsyan Journal of the American Heart Association. 2016;5:e004245 23Nov 2016.

MBI-C Checklist captures new predementia diagnosis of mild behavioral impairment MICHELE G. SULLIVAN, Internal Medicine News 4AUG2016 AAIC 2016 Alzheimers Assocation International Conference

TORONTO – Researchers have described a behavioral syndrome that they say can be a forerunner of Alzheimer’s disease and other neurodegenerative diseases and released a tool for diagnosing it.

Mild behavioral impairment (MBI) defines a syndrome of new-onset neuropsychiatric symptoms that appear in nondemented people older than 50, and are sustained for at least 6 months. Symptoms can occur in any of five domains: apathy/drive/motivation; mood/affect/anxiety; impulse control/agitation/reward; social appropriateness; and thoughts/perception.

Zahinoor Ismail, MD, described the concept of MBI for the first time at the Alzheimer’s Association International Conference 2016, and unveiled the MBI Checklist (MBI-C), a two-page screen that identifies and scores these symptoms. The MBI-C is a project of the Alzheimer’s Association International Society to Advance Alzheimer’s Research and Treatment (ISTAART), and is still being validated, although is available for clinical use now, said Dr. Ismail of the University of Calgary (Alta.).

Dr. Zahinoor Ismail Changes in personality are often the earliest signs of an emerging neurocognitive disorder, appearing well before any problems with memory or cognition. The MBI-C will allow clinicians to identify and track these changes in patients.

“We can now describe this preclinical dementia phenotype and use this tool to diagnose it and to capture change over time,” Dr. Ismail said.

In addition to being clinically useful, he said the checklist will wield great power in research: It could target a population at the greatest risk for neurocognitive decline, at a time where any future disease-modifying drugs could be most beneficial.

“We all know that dementia is much more than memory or cognitive impairment alone. The neuropsychiatric symptoms of dementia are associated with functional impairment, caregiver burden, institutionalization, accelerated rates of progression, and a greater burden of plaques and tangles. There is a great need to identify people early on, people in whom we might be able to change the course of illness. These patients, who present with early neuropsychiatric symptoms, may be a population we can examine to see if that is possible.”

A large body of research has already linked new-onset neuropsychiatric symptoms with neurocognitive disease, particularly frontotemporal dementia, Dr. Ismail said. One of the most compelling studies comprised about 500 subjects enrolled in the ongoing Mayo Clinic Study of Aging, who were followed for 5 years (Am J Psychiatry. 2014;171[5];572-81). This study found that the emergence of neuropsychiatric symptoms in cognitively normal older adults was associated with significant increases in the risk of developing mild cognitive impairment MCI. Agitation conferred the highest risk (hazard ratio, 3.06), followed by apathy (HR, 2.6), anxiety (HR, 1.87), irritability (HR, 1.84), and depression (HR, 1.63).

Dr. Ismail said new-onset neuropsychiatric symptoms are already quite common by the time patients enter care for memory concerns. At the meeting, he presented data on a group of about 300 patients with mild cognitive impairment MCI who attended a memory clinic. A total of 82% endorsed at least one neuropsychiatric symptom. When sorted into the five MBI-C mild behavioral impairment checklist domains, 78% of patients expressed mood symptoms; 64% impulse control symptoms; 52% apathy symptoms; 28% social appropriateness symptoms; and 9% psychotic symptoms.

“Our study suggests that this concept of mild behavioral impairment MBI may be a common and clinically relevant syndrome, particularly given that neuropsychiatric symptoms are associated with greater caregiver burden,” Dr. Ismail said.

Dr. Ismail did not address how the screen should be scored or interpreted. It is composed of five overall domains, each asking about the emergence of a new, persistent symptom. Patients rate the presence and severity of those symptoms on a 3-point scale. The researchers who developed it chose age 50 as the cutoff point because symptoms that emerge at that age can herald the onset of frontotemporal dementia FTD in relatively young patients.

“This idea of symptoms persisting for at least 6 months is important,” Dr. Ismail said. “What we’re talking about is a sustained change from baseline personality. But these are still nondemented patients. Function is maintained. Independent activities of daily living are intact.”

The most comprehensive domain is impulse control, agitation, and reward. “This captures a lot of function with regard to agitation in dementia, new-onset substance abuse SUD, irritability, new-onset road rage … things we might not otherwise capture.”

The social appropriateness domain examines symptoms like a loss of the ability to share appropriately, acting out sexually, and loss of social judgment. The psychosis domain inquires about feelings of aggrandizement [narcissism], persecution, and suspicion [paranoia], as well as auditory and visual hallucinations.

The mood domain asks about new-onset anxiety, panic, and depression. The motivation domain asks about the development of apathy or disinterest in family, friends, and [formerly pleasurable] activities.

Validation studies in large cohorts are ongoing, as well as studies that Dr. Ismail hopes will link these early behavioral changes to well-established Alzheimer’s biomarkers. MBI-C mild behavioral impairment checklist.

The sins of the flesh are bad, but they are the least bad of all sins. All the worst pleasures are purely spiritual: the pleasure of putting other people in the wrong, of bossing and patronizing and spoiling sport, and back-biting; the pleasures of power, of hatred.

CS Lewis

Portland State University, the National Policy Consensus Center, worked with the City of Hillsboro to engage and prepare a diverse group of residents to serve in a range of civic leadership capacities within the city. Accepting new challenges combats cognitive deterioration as long as one avoids recreational chemicals

Dear Class of 2014: Allow me to be the first to offend you, baldly and unapologetically. Here you are, 22 or so years on planet Earth, and your entire lives have been one long episode of offense-avoidance. This spotless record has now culminated in your refusals to listen to commencement speakers whose mature convictions and experiences might offend your convictions and experiences, or what passes for them. Modern education has done its work well: In you, Class of 2014, the coward soul has filled the void left by the blank mind.

When I last delivered a commencement address via column to the Class of 2012, I complained about the dismaying inverse relationship between that class's self-regard and its command of basic facts. This led to one cascade of angry letters, blog posts and college newspaper columns from the under-25 set—and another cascade of appreciative letters from their parents, professors and employers. Of the former, my favorite came from a 2012 graduate of an elite Virginia college, who wrote me to say that "America has a hefty appetite for BS, and I'm ready and willing to deliver on that demand." I gave him points for boldness and cheekily wrote back asking if we might consider his letter for publication. The bravado vanished; he demurred.

Well, Class of 2012, I did you a (small) injustice. At least the pretense of knowledgeability was important to you. For the Class of 2014, it seems that inviolable ignorance is the only true bliss. It's not just the burgeoning list of rescinded invitations to potentially offensive commencement speakers: Ayaan Hirsi Ali at Brandeis, Condi Rice at Rutgers, Christine Lagarde at Smith and Robert Birgeneau at Haverford.

In February, students at Dartmouth issued a list of 72 demands for "transformative justice." Among them: "mandate sensitivity training"; "organize continuous external reviews of the College's structural racism, classism, ableism, sexism and heterosexism"; and "create a policy banning the Indian mascot." When the demands weren't automatically met, the students seized an administration building. At Brown, a Facebook page is devoted to the subject of "Micro/Aggressions," a growth area in the grievance industry. Example of a micro-aggression: "As a dark-skinned Black person, I feel alienated from social justice spaces or conversations about institutional racism here at Brown when non-Black people of color say things like 'let's move away from the White-Black binary.' "

And then there are "trigger warnings." In Saturday's New York Times, Jennifer Medina reports that students and like-minded faculty are demanding warnings on study material that trigger "symptoms of post-traumatic stress disorder." Chinua Achebe's "Things Fall Apart" was cited by one faculty document at Oberlin as a novel that could "trigger readers who have experienced racism, colonialism, religious persecution, violence, suicide and more." Similar Tipper Gore-type efforts are under way at UC Santa Barbara, George Washington University and other second- and third-tier schools. Did I just offend some readers by saying that? Sorry, but it's true.

Any student who demands—and gets—emotional pampering from his university needs to pay a commensurate price in intellectual derision.

College was once about preparing boys and girls to become men and women, not least through a process of desensitization to discomfiting ideas. Now it's just a $240,000 extension of kindergarten. Maybe Oberlin can start offering courses in Sharing Is Caring. Students can read "The Gruffalo" with trigger warnings that it potentially stigmatizes people with hairy backs.

This is the bind you find yourselves in, Class of 2014: No society, not even one that cossets the young as much as ours does, can treat you as children forever.

A central teaching of Genesis is that knowledge is purchased at the expense of innocence.

A core teaching of the ancients is that personal dignity is obtained through habituation to virtue. And at least one basic teaching of true liberalism is that the essential right of free people is the right to offend, and an essential responsibility of free people is to learn how to cope with being offended.

I'll grant you this: It's not all your fault. The semi- and post-literates who overran the humanities departments at most universities long before I ever set foot in college are the main culprits here. Then again, it shouldn't be that hard to figure out what it takes to live in a free country. The ideological brainwashing that takes place on campus isn't (yet) coercive. Mainly, it's just onanistic.

There's good news in that. You can still take charge of your education, and of your lives. The cocoon years are over; the micro-aggressions are about to pour down.

Deal with it. Revel in it.

No consequential idea ever failed to offend someone; no consequential person was ever spared great offense.

Those of you who want to lead meaningful lives need to begin unlearning most of what you've been taught, starting right now.

BRET STEPHENS WSJ May 19, 2014 bstephens@wsj.com

DVD Hector and the Search for Happiness Simon Pegg Rosamund Pike comedy. DVD Happy documentary interviews with happy people worldwide. DVD Stuart Saves His Family Vincent D'Onofrio Laura San Giacomo Shirley Knight Harris Yulin. book I'm good enough, I'm smart enough and doggone it people like me. Stuart Smalley Saturday Night Live.

25Nov2016 Stefanie Lynn Gillson, BSc The Patient’s Son Is Normal

It’s a slow night during the third week of my internal medicine rotation, and I am sitting in a small windowless workroom with my resident. While I am intermittently glancing at the clock and finishing small tasks left over from the day, the phone rings and delivers a request from the ER: please come admit “Jim,” a 65-year-old man who was found alone in his home by EMS. As the enthusiastic medical student, I head down immediately to begin working on a thorough history and physical exam.

The paramedics tell me that Jim’s neighbor called 911 after not seeing him for a few days. They live in a mobile home community and noted that it was strange not to see him outside given the small distance between their homes. After knocking on the door and hearing only pained grunts in return, the paramedics entered and found Jim on his couch surrounded by empty liquor bottles and beer cans, soiled from lying in place for days.

I enter Jim’s room, and my eyes water because of an overwhelming smell that burns my nostrils. Among the blankets I find him sitting up slightly, his skin tinged yellow and clinging tightly to his bones, with a bulging belly impregnated with fluid. He is in bad condition, alternating in and out of consciousness and only able to answer a few yes or no questions.

In the absence of a responsive patient, I click open endless tabs on the computer to sort through previous admissions. Jim is a Vietnam veteran who has been drinking heavily ever since he returned from overseas.

My resident calls Jim’s son to inform him of the seriousness of the situation—Jim probably would have died if his neighbor hadn’t called. His son is not surprised. He seems comfortable receiving this news, answering questions in a manner that suggests he might have done this several times in the past. The resident discusses care plan options, hangs up, and begins typing. A couple minutes go by and he looks up.

“You know what’s crazy? His son is so normal,” he says. “He’s a successful businessman out in California. You just never think people like that can have normal children.” He shakes his head in a way that says “now I’ve seen it all.”

I lean back in my chair and nod in agreement, wait for him to return to his typing, and stare hard at the floor.

I think of when I was 14 years old and answered a late-night phone call at home.

“Stefanie? This is Officer Peterson—your mother is making another scene at Rudy’s Bar. If you don’t come get her, I’ll have to take her in.”

I let out a sigh, find my shoes, and start walking. I find her standing outside the bar, her balance maintained only by the officer’s hand. She is sheepish toward me; her face is grimaced and displays an emotion somewhere between anger and embarrassment. I can tell she’s had a few too many, and evidence of this is spilled across her shirt. A quick search of the bar and I find her purse slung over a chair, its contents spilled across the floor. The officer—eager to be relieved of this responsibility—nods and leaves.

I find her keys in the mess and guide her to the back door of her old white Ford. She crawls in and slumps across the seat. The car’s paint is chipped and the sides are dented, revealing small patches of rust and rot. I remember when the car was kept clean, free from these blemishes. I climb into the driver’s side, pull the seat as far forward as it goes, and kick some bottles away from the gas pedal. I adjust the mirrors and see that the police are well out of sight, so I start the car and drive my mom home. I put her in bed and lie down next to her, listening to make sure she continues to breathe into the morning hours.

Ten years later I am in medical school studying the day before a big exam. I glance at my silenced phone to find 4 missed calls—3 big brothers and 1 dad. Figuring standard family drama, I call my brother Eric. No one had heard from Mom in a few days, and her sister called 911. EMS found her on the couch barely clothed, in her own filth, surrounded by various bottles of liquor. She was taken to the local ER after the detox center refused to accept her because of an abnormal heart rhythm. After a couple hours of sobering up, she was given a bus pass and sent home at 3:00 am. The next morning my mom was found dead on the couch surrounded by her vices.

While Jim was admitted to the hospital at his worst moment and seen by countless physicians, my mom was sent home. I sometimes wonder if my mom had been admitted as well, would she still be alive? I don’t know.

I don’t blame anyone for my mom dying. I realize there are countless factors that play into cases like this, and I don’t fault any of the physicians who saw her that night. But being on Jim’s treatment team so soon after her death was difficult, as was talking to his family members. The stigma of alcoholics and their families is persistent and unrelenting. Worse, the stereotypes that fuel this stigma often play out in similar patterns again and again.

Back in the present I look around at the rounding team. Everyone is still impressed Jim’s son turned out “so normal.”

My white coat is freshly cleaned, my stethoscope swinging back and forth as I walk from room to room. I have a little book in my pocket that contains an enormous amount of medical knowledge I am trying to somehow fit in my head. I wonder what my team would think if they knew about my family. Would they be equally impressed with me being “so normal” and exclaim, “She’s even going to be a doctor!”

A week later I walk into Jim’s room, but now he has a fresh set of clothing and a new haircut. His abdomen has returned to a smaller size. He can now join a conversation and is planning to go into treatment again for his alcohol addiction. I nod. I have heard this story many times.

I’m not sure if he will indeed go through with this plan, or if he does, how long he will stay sober. I reflect on the careful balance between cynicism and optimism that often accompanies knowing alcoholics. But today I am content. Regardless of what Jim may ultimately do, I know we’re giving him another shot to try, and I find a simple peace with this. I am hopeful that this is the last time I see him in this setting, a place so close to where I lost my mother.

I don’t know exactly what “normal” is, but I do know that it is a waste of time to search for its meaning. In medicine we learn to identify the abnormal based on symptoms and diagnostic criteria. But there is no checklist for “normal.” So instead I focus on cultivating optimism, both for my patients confronting their demons—as well as in my own life.

Strokes double ages 35-44yrs in US. Stroke Rates Increasing in Under 50s Sue Hughes 23Nov2016

Alcohol Boosts Stroke Risk More Than Do Hypertension, Diabetes

Cerebrovascular Accident (CVA) = stroke Magnetic Resonance Imaging

While stroke rates have been declining for some time in the western world, new research suggests that this trend may be set to reverse, with a worrying increase in stroke rates occurring in the younger age group.

A new study, published online November 23 in the Journal of the American Heart Association shows stroke rates continuing to decline in people aged 55 years and older, but in those aged under 55 years the incidence of stroke appears to be increasing.

"There appears to be a golden generation — the baby boomers born between 1945 and 1954, who have the lowest risk of stroke," lead author, Joel N. Swerdel, MS, MPH, Rutgers University School of Public Health, New Brunswick, New Jersey, commented to Medscape Medical News. "In people born from 1955 onwards, the stroke rate is rising again."

The study — which analyzed a database of all hospital discharges in New Jersey from 1994 to 2014 — found that between 1995–1999 and 2010–2014, the rate of strokes doubled in those aged 40 to 44 years and more than doubled in people 35 to 39 years.

Commenting on the findings for Medscape Medical News, Ralph L. Sacco, MD, professor and Olemberg Chair of Neurology, Miller School of Medicine, University of Miami, and president-elect, American Academy of Neurology, said, "This is an interesting set of data that suggests an alarming trend for rising stroke rates among younger adults."

The data confirm what has also been observed in other cohorts, he added. "Although stroke rates have been declining, the decline may be levelling off in older adults and actually increasing in younger adults."

The researchers suggest the trends are all to do with lifestyle factors.

"People born between 1945 and 1954 seem to have benefitted from better living standards and healthcare than those before them, and this would have been the first generation with the knowledge that smoking kills," Swerdel said. "But they have also escaped the sugar revolution and the obesity and diabetes epidemics which are affecting those born later. The influx of heavily sugar-laden food didn't really start until the mid-60s, so those born in the 40 and 50s were not brought up on sugar-coated cereals and the like. This likely explains the increase in obesity and diabetes that occurred in later years."

A 'Wake-Up Call' for the Younger Generation

He stressed that younger people need to take heed of these new data. "This is a wake-up call. People in their 30s and 40s have time and the opportunity to improve their lifestyle and take medications to control risk factors to head off these effects."

Dr Sacco agreed that lifestyle factors are the culprit. "We have definitely improved the control of smoking, blood pressure and cholesterol, but obesity, physical inactivity, poor diet, and diabetes are still on the rise. These conditions could be having a detrimental effect on stroke rates in younger adults."

He added: "The American Heart Association/American Stroke Association has made improving the cardiovascular health of all Americans across all age groups a major strategic priority for 2020. We need to get younger people more focused on healthy habits, such as regular exercise, following the AHA [American Heart Association] diet, and losing weight before it is too late. It is never too early to start thinking about improving heart and brain health."

For the study, the researchers obtained data on stroke and ST-segment elevation myocardial infarction (STEMI) for the years 1995–2014 from the Myocardial Infarction Data Acquisition System, a database of hospital discharges in New Jersey. Rates by age for the time periods 1994–1999, 2000–2004, 2005–2009, and 2010–2014 were obtained by using census estimates as denominators for each age group and period.

Results showed the rate of stroke more than doubled in patients aged 35 to 39 years from 1995–1999 to 2010–2014 (rate ratio [RR], 2.47; P < .0001). For the same time period, comparison stroke rates doubled in the age group 40 to 44 years (RR, 2.01; P < .0001) and showed a 23% increase in those aged 50 to 54 years (RR, 1.23; P = .001).

In contrast, strokes rates in those older than 55 years decreased during these time periods.

Those born from 1945 to 1954 had lower age-adjusted rates of stroke than those born both in the prior 20 years and in the following 20 years.

STEMI rates, however, showed a different pattern, decreasing in all age groups and in each successive birth cohort, although the reduction did appear to be flattening out.

"STEMI rates have dropped like a rock over last 20 years, but this fall is getting slower in the younger age groups," Swerdel commented. "This has also been seen in other US-wide data and has been attributed to the increase in diabetes we are seeing recently."

Dr Sacco said it was surprising that STEMI did not follow the same pattern as stroke, but he noted that the two conditions may be affected differently by different risk factors, with cholesterol control having a greater impact on for myocardial infarction than for stroke.

Study coauthor John B. Kostis, MD, professor of cardiology, medicine and pharmacology, Rutgers Robert Wood Johnson Medical School, New Brunswick, agreed. "Stroke may be more affected by blood pressure than STEMI, while STEMI is more affected by LDL [low-density lipoprotein] cholesterol. But we didn't have data on these risk factors in this study — just reasons for admissions to hospital."

Dr Kostis pointed out that while cardiovascular and cerebrovascular diseases have been declining in the West, they are growing in newly developed countries such as Russia, India, and Asia. "We had thought we had dealt with this in the US, but it appears that it might be coming back again."

He added: "The message is clear. We have to start taking care of ourselves early in life and continue this throughout life. Don't smoke, look after your weight, partake in exercise, take medicines for blood pressure and cholesterol if they are high. Start all these things early in life."

Quoting the Latin "Dum spiro spero — While I breathe, I hope," Dr Kostis said of their findings, "Yes, this is a red flag but we can do something

J Am Heart Assoc 23Nov2016

Ischemic Stroke Rate Increases in Young Adults: Evidence for a

Generational Effect? Joel N. Swerdel et al the Myocardial Infarction [MI = heart attack] Data Acquisition System (MIDAS 29) Study Group, Javier Cabrera, John Pantazopoulos and Davit Sargsyan

Journal of the American Heart Association. 2016;5:e004245 23Nov 2016

First generation where parents functionally and cognitively outlive their children.

Plant vs. animal protein intake in CV mortality risk American College of Cardiology Aug82016

Animal protein intake may be associated with a higher risk for cardiovascular mortality, as compared to plant protein intake in patients with at least one lifestyle risk factor, according to a study published Aug. 1 in JAMA Internal Medicine. The prospective cohort study, by Mingyang Song, MD, ScD, et al., looked at 131,342 participants in the Nurses’ Health Study and the Health Professionals Follow–up Study. The median protein intake was 14 percent for animal protein and 4 percent for plant protein. After adjusting for major lifestyle and dietary risk factors, results showed that animal protein intake was “weakly associated” with higher mortality, particularly cardiovascular mortality since “every 10 percent increment of animal protein from total calories was associated with a 2 percent higher risk” for all–cause mortality, and an 8 percent increased risk for cardiovascular mortality. In comparison, plant protein intake “was associated with a 10 percent lower risk” of all–cause mortality “for every 3 percent increment of total calories and a 12 percent lower risk” for cardiovascular mortality. The authors add that these associations “were confined to participants with at least one unhealthy lifestyle factor based on smoking, heavy alcohol intake, overweight or obesity, and physical inactivity,” but not seen in patients without any of these risk factors. “Substitution of plant protein for animal protein, especially from processed red meat, may confer substantial health benefit. Therefore, public health recommendations should focus on improvement of protein sources,” the authors conclude.

Age-Adjusted Suicide Rates by Method in US MMWR; ePub 20May2016; Hedegaard, Curtin 14JUN2016 The age-adjusted suicide rates in the US increased from 4.0 to 5.8 per 100,000 for females and from 17.7 to 20.7 for males from 2000 to 2014, with suicide by suffocation the most common method used overall, according to a recent report. The report, which also examines the most common method used to commit suicide among the study population, found:

• Suicide rates by specific methods also increased, with the greatest increase seen for suicides by suffocation.

• During the 15-year study period, the rate of suicide by suffocation more than doubled for females from 0.7 to 1.6 and increased from 3.4 to 5.6 for males.

• Among females in 2014, suicide by poisoning had the highest rate (1.9); suicide by firearm had the highest rate among males (11.4).

Citation: QuickStats: Age-adjusted suicide rates for females and males, by method — National Vital Statistics System, United States, 2000 and 2014. MMWR Morb Mortal Wkly Rep. 2016;65:503. doi:http://dx.doi.org/10.15585/mmwr.mm6519a7.

Commentary: Suicide is tragic, and tragically increasing in incidence over the last decade. It is the tenth leading cause of death in the US, and the second leading cause of death among persons aged 15 to 34 years, accounting for over 100 suicides in the US every day. Males commit suicide at almost four times the rate of females and account for 80% of all completed suicides, most often using a gun. Of individuals who commit suicide, a third has been drinking alcohol and 20% test positive for opioids. Approximately 1 in 200 adults have attempted suicide in the past year, of whom 80% had first made a suicide plan, perhaps presenting an opportunity for intervention.1 This is a vexing and tragic problem, with no clear solution in site, but something that needs to be in the forefront of thinking for all primary care clinicians. Neil Skolnik, MD

1. Centers for Disease Control & Prevention. Suicide – CDC Facts at a Glance 2015. cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf" cdc.gov/violenceprevention/pdf/suicide-datasheet Accessed 13Jun2016.

DVD Frontier House 6 episodes overweight 2001 moved to 1883 physical activity, physical fitness, need to increase water, not alcohol intake to maintain fitness. Decreased life expectancy with obesity epidemic due to carbohydrate consumption marketed by food and restaurant industries JAMA 7Jun2016.

Takotsubo cardiomyopathy Super Bowl Heart Attack, Broken Heart Syndrome Angry outbursts tied to heart problems

Northwestern University 10Jun2016 New research on emotions and health also links stonewalling to back pain. Those who rage with frustration during a marital spat have an increased risk of cardiovascular problems such as chest pain or high blood pressure later in life, according to new research from Northwestern University and the University of California, Berkeley. Conversely, shutting down emotionally or “stonewalling” during conflict raises the risk of musculoskeletal ailments such as a bad back or stiff muscles, according to the study, published online in the journal Emotion. It’s well known that negative emotions may harm physical health, but it turns out that not all negative emotions have equal consequences. Using 20 years of data, and controlling for such factors as age, education, exercise, smoking, alcohol use and caffeine consumption, the researchers were able to connect specific emotions to corresponding health problems. Overall, the link between emotions and health outcomes was most pronounced for husbands, but some of the key correlations also were found in wives. The researchers analyzed married couples in the throes of tense conversations for just 15 minutes, but that was long enough to predict the development of health problems over 20 years later. The findings could spur hotheads to consider such interventions as anger management, while people who withdraw during conflict might benefit from resisting the impulse to bottle up their emotions, the researchers said.

Mortality inequality compares poorest vs richest counties in US according to age group 1990-2010. Males 65 years and older increasing survival in high income counties particularly among those born before 1940. Males 20-64 decreasing difference in survival between high and low income counties: high income counties exhibit decreasing survival relative to low income cohorts for males from ages 20-59 in 2010. Working age males accelerated mortality in high income counties vs poor counties.

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

Measles outbreak Switzerland (measles death) Italy Romania 31Mar2017 ECDC; WHO Regional Office for Europe The European Centre for Disease Prevention and Control (ECDC) update concerning ongoing measles outbreaks reported in EU/EEA countries weekly Communicable Disease Threats Report 31Mar2017. The largest current measles outbreaks in Europe are taking place in Romania and Italy. In addition, Switzerland reports its first measles death since 2009 in a vaccinated man.

Romania

Between 1 January 2016 and 24 March 2017, Romania reported 3,911 cases of measles, including 17 deaths. Cases are either laboratory confirmed or have an epidemiological link to a laboratory-confirmed case. Infants and young children are the most affected population.

Thirty-seven of the 42 districts are reporting cases, with Caras Severin being the most affected district with 853 cases. Vaccination activities are ongoing in order to cover communities with suboptimal vaccination coverage.

On 28 March 2017, the World Health Organization (WHO) posted a press release on the measles outbreaks across Europe. According to reported data, the three measles genotypes circulating in Romania since January 2016 have never been recorded in the country before, instead they have been reported in other locations in 2015, including several other European countries. Comprehensive laboratory and epidemiological data are needed before the origin of infection and the routes of transmission can be determined.

Italy

Since the beginning of 2017 and as of 26 March 2017, Italy reported 1,010 cases of measles, with 113 cases among healthcare workers. Nineteen of the 21 regions in Italy report cases. The majority of cases (86%) are from Piedmont, Lombardy, Lazio, Tuscany and Abruzzo. The majority of cases are above the age of 15 years, and 90% of the cases were not vaccinated. At least one complication was reported; 41% of the cases were hospitalised.

Switzerland

Since the beginning of 2017 and as of 21 March 2017, Switzerland has reported 52 cases of measles. In February 2017, a vaccinated man died of measles in Switzerland. He was undergoing strong immunosupressive treatment for leukaemia,

which explains why the measles vaccination did not protect him. This is the first measles death in Switzerland since 2009.

WHO update

The press release by WHO European Region on 28 March 2017 noted that over 500 measles cases were reported for January 2017 in the region. It said that measles continues to spread within and among European countries, with the potential to cause large outbreaks wherever immunization coverage has dropped below the necessary threshold of 95%.

Two-thirds of the Region’s 53 countries have interrupted endemic transmission of measles; however, 14 remain endemic, according to the Regional Verification Commission for Measles and Rubella Elimination (RVC).

There were 559 measles cases reported in the Region for January 2017. Of these, 474 cases were reported in 7 of the 14 endemic countries (France, Germany, Italy, Poland, Romania, Switzerland and Ukraine). Preliminary information for February indicates that the number of new infections is sharply rising. In all of these countries, estimated national immunization coverage with the second dose of measles-containing vaccine is less than the 95% threshold.

The WHO Regional Office for Europe is working closely with the national health authorities of countries at risk and in the midst of large measles outbreaks to plan and implement appropriate response measures. These include enhancing surveillance and identifying and immunizing those at heightened risk of infection, especially susceptible persons who may be or come in contact with infected persons, as well as engaging communities to encourage vaccination for all those who need it.

California Measles outbreak 30Dec2016 Santa Barbara County Public Health Department (California), is investigating exposures to a confirmed measles patient. The one confirmed case in Santa Barbara County is linked to the measles outbreak in Los Angeles that currently involves 11 patients. Of the 12 measles cases now involved in the Los Angeles outbreak, only one has provided documentation of vaccination.

The exposures in Santa Barbara occurred at Goleta Valley Cottage Hospital on Tuesday, December 27th between 7:24 p.m. and 10:16 p.m. There were no other exposures. All exposed healthcare workers, patients, and visitors have already been contacted and appropriate measures are being taken to protect their health and the community. Cottage Health was able to quickly verify that all exposed healthcare workers were fully vaccinated against the measles virus.

Measles is a highly contagious virus spread through the air from person to person through coughing or sneezing. The virus spreads rapidly among people who are not immune. Symptoms include rash, cough, runny nose, and conjunctivitis. By the time an individual shows symptoms they have typically already been infectious for four days. This can result in many community exposures and requires rapid public health contact tracing. The incubation period for developing measles after an exposure is up to 21 days. Unvaccinated individuals who have been exposed to the virus and cannot or will not receive the MMR vaccine may be placed under quarantine to protect others. This is the standard public health protocol with air-borne communicable diseases.

Santa Barbara County Public Health is working closely with the public health departments in Ventura and Los Angeles Counties where additional exposures to this case have occurred. A critical piece of the investigation is documenting that exposed individuals have received two doses of the MMR vaccine. Community members who are unsure of their vaccination status should contact their healthcare provider to determine if they need to receive the vaccine.

USA Mumps, steady increase in cases

30Dec016 Washington State Department of Health continues to remind people across the state to take precautions to help stop the spread of mumps.

30Dec2016 129 confirmed and probable cases mumps reported in WA state. King County reports the highest number of cases at 111

Arkansas. As of December 30, 2016 there are a total of 2,405 cases under investigation, which include individuals who have displayed symptoms related to mumps or have received lab confirmation that they are positive for the virus. 53 workplaces, 44 schools in 9 school districts, 5 colleges/vocational schools, and 5 private schools impacted.

Oklahoma State Department of Health and county health departments of Garfield, Kay and McCurtain counties continue to investigate and provide a public health response to an outbreak of mumps. State and local public health officials are working closely with schools and healthcare providers to rapidly identify suspected cases and exclude affected persons from childcare centers, schools or workplaces during the timeframe they are able to transmit mumps to other persons. December 29, 2016, the state has reported 406 cases in 10 counties Ill people range in age from 6 months to 65 years, with a median age of 16 years. Two of them require hospitalization. Of the reported cases, 255 (63%) are vaccinated, 38 (9%) with no vaccination history, 2 (<1%) are under age for vaccination, and 111 (27%) with unknown vaccination history.

Missouri

University of Missouri (MU) Health Center is continuing to identify active cases and is receiving reports of cases seen at other health care facilities in the Columbia area and outside. Since the beginning of the Fall Semester on August 22, 2016, 274 cases of mumps have been identified (both confirmed and probable) in Mizzou students. It's important to note this represents less than 1 percent of students. As of December 28, at least 260 of these cases are considered recovered, meaning they are no longer infectious to others. Most of the students are reporting associations with friends who have mumps, Greek organizations, or interactions in local bars. The median age is 20 years and cases are almost evenly split between males and females. All infected students met the immunization policy requirement of two Measles/Mumps/Rubella (MMR) vaccines.

Texas

Texas Department of State Health Services (DSHS) 22Dec2016 announced that it is investigating two outbreaks of mumps in North Texas.

TX State health officials are working with event organizers to notify people who attended one of four cheerleading competitions in North Texas in November and December that they may have been exposed to a person with mumps. So far, DSHS has identified 11 mumps cases associated with the outbreak.

72 cases in the outbreak, including 71 Johnson County residents and one Tarrant County resident. Most of the people involved are students, and DSHS has been working with school districts in the area to limit the spread of the disease.

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

Icky Sticky Snot and Blood Book American Association for Advancement of Science book of the year for children. Risk literacy in medical decision-making How can we better represent the statistical structure of risk? sciencemag.org 22Apr2016 p413 y Joachim T. Operskalski Aron K. Barbey Imagine that you have received a positive result on a routine cancer screening

test. Follow-up biopsies were

inconclusive, and the decision to treat aggressively or monitor conservatively is yours. Consider the following information: 0.1% of the population has a terminal

version of this form of cancer, 99%

of those people will appear positive on the test you have been administered, and 5% of those without terminal cancer will still

have a benign condition that tests positive. Given your test result, what is the probability that you have terminal cancer and should treat it aggressively? When judging

risks and trying to predict the future,

how should you decide? We need to better understand the structure of risks and how the human mind creates representations of risk and probability. In the scenario above, if your rapid impression of the information at hand supports

the intuition that the probability of

terminal cancer is close to 95%, then your line of thinking is not surprising, but you would be wrong. The true probability is 2%, with a complementary 98% risk of having

undergone unnecessary (and even dangerous) treatment (1).

This is hard to grasp intuitively without using Bayes’ theorem

of conditional probability (2); even physicians and medical students are prone to this error without having been explicitly instructed on the statistics of rare events (3). However, it might be understood more readily if you considered the situation in another way: The small number of false positives in the large population without cancer is a greater number than the majority

of true positives in the smaller subpopulation that actually have the disease.

Far from being a statistical curiosity,

this is the exact dilemma faced by patients and their physicians every day, and it will become more common as we learn more

about the genetic factors that affect health. A “precision medicine” approach formalizes the insight that no two patients are alike (4,5). Improving medical diagnostic technology will improve many people’s lives, but to prevent doing harm, the medical field and society at large need to understand that technological advances will not remove uncertainty. By understanding the way we think about risk, we can bring insight from the pages of statistical textbooks into legislative sessions, hospital exam rooms, and family discussions alike. Contemporary research on medical decision-making originates from two traditions in the psychological sciences. The “heuristics and biases” view claims that errors in reasoning are an unavoidable consequence of our mental architecture as humans. Under this view, we each possess a fast and impression-based system of decision-making, in addition to a slower, reflective one capable

of complex calculations that checks and verifies our quick impressions (6). Errors in reasoning may result when time pressure or situational complexity cause the reflective

system to accept as fact the incorrect output of the impression-based system.

Thus, the primary solution to such errors is education in statistics and awareness of our own biases. The “ecological rationality” view of decision-making offers another way

out, however. By considering reasoning errors as the consequence of having evolved

to mentally process information in specific formats, we can better understand risk and uncertainty by communicating with one another

using the right types of information

(3). For example, abstract concepts, such as single-event probabilities (e.g., 1% chance), would not have appeared naturally in environments

inhabited by primitive humans,

so we never evolved to think about single event probability with ease (7). Instead, thinking about long-run frequencies relative to a reference class (e.g., 1 out of 100 times) is easier because it conveys the same

information as percents or probabilities in a way that reflects how we experience the natural world. Indeed, even experts in statistics have difficulty making judgments of single-event probabilities without explicitly

calculating them. However, when the same problems are represented as event frequencies, even the statistical layperson can generate

a response in accordance with Bayes’ theorem. For example, when a sample of college undergraduates was asked to solve problems on the basis of single-event probabilities,

only 12% generated a Bayesian

response, whereas 56% of another sample did so when given numbers in a natural frequency format (8). Using probing questions and visual aids depicting frequency information raised the accuracy to 76% and

92%, respectively.

Few believe that numerical formats automatically endow us with the ability to mentally calculate the probability of some event by counting observations and comparing them to our prior beliefs. Which cognitive processes, then, account for this remarkable facilitation of Bayesian inference

under “natural” or event frequencies? The mind embodies a natural capacity to perform elementary set operations, such

as taking the intersection of sets (e.g., “A and B”) and union of sets (e.g., “A or B”) (9).

Such set operations can be induced by frequency formats, which provide cues to the set structure of the problem and therefore

facilitate Bayesian inference (9). Indeed, the key variable that predicts accurate inference

is not the statistical format of the

problem but the transparency of nested set relations (8, 9). As long as the nested set structure of events in a larger reference

class is made accessible, one can accurately understand and reason from single-event probabilities (10). However, when the set structure of the problem is obscured by the

use of unusual (small or large) reference class sizes, even frequency formats are difficult to understand (11).

Where does contemporary research on human judgment and decision-making leave us as patients, physicians, and policymakers?

Even among professionals, there

remains a lack of consensus on screening guidelines for diseases such as breast or prostate cancer when their prognostic values are ambiguous (12). In 2014, the

U.S. Preventive Services Task Force recommended against using prostate-specific antigen (PSA) test results in diagnosing and treating prostate cancer because the false

positive rate and ambiguity of prognosis meant that men with benign or slow-growing tumors were undergoing unnecessary and risky treatment procedures (13). How

did policy-makers arrive at this decision?

They understood the statistical structure of risk in medical health problems. Health care systems that screened healthy men for PSA regularly had an approximately 98%

5-year survival rate for those diagnosed with cancer, whereas those that tested only men with symptoms had a 71% survival

rate. Why, then, was there no significant difference in cancer mortality (26 versus 27 out of 100,000) between the systems

across the entire population? Screening people aggressively when they are young ends up diagnosing extra cases who do

not truly have cancer, or whose cancer is so slow-growing that they would not have been at risk for far beyond 5 years anyway.

This may seem like an innocuous difference, but the extra diagnoses are associated with treatments that have their own risks [urinary incontinence erectile dysfunction]. Using natural frequencies and drawing attention to the appropriate reference class (the whole population, not just people

who are diagnosed before dying) draws attention to the fact that a higher survival rate is associated with a higher overall rate of positive test results and no difference in

base rates of cancer (as indicated by mortality in the whole population) (14). Our instincts may tell us that 5-year survival rates are important, but only if placed in the appropriate context—natural frequencies

or nested sets.

What measures can be applied to improve the ability to draw accurate statistical inferences and to fully appreciate the risks posed by medical decisions? It is important to consider conditions that lead to errors, such as risks that could be framed equivalently as gains or losses. Considering all possible outcomes (instead of only survival or mortality) [disability decreased quality of life lack of function] can prevent inappropriate use of heuristics.

Representing the problem in natural frequency formats or highlighting its nested set structure is helpful, and depicting outcomes using visual diagrams can facilitate fully informed

decision-making via the creation of

mental simulations (see the figure online page 414 Visual Representation of Risk). In the era of precision medicine, we are

using a data-driven approach to understand patients as individuals rather than group averages. We are moving away from doctors telling patients with certainty what is wrong and what to do, toward a model in which doctors empower patients

to take charge of their own care. To facilitate safe self-stewardship, the biomedical field needs to equip patients with the tools to make well-informed decisions in the

face of uncertainty. [statistical literacy numeracy]

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

Mindfulness based stress reduction MBSR move from empathy which leads to burnout to compassion which acknowledges suffering while remaining functional helpful. DVD Healing and the Mind Bill Moyers 5 episodes, Tai Chi meditation David Eisenberg MD, Chronic Pain MBSR mindfulness based stress reduction Jon Kabat Zinn, metastatic breast cancer David Spiegel 2016 research self efficacy mindfulness based stress reduction for breast cancer patients MBSR more effective than SET supportive therapy, Commonweal Rachel Remen MD author Kitchen Table Wisdom.

Strokes double ages 35-44yrs in US. Stroke Rates Increasing in Under 50s Sue Hughes 23Nov2016

Alcohol Boosts Stroke Risk More Than Do Hypertension, Diabetes

Cerebrovascular Accident (CVA) = stroke Magnetic Resonance Imaging

While stroke rates have been declining for some time in the western world, new research suggests that this trend may be set to reverse, with a worrying increase in stroke rates occurring in the younger age group.

A new study, published online November 23 in the Journal of the American Heart Association shows stroke rates continuing to decline in people aged 55 years and older, but in those aged under 55 years the incidence of stroke appears to be increasing.

"There appears to be a golden generation — the baby boomers born between 1945 and 1954, who have the lowest risk of stroke," lead author, Joel N. Swerdel, MS, MPH, Rutgers University School of Public Health, New Brunswick, New Jersey, commented to Medscape Medical News. "In people born from 1955 onwards, the stroke rate is rising again."

The study — which analyzed a database of all hospital discharges in New Jersey from 1994 to 2014 — found that between 1995–1999 and 2010–2014, the rate of strokes doubled in those aged 40 to 44 years and more than doubled in people 35 to 39 years.

Commenting on the findings for Medscape Medical News, Ralph L. Sacco, MD, professor and Olemberg Chair of Neurology, Miller School of Medicine, University of Miami, and president-elect, American Academy of Neurology, said, "This is an interesting set of data that suggests an alarming trend for rising stroke rates among younger adults."

The data confirm what has also been observed in other cohorts, he added. "Although stroke rates have been declining, the decline may be levelling off in older adults and actually increasing in younger adults."

The researchers suggest the trends are all to do with lifestyle factors.

"People born between 1945 and 1954 seem to have benefitted from better living standards and healthcare than those before them, and this would have been the first generation with the knowledge that smoking kills," Swerdel said. "But they have also escaped the sugar revolution and the obesity and diabetes epidemics which are affecting those born later. The influx of heavily sugar-laden food didn't really start until the mid-60s, so those born in the 40 and 50s were not brought up on sugar-coated cereals and the like. This likely explains the increase in obesity and diabetes that occurred in later years."

A 'Wake-Up Call' for the Younger Generation

He stressed that younger people need to take heed of these new data. "This is a wake-up call. People in their 30s and 40s have time and the opportunity to improve their lifestyle and take medications to control risk factors to head off these effects."

Dr Sacco agreed that lifestyle factors are the culprit. "We have definitely improved the control of smoking, blood pressure and cholesterol, but obesity, physical inactivity, poor diet, and diabetes are still on the rise. These conditions could be having a detrimental effect on stroke rates in younger adults."

He added: "The American Heart Association/American Stroke Association has made improving the cardiovascular health of all Americans across all age groups a major strategic priority for 2020. We need to get younger people more focused on healthy habits, such as regular exercise, following the AHA [American Heart Association] diet, and losing weight before it is too late. It is never too early to start thinking about improving heart and brain health."

For the study, the researchers obtained data on stroke and ST-segment elevation myocardial infarction (STEMI) for the years 1995–2014 from the Myocardial Infarction Data Acquisition System, a database of hospital discharges in New Jersey. Rates by age for the time periods 1994–1999, 2000–2004, 2005–2009, and 2010–2014 were obtained by using census estimates as denominators for each age group and period.

Results showed the rate of stroke more than doubled in patients aged 35 to 39 years from 1995–1999 to 2010–2014 (rate ratio [RR], 2.47; P < .0001). For the same time period, comparison stroke rates doubled in the age group 40 to 44 years (RR, 2.01; P < .0001) and showed a 23% increase in those aged 50 to 54 years (RR, 1.23; P = .001).

In contrast, strokes rates in those older than 55 years decreased during these time periods.

Those born from 1945 to 1954 had lower age-adjusted rates of stroke than those born both in the prior 20 years and in the following 20 years.

STEMI rates, however, showed a different pattern, decreasing in all age groups and in each successive birth cohort, although the reduction did appear to be flattening out.

"STEMI rates have dropped like a rock over last 20 years, but this fall is getting slower in the younger age groups," Swerdel commented. "This has also been seen in other US-wide data and has been attributed to the increase in diabetes we are seeing recently."

Dr Sacco said it was surprising that STEMI did not follow the same pattern as stroke, but he noted that the two conditions may be affected differently by different risk factors, with cholesterol control having a greater impact on for myocardial infarction than for stroke.

Study coauthor John B. Kostis, MD, professor of cardiology, medicine and pharmacology, Rutgers Robert Wood Johnson Medical School, New Brunswick, agreed. "Stroke may be more affected by blood pressure than STEMI, while STEMI is more affected by LDL [low-density lipoprotein] cholesterol. But we didn't have data on these risk factors in this study — just reasons for admissions to hospital."

Dr Kostis pointed out that while cardiovascular and cerebrovascular diseases have been declining in the West, they are growing in newly developed countries such as Russia, India, and Asia. "We had thought we had dealt with this in the US, but it appears that it might be coming back again."

He added: "The message is clear. We have to start taking care of ourselves early in life and continue this throughout life. Don't smoke, look after your weight, partake in exercise, take medicines for blood pressure and cholesterol if they are high. Start all these things early in life."

Quoting the Latin "Dum spiro spero — While I breathe, I hope," Dr Kostis said of their findings, "Yes, this is a red flag but we can do something

J Am Heart Assoc 23Nov2016

Ischemic Stroke Rate Increases in Young Adults: Evidence for a

Generational Effect? Joel N. Swerdel et al the Myocardial Infarction [MI = heart attack] Data Acquisition System (MIDAS 29) Study Group, Javier Cabrera, John Pantazopoulos and Davit Sargsyan

Journal of the American Heart Association. 2016;5:e004245 23Nov 2016

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

How to Make a Book Paul Johnson illustration, lettering vs calligraphy, two stories parallel one in pictures one in word content, colophon, story arc, crisis, resolution, safe return home, titling, cover art, back cover endorsements, scan code, author statement.

Mental health disorders precede chronic physical health conditions. JAMA Psychiatry 2016:73(2)150-158 Public Health Mental and Medical Comorbidity Elizabeth Reisinger Walker and Benmamin Druss.

Marijuana heart attack = myocardial infarction, Takotsubo cardiomyopathy Super Bowl Heart Attack, Broken Heart Syndrome Angry outbursts tied to heart problems Northwestern University 10Jun2016 New research on emotions and health also links stonewalling to back pain.

Those who rage with frustration during a marital spat have an increased risk of cardiovascular problems such as chest pain or high blood pressure later in life, according to new research from Northwestern University and the University of California, Berkeley. Conversely, shutting down emotionally or “stonewalling” during conflict raises the risk of musculoskeletal ailments such as a bad back or stiff muscles, according to the study, published online in the journal Emotion. It’s well known that negative emotions may harm physical health, but it turns out that not all negative emotions have equal consequences. Using 20 years of data, and controlling for such factors as age, education, exercise, smoking, alcohol use and caffeine consumption, the researchers were able to connect specific emotions to corresponding health problems. Overall, the link between emotions and health outcomes was most pronounced for husbands, but some of the key correlations also were found in wives. The researchers analyzed married couples in the throes of tense conversations for just 15 minutes, but that was long enough to predict the development of health problems over 20 years later. The findings could spur hotheads to consider such interventions as anger management, while people who withdraw during conflict might benefit from resisting the impulse to bottle up their emotions, the researchers said.

Working age Americans dying at faster rate than young or elderly 6May2016 American Association for Advancement of Science

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

infectious disease Budget of Dumb Asses. 2016 Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016 I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

First generation where parents functionally cognitively outlive children. Early marijuana use may result in abnormal brain function and lower IQ researchers in London, Ontario have discovered. Previous studies have suggested that frequent marijuana users, especially those who begin at a young age, are at a higher risk for cognitive dysfunction and psychiatric illness, including depression, bipolar disorder and schizophrenia. Dr. Elizabeth Osuch, a Scientist at Lawson Health Research Institute and the Dr. Joseph Rea Chair in Mood Disorders at the Schulich School of Medicine & Dentistry at Western University, is a Canadian leader in studying both mood and anxiety disorders and the effects of marijuana.

Dr. Osuch and her team recruited youth in four groups: those with depression who were not marijuana users; those with depression who were frequent marijuana users; frequent marijuana users without depression; and healthy individuals who were not marijuana users. In addition, participants were later divided into youth who started using marijuana before the age of 17 and those who began using it later or not at all. Participants underwent psychiatric, cognitive and IQ testing as well as brain scanning. The study found no evidence that marijuana use improved depressive symptoms; there was no difference in psychiatric symptoms between those with depression who used marijuana and those with depression who did not use marijuana. In addition, results showed differences in brain function among the four groups in areas of the brain that relate to reward–processing and motor control. The use of marijuana did not correct the brain function deficits of depression, and in some regions made them worse. Of additional interest, those participants who used marijuana from a young age had highly abnormal brain function in areas related to visuo–spatial processing, memory, self–referential activity and reward processing. The study found that early marijuana use was also associated with lower IQ scores. The study, “Depression, marijuana use and early–onset marijuana use conferred unique effects on neural connectivity and cognition”, was published in the journal Acta Psychiatrica Scandinavica 2016

Confounding of dementia diagnosis in women by facile verbal function which obscures with plausibility deteriorating capacity for planning logic decision making executive frontal cortex cognitive skill

measles risk to cancer patients, transplant patients, chronic steroid users SLE systemic lupus erythematosus patients, RA rheumatoid arthritis patients, autoimmune disorder patients on chronic steroid ttherapy. Autonomy right to refuse vaccination impacts wider population herd immunity, impinging on the rights of others without innate protective immunity to maintain their health. SSPE subacute sclerosing panencephalitis appears 10 years after initial measles infection, orchitis, pneumonia.

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

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infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

Nkishi of Songye of Congo Basin. Large male head, hands on distended abdomen carrying ritual magical items which engage spiritual powers. The Nganaga chooses which magical ingredients bishimba to use. Protective against epidemics (like the current measles epidemic in Ireland) or for an indivudal with a specific disease like trypanosomiasis. International Journal of Infectious Diseases

Undervaccinated Kindergarteners

JAMA. 2016;316(20):2079 The vast majority of US kindergarteners received a passing grade for being fully vaccinated on their first day of class last year. Even so, many kindergarteners are undervaccinated because they haven’t completed their immunization doses. For the 2015-2016 school year, the CDC collected school vaccination data from all 50 states and the District of Columbia. The data showed that median vaccination coverage was 94.6% for 2 doses of measles, mumps, and rubella vaccine (MMR); 94.2% for diphtheria, tetanus, and acellular pertussis vaccine (DTaP); and 94.3% for the 2-dose varicella vaccination in the 42 states that require it. Coverage with MMR vaccine increased in 32 states last year, likely due to the 2015 measles outbreak primarily among unvaccinated children in 18 states. Centers for Disease Control and Prevention CDC 22/29Nov2016.

Fatal measles complication occurs more often than realized 2Nov2016

Sharon Worcester Frontline Medical

Key clinical point: SSPE, a fatal complication of measles, can develop years after measles infection and appears to occur much more often than published reports suggest.

Major finding: The incidence of SSPE among measles cases was 1 in 1,367 children under age 5 years and 1 in 609 children under age 12 months at the time of measles disease.

Data source: A review of records and 17 cases of SSPE subacute sclerosing panencephalitis at IDWEEK infectious disease week 2016 NEW ORLEANS A fatal complication of measles known as subacute sclerosing panencephalitis (SSPE) can develop years after measles infection and appears to occur much more often than published reports suggest, according to a review of cases in California from 1998 to 2015.

The findings underscore the vital importance of herd immunity by vaccination, Kristen Wendorf, MD, reported at an annual scientific meeting on infectious diseases.

The risk of SSPE, a neurologic disorder that is 100% fatal, decreases with routine measles vaccination, but is of particular concern in unvaccinated infants who contract measles. During the study period, 17 cases were identified, and a subanalysis of data from the California Department of Public Health (CDPH) showed that the incidence of SSPE among measles cases was 1 in 1,367 children under age 5 years and 1 in 609 children under age 12 months at the time of measles disease, said Dr. Wendorf of the CDPH, Richmond, Calif.

The incidence of postmeasles SSPE was previously thought be about 1 in 100,000, according to an IDWeek Infectious disease week press release.

“There is no cure for SSPE, and the only way to prevent it is to vaccinate everyone against measles,” the release stated.

The cases in the current study were among children with a clinically compatible illness, and either measles IgG antibody detected in cerebrospinal fluid, a characteristic pattern on electroencephalography, typical histologic findings on brain biopsy, or medical record documentation of SSPE-related complications. They were identified based on death certificates, reports from the Centers for Diseases Control and Prevention, or through investigations for undiagnosed neurologic disease. Twelve of the 17 affected children had a clinical history of a febrile rash illness compatible with measles, and all 12 of those experienced illness before age 15 months and before measles vaccination.

Most (67%) were living in the United States when they had measles, Dr. Wendorf said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

The median age at diagnosis of SSPE was 12 years, although the range was 3-35 years, and the mean latency period was 9.5 years. In many cases, long-standing cognitive or motor problems were experienced prior to diagnosis, she noted.

The findings suggest that SSPE is more common than previously recognized in unvaccinated children with measles during infancy, Dr. Wendorf said.

Protection of infants younger than 12-15 months of age – before the time when measles vaccine is routinely administered – and in those who can’t be vaccinated because of immune system disorders requires avoidance of travel to endemic areas [Europe]. Parents also may consider early vaccination prior to such travel.

Further, clinicians should be aware of the risk of SSPE in patients with symptoms suggestive of the disease. This is true even among older patients in whom no specific history of measles infection is known, she said.

In the press release, coauthor James D. Cherry, MD, professor of pediatrics at the University of California, Los Angeles, further stressed the importance of protecting unvaccinated infants.

“Parents of infants who have not yet been vaccinated should avoid putting their children at risk. For example, they should postpone trips overseas – including to Europe – where measles is endemic and epidemic until after their baby has been vaccinated with two doses,” he said. “It’s just not worth the risk.”

infectious disease blog- Budget of Dumb Asses. 2016 Edition.

Mark Crislip, MD, Infectious Diseases, 01:16PM Oct 22, 2016

I am somewhere over Western Washington. Not Washington State. I live in the Portland, so Washington is always the slighter lessor state to the North. The capitol is Washington DC. Anyway. I am heading east to play in Charleston for a few days before going to ID Weak in New Orleans to sit in an overly air conditioned rooms listening to mostly unexcited speakers read me their powerpoint slides telling me things I already know. I can hardly wait. I can feel the pressure sore just thinking about it. The things we do for CME. Between blogging and podcasting I easily spent 30 hours a month on medical education, but I have yet to figure out how to get CME for it. I may spend most of my time in the hotel bar where the vieux carre was invented. I'll probably learn more, like the symptoms of alcoholic hepatitis and the DT's.

But since I will not be on the wards for the next week I will have to clinical material with which to wow you. So now is a good time to publish my yearly rant about flu vaccination.

Some clarifications and notes.

I have been publishing this yearly for at least a decade. For those of you who get upset at what some may deem unprofessional, high school level name calling, stop here. No point in reading futher as your delicate sensitivities will be offended. And there no point in complaining as there is zero chance it will alter this or future editions of this entry.

This essay is directed at healthcare providers, not patients or the public. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the worlds medical knowledge and should be able to rise above superstition and ignorance.

There are those in the past who have objected to the term Dumb Ass in a medical blog. Not professional, they say. Perhaps. But this is an opinion piece, and my opinion of excuses for not getting the flu vaccine. Sure, an opinion supported by the medical literature and reality, but an opinion none-the-less. Dumb Ass is the milder form of the phase that actually goes through my mind and my honest reaction to HCWs who do not get vaccinated for any of the following reasons. If the shoe fits and all that.

The main reason for getting the flu shot is to protect our patients and I have zero respect for HCWs healthcare workers who do not put patients first.

This essay is not meant to convince anyone. It is clear that opinions that are not derived from evidence and critical thinking are amenable to alternation by evidence and critical thinking.

This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about (influenza) vaccines may not be an effective approach to promoting immunization.

Health care workers who use the following excuses to avoid vaccination are like astronomers believing in astrology, physicists believing in a perpetual motion, or chemists believing in homeopathy. If you are not convinced by the voluminous information at the CDC and and the 27,143 articles on PubMed, 2000 words by me are not going to change your mind.

At the end are a list of links to the heavily referenced articles I have written on various aspects of the flu and the flu vaccine. Someone is sure to mention Jefferson/Cochrane in the comments, read links 2,3,4,5 below before you do to see why that may not be the most compelling of arguments.

And, yes, I too am a Dumb Ass, but for different reasons.

So I'll be back in a week and in the meantime, like It's the Great Pumpkin Charlie Brown, a fall tradition:

I wonder, are you one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested and there is an egg free vaccine), you may have had Guillain-Barre (most can be vaccinated safely and the risk of GBS is much higher from influenza than the vaccine), in which case I will cut you some slack. Not much. But some. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.

The flu shot gives me the flu. Dumb Ass. The shot is a killed vaccine. It cannot give you influenza. It is impossible to get flu from the influenza vaccine, either from the shot or the live attenuated vaccine.

I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool. As a HCW, when you do get influenza and come to work, you can pass it on to the most vulnerable hosts, you patients. Nice going.

Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. Like your patients. You can help prevent your old, sickly grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Influenza, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, granny may be sitting on a fortune that will come to you, and killing her off with influenza is a great way to get her out of the way and never be caught. That would make a good episode of CSI.

I can prevent influenza or treat it by taking echinacea, vitamin C, vitamin D, oscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy against flu, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you cant boost your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.

Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach flu? No such thing.

I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Anaphylaxis from the vaccine. Former President Clinton, who evidently doesn't inhale. And people who are safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough to decrease the chance of passing the virus on to your vulnerable patients.

I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot.

The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.

I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect (60% effective in preventing the flu, depending on the population tested) and you may have indeed had the flu. But it is superior to doing nothing. More likely you called one of the many respiratory viruses (viri?) people get each year that they call the flu. Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? That is like saying, I do not believe in reality. Belief is what you do when there is no data. You probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

I will wait until I have symptoms and stay home. Dangerous Dumb Ass. About 1 in 5 cases of influenza are subclinical and hospitalized patients are more susceptible to acquiring influenza from HCWs than the general population with 27% of nosocomial acquired H1N1 dying. And you will never realize that you were the one responsible for killing that patient by passing on the flu.

The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 2462 references on the PubMeds on safety of the flu vaccine as I write this and the vaccine usually causes at most only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. And if you are worried about toxins, good news. There are neither toxins, mercury (single dose vaccine) nor gluten in the flu vaccine. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.

The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesnt work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable compared to the others. Paranoid Delusional Dumb Ass. You probably think General Jack D. Ripper offers a rational argument rather than satire. Besides, this year we are putting the vaccine with it's nanobots in the chemtrials.

You can't be trusted as you and yours are Big Pharma shills. This charge is perhaps the last refuge of Dumb Asses. In my case, it is not true. In 33 years I have taken almost nothing from any drug company. Plug my name into Dollars for Docs. Zip. The one 'gift' I have accepted is a Fleets enema package with a Unasyn sticker on it, given to me years ago by the Unasyn rep on his last day, to show his opinion of me. And really, Dumb Ass may be infantile, but there is no worse insult than to call a physican a shill. It implies that a physician is deliberately ignoring or spinning the literature to harm patients for money. It is the ultimate slander. And sadly the editors of Medscape have no issue with calling me and mine shills.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

So for good or ill, I have to take full credit for doing all this on my own with no external bribes.

So get the vaccine. And pass this essay on to someone else instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

One final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year. Despite that information, when you are admitted to the hospital you have a greater than one in four chance that the HCW taking care of you is ignoring that information and going unvaccinated. So they are putting you and yours at risk for no legitimate reality-based reason.

The preponderance of data is clear: when health care workers are vaccinated against the flu, patient mortality declines.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough Dumb Ass to avoid the flu vaccine, in what other areas of medicine are they equally incompetent ? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is Dumb Ass enough to not get the flu vaccine, putting you and yours at risk when most vulnerable? Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a Dumb Ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers, even though sick, vulnerable people should be able to trust that their HCW is maximally protecting them. No one wants to piss off their HCW, especially if that person holds the key to the morphine.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

My co-bloggers and I over at Science-Based Medicine, the home of big pharma shills, have written at length about vaccines, influenza, the influenza vaccine, and the anti-vaccination movement. Here are links to some of my extensively referenced essays on influenza and vaccines, including essays on that pile of fetid dingoes kidneys that is the Cochrane Reviews (2-4) on influenza vaccine and treatment. Laissez les bons temps rouler.

1922 museum expedition Brooklyn Museum Nkishi plural is mankishi, community Songre Power Figures collectively benefit all as protection from infectious epidemics witchcraft war and famine

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