Week of November 13, 2023
Recently, a patient told me, "I do not trust the FDA." This person seeks out "natural" supplements, believing they are inherently better than a medicine or device approved by a government agency, mainly because the approving body is a government agency. Since the height of the pandemic, anti-science is emerging in areas of healthcare beyond vaccines. Irrespective of why this is happening, it is a significant challenge I am not well equipped for - the discussions take time, a disproportionate amount of energy, and often unsatisfyingly end by agreeing to disagree.
I'm sorry; this week's newsletter shows that this topic is on my mind.
A link to Dr. Peter Hotez's recent interview and his book on anti-science.
https://www.jci.org/articles/view/176284
and
https://www.goodreads.com/book/show/123164088-the-deadly-rise-of-anti-science
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Wastewater mRNA concentrations are rising - while hospitalizations are still falling. These data are consistent with many anecdotes of asymptomatic or minimally symptomatic infections across schools, hospitals, and other communities. Remember, strategic masking and air filtration help.
The N.Y. Times COVID Tracker reflects only CDC-gathered hospital data. Hospitalization data are a (lagging) indicator.
https://www.nytimes.com/interactive/2023/us/covid-cases.html
Wastewater monitoring is more of a LEADING indicator.
The Inside Medicine COVID dashboard
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COVID-related articles
In the same vein as my patient who prefers supplements, several articles on vaccine hesitancy (and its complications) showed up in my news feeds last week.
The CDC reported that 3% of children entering kindergarten during the 2022-2023 school year obtained a vaccine exemption from their state, the highest exemption rate ever documented in the U.S. These data speak to the actual damage of the anti-science movement. Vaccine hesitancy is an intellectual pit of self-reinforcing cognitive biases - a synergy of loss aversion and the gambler's fallacy. Patients over-value low-probability events and anecdotal data (such as potential side effects or known low-frequency vaccine complications) while significantly undervaluing protection from higher-likelihood events, like severe or permanent illness from COVID, flu, and RSV. For children, not vaccinating against preventable diseases can be even more consequential - such as death (like measles) or permanent disability (like mumps).
NBC News report about the CDC data:
The CDC Report
https://www.cdc.gov/mmwr/volumes/72/wr/mm7245a2.htm?s_cid=mm7245a2_w
A 2022 peer-reviewed journal article exploring cognitive bias in parental vaccine hesitancy:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9289735/
Loss aversion:
https://community.thriveglobal.com/why-we-focus-on-losses-more-than-wins/
Gambler's Fallacy:
https://thedecisionlab.com/biases/gamblers-fallacy
Two related articles:
Man dies of rabies after refusing vaccine post-bat bite. He was "afraid of vaccines."
https://thebulletin.org/2023/09/rabid-anti-vaxxers-could-help-spread-deadly-disease/
Finland's public health campaign promoting the use of the HPV vaccine has been very successful. Rates of the cancer-causing types of HPV are so low that routine testing (in the latest generation of vaccinated Finnish females) may no longer be warranted.
https://www.statnews.com/2023/11/08/hpv-vaccines-cancer-screenings/
Medical Trends and Technology
At the American Heart Association meeting last week, researchers reported data from a large, well-designed trial looking at the impact of Wegovy (the GLP-1 drug, also known as semaglutide or Ozempic) on the risk of heart attack, stroke, or death. Reading both the lay media's interpretation of the study and a more data-driven review is essential. This study is an important step forward in care, but I suspect these data will further fuel an "irrational exuberance" about these drugs. Either way, this is a great real-world example of how nuanced medical data reporting needs to be.
New York Times
"Wegovy Is Shown to Reduce Risk of Heart Attacks and Strokes in Some Patients"
Eric Topol's review is a more balanced review of the data:
https://erictopol.substack.com/p/the-big-trial-of-a-glp-1-drug-wegovy
Topol offered several important take-home points about the same data:
- Semaglutide reduced major cardiovascular events in a high-risk population by 20% - the first drug directed at obesity to achieve this goal.
- The 40-month follow-up of this study (the longest thus far for a large trial of semaglutide vs placebo) offers increased confidence in the safety of these medications.
- However, the absolute reduction of cardiovascular disease is only 1.5 per 100 people treated - and the people in the trial were at very high risk for heart attacks and strokes. To be clear - these data tell us that 1.5 out of every 100 very high-risk patients have a reduced risk of heart attack and stroke when treated with Wygovy for 3+ years (at an average of $1300 per month).
- There is no exit strategy. Weight loss (and presumably the resultant cardiovascular protection) is maintained only with ongoing drug use. These drugs (GLP-1s) are associated with loss of muscle mass and bone density - which may lead to long-term consequences (illness and healthcare costs) that we don't yet fully appreciate.
Infographics
The U.K. sleep-related review website Morning Life analyzed Google data on dream interpretation queries and sorted them by country. Oddly, "teeth falling out" is the most frequently searched-for dream in the U.S., U.K., Nordic countries, and Australia. Much of the rest of the world is dreaming about snakes. If you are born elsewhere and move to the U.S., do you dream about snakes falling out of your mouth?
https://morninglife.co.uk/wp-content/uploads/2022/03/01_Dreaming-Across-Borders_World-Map_Hi-RES.png
from
https://morninglife.co.uk/most-common-dream-by-country/
Things I learned this week
A loyal reader who knows my proclivity for historical reading on ancient Rome pointed me to this amusing set of articles stemming from an informal TikTok poll: "How Often Do Men Think About The Roman Empire?" The answer, it appears, is more than you might think.
and
https://www.washingtonpost.com/lifestyle/2023/09/14/roman-empire-trend-men-tiktok/
Speaking of which (and a case in point), I am reading Cambridge University classics Professor Mary Beard's recent book Emperor of Rome (https://www.goodreads.com/en/book/show/128747007). Beard's book is a fantastic discussion about the politics, public relations, and best-knowable realities of ancient Roman autocrats. Beard details numerous anecdotes filled with curious ephemera and rabbit holes worth following. One such story I dug into is from Beard's chapter on imperial dining as a demonstration of power. I found an article detailing the meaning and misinterpretation of Emperor Vitellius' famous dish, "The Shield of Minerva." Here is a taste (ahem) of the article:
Vitellius served the 'Shield of Minerva,' a platter filled with pike livers, pheasant and peacock brains, flamingo tongues, and lamprey milt (roe). As Vitellius' passion for food is [often] distorted into gluttony, the Shield of Minerva has been misrepresented as a culinary abomination and the worst of the emperor's excesses. [However,] critical reading of our sources reveals the dish as a mix of carefully chosen ingredients for their gustatory and visual appeal - driving political and military symbolism.
from
https://www.researchgate.net/publication/369072373_VITELLIUS_AND_THE_SHIELD_OF_MINERVA
To be fair, I think Vitellius's bust projects a certain "I eat peacock brains and flamingo tongue" sort of vibe.
https://simple.wikipedia.org/wiki/Vitellius
(FYI - I note that Professor Beard and this article's author, Professor Serena Connolly from Rutgers, are women.)
Living with A.I.
John Burns-Murdoch, the Financial Times data guru, offered a fantastic analysis of a recent paper looking at A.I.'s impact on the workforce - The Short-Term Effects of Generative Artificial Intelligence on Employment: Evidence from an Online Labor Market. Here's the punchline - having a mix of complex skills is a good strategy for not having your job replaced by artificial intelligence, at least for now.
https://x.com/jburnmurdoch/status/1722938749519077688?s=20
and the paper.
https://p apers.ssrn.com/sol3/papers.cfm?abstract_id=4527336
Former Apple employees have developed a wearable A.I. device worth checking out - the Humane AI Pin. It is like a Star Trek communicator - pins to your clothes and marries a cell phone + wearable Alexa + ChatGPT that monitors hand gestures, reports information audibly, and projects information on the user's palm. I'm sure it is just the first of many A.I. wearables and embedded A.I. tools we will see.
https://twitter.com/humane/status/1722668651705430154
Dr. Nathan Gray (assistant professor of medicine at the Johns Hopkins University School of Medicine and an artist) drew a comic/op-ed for the L.A. Times exploring the recent data reporting ChatGPT is more compassionate than human physicians. As best I can tell, the comic is hand-drawn.
https://www.latimes.com/opinion/story/2023-11-12/ai-healthcare-doctors-empathy-chatgpt
A.I. art of the week, based on text and topics from this week's newsletter
"A Dali-like painting of a physician with a computer monitor for a head (with "chatGPT" written on the screen) , wearing a white coat and having a stethoscope around his neck. The physician is surrounded by Roman centurions. They are all standing in front of the Roman colosseum."
https://drive.google.com/file/d/1YWQAPqlQuRJ3SDiRTARCeqIrhML9yFU1/view?usp=sharing
Clean hands and sharp minds,
Adam
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