Week of December 4, 2023
On Friday, a young patient I've cared for since 2007 (when she was a late teenager) had a routine office appointment. She brought her husband to the visit, and for his entertainment, she recounted our years of working together, repeating (often verbatim) the many ways I've attempted to educate her about her illness and its consequences - from blood pressure control to family planning (pregnancy can be more difficult with kidney dysfunction). My typical practice patient is about 76 years old. While the most satisfying aspect of nephrology is the long-term relationships, it is atypical for a patient to recall (with the clarity of youth) all the absurd and mildly provocative comments a physician might employ while "coaching" a chronically ill, super outgoing teenager transitioning into adulthood. It is a good reminder of how much weight words can carry. And I am grateful this patient thinks I am amusing and helpful.
(P.S. The patient permitted me to write about her.)
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Over the last two weeks, hospital admissions are up by about 5%. Wastewater RNA concentrations are tracking similar to post-Thanksgiving COVID surges from 2022 and 2020 (see the YOY data on the wastewater link below). Here are some of the data trends we will likely see for the next few weeks - 65 and older individuals in Illinois are seeing a rapid rise in hospitalizations.
https://x.com/jpweiland/status/1731431381631205630
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 articles
I note the relative lack of media interest in the COVID variants (remember the Omicron discussions?). This dearth of attention is partly due to the rapidity with which the virus is mutating - it is hard to keep up with the names and letter designations. Second, the variants are now overlapping - typical people don't know (or care) what variant they get. Yet, understanding how new and emerging variants respond to prior vaccination or infection can be significant. Here are some resources:
CDC variant data: https://www.cdc.gov/nwss/rv/COVID19-variants.html
Yale offered a 1-pager on variant EG.5 (Eris), the most common variant sequenced in U.S. wastewater in the last 30-60 days.
https://www.yalemedicine.org/news/covid-eg5-eris-latest-coronavirus-strain.
In Europe, the predominant strains are now BA.2.86, HV.1, and JN.1. These will likely be common in the U.S. shortly.
https://www.nbcnews.com/health/health-news/covid-variants-know-jn1-ba286-rcna127648
I push my patients (and family) to get each new vaccine formulation. The more recent and updated XBB vaccines offer the most protection against the latest strains.
Dr. Victoria Male (immunologist) offered a collection of voluminous data demonstrating ongoing vaccine safety and efficacy in pregnancy. While no one study is perfect, there are now three prospective trials and 40 observational studies (including more than 450,000 individuals) indicating the protection offered from immunization vs. the increased risk of preterm birth, preeclampsia, stillbirth, or neonatal death associated with COVID-19 infection, unvaccinated pregnant women.
https://docs.google.com/document/d/19FNXcmdI0MU6RPmvKYo_g9zEWPKl2-l760OX_8zww3E/edit
and
https://twitter.com/VikiLovesFACS/status/1730535626687050052
Proceed with caution on her Twitter feed - anti-vaccine, anecdotal data lovers are out in force.
https://x.com/VikiLovesFACS/status/1730560345545023763
As I have said, vaccine hesitancy is often an intellectual pit of self-reinforcing cognitive biases - a synergy of loss aversion and the gambler's fallacy. These individuals 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 the consequences of getting COVID.
For reference:
Loss aversion: https://community.thriveglobal.com/why-we-focus-on-losses-more-than-wins/
Gambler's Fallacy: https://thedecisionlab.com/biases/gamblers-fallacy
Medical Trends and Technology
I will introduce this topic with the article's headline, "Tiny robots made from human cells heal damaged tissue." It is bench-top science, but still pretty damn cool.
"Scientists have developed tiny robots made of human cells that repair damaged neural tissue. The 'anthrobots' were made using human tracheal cells and might be used in personalized medicine in the future."
and
"Anthrobots can spontaneously fuse to form a larger structure called a 'superbot,' which was able to encourage the growth of neurons."
I believe I received anthrobots that merged into a superbot for Hannukah in 1986.
https://www.nature.com/articles/d41586-023-03777-x
Infographics
The Chemistry of Hunger, Satiety, and Digestion
https://twitter.com/compoundchem/status/1727446733242675579/photo/1
Things I learned this week
I found several articles about the trade-offs of time, money, and happiness.
This economics paper demonstrates that in middle and upper-class cohorts, buying free time, i.e., buying services like grocery shopping or lawn care, promotes happiness. My favorite takeaways are the notions of "prosperity-induced time scarcity," "time famine," and the time-pressure to life satisfaction spectrum.
https://www.pnas.org/doi/10.1073/pnas.1706541114
and
https://x.com/emollick/status/1730977811806945689
On the other end of the economic spectrum, a recent multi-armed study from MIT economists (and their company GiveDirectly) tested several methods of Universal Basic Income (UBI) in rural Kenya - a $500 single lump sum, $20 a month for two years, or $20 a month for 12 years. Over the first two years, the lump sum and the 12-year groups demonstrated more entrepreneurial and long-term investment activities. There was no evidence the payments discouraged work or increased purchases of alcohol.
How translatable are these results outside of rural areas of less developed nations? Asked and answered, to some degree.
Living with A.I.
How about letting an LLM with multi-agent A.I. act as a multi-player strategy tool to simulate countries' various actions and reactions in different wars? We can do that. It's like the 1983 Matthew Broderick movie War Games on steroids and without Matthew Broderick. This paper demonstrates how LLM AI tools can simulate various permutations of historical events and offer counterfactuals and alternative probabilities. It is a long read, but poking through the results and conclusions is fascinating. Imagine other uses for multi-agent A.I. counterfactual scenario generators - business plans, life coaching, and fantasy sports (to name a few). (A quick Google search demonstrates numerous A.I.-driven fantasy football simulators.)
https://arxiv.org/pdf/2311.17227.pdf
and
https://twitter.com/emollick/status/1731059401107153281
And for all the non-GenX folks out there, https://en.wikipedia.org/wiki/WarGames
Dr. Eric Topol highlighted an amazing meta-analysis of 33 trials (including 27,000 patients) demonstrating the value of A.I.-supported colonoscopy. This means having A.I. read real-time images from a colonoscope during the procedure, highlighting areas of suspected pre-cancerous polyps. Overall, these studies demonstrated a decrease in missed polyps and an increase in identified polyps per colonoscopy. Future studies will need to monitor for increased colonoscopy time, data on cost-effectiveness, and the number of false-positive polyp resections. The authors address some of these concerns in their discussion. Overall, this is an excellent example of A.I.-augmented healthcare quickly demonstrating value.
https://erictopol.substack.com/p/the-ai-resident-enters-the-colonoscopy
and
https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00518-7/fulltext
AI-generated social media stars and models (with 18+ content) now appear in advertisements. Meet Aitana Lopez, who now has 200K followers. Her creator (generator?), Ruben Cruz (who owns a modeling agency), makes over $10K monthly on Aitana.
https://x.com/heyronir/status/1730818748981158299
A.I. art of the week. I now use DALLE-4 (through ChatGPT Pro) with Runwayml.com's A.I. animation from text and image generator).
"A human with sunglasses and a Hawaiian shirt sitting in a lawn chair, holding a tropical drink. Nearby, one robot is photographing another robot in a sultry pose in front of a backdrop. The setting has a relaxed, tropical feel with foliage in the background."
https://app.runwayml.com/creation/cb4a7934-44c2-45db-96c2-ecf634590636
(Don't forget to hit play to see it move!)
Clean hands and sharp minds,
Adam
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