Week of January 15, 2024
Healthcare often breeds cynicism. The combination of complex bureaucracy, underfunding, and frequently misaligned incentives (between patients, payers, and providers) feels like a mashup of Kafka and A Brave New World. However, there are moments of amazement. In clinic last Friday, a patient and I had a moment of shared, mutual optimism while updating their chart. The patient's kidney function-preserving medications, recent minimally invasive aortic valve replacement (TAVR), and nerve growth factor eyedrops are all a result of biotech and medical innovation from the last ten years. While there are dozens of hours of administrative work getting these treatments approved, I love hearing patients express gratitude for being alive at the right time in history.
History of Trans-catheter aortic valve surgery (just read the introduction):
https://www.ncbi.nlm.nih.gov/books/NBK431075/
History of Nerve Growth Factor (NGF) for ophthalmologic use:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8551931/
Shameless self-promotion - a 2016 article I wrote on the future history of dialysis:
https://www.healio.com/news/nephrology/20180227/zen-and-the-future-of-nephrology
P.S. - I am traveling next weekend and may be late on the newsletter.
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Hospitalization rates are still rising, but wastewater concentrations are plateauing, implying we may see the peak of the JN.1 surge in the U.S. in the next few weeks.
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.
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COVID articles
Fortune published a summary of a World Health Organization briefing on concerns I discussed last week - the gap between COVID-19 wastewater concentration data and reported COVID-19-positive testing rates, along with the risk of long COVID-19 due to repeat infections. In short - the virus may be more prevalent than we know; there are a lot of minimally symptomatic individuals, and the long-term effects of repeated infection are concerning.
And in the category of small silver linings, the pandemic has provided an endless series of new, specific insights into physiology. UC Berkley researchers recently submitted this pre-release paper (not yet peer-reviewed) that highlighted the mechanism by which coronavirus (and, I suspect, other viruses) makes infected individuals sneeze and feel like their "skin is crawling." They describe how the coronavirus releases a protein (papain-like protease) that activates specific nerves - a type of pain receptor - in the nasal lining and the skin, leading to sneezing and, possibly, the uncomfortable (but hard to describe) tingling, burning, and crawling sensation on the skin. The implications are interesting - I would love to have a nasal spray that mitigates sneezing or a topical agent that helps numb an area of skin more effectively.
https://www.biorxiv.org/content/10.1101/2024.01.10.575114v1
and
https://twitter.com/ejustin46/status/1745644524460818879?s=42&t=cHtDhpWgAdi0UhIayqsoag
Medical Trends and Technology
I have prescribed medical cannabis for a few years to a handful of chronic kidney disease patients with severe pain who are unable to use NSAIDs and opiates. However, I frequently remind them how many "unknown unknowns" there are - there is very little rigorous, peer-reviewed data on long-term cannabinoid use. Thanks to the wave of states and various countries decriminalizing cannabis, a trickle of better (but not great) data is emerging. There are many anecdotal positive data articles (pain relief, quality of life, improved appetite). However, Danish researchers recently published data demonstrating a slight increase in the risk of heart rhythm abnormalities amongst some patients (like cancer patients) who routinely use cannabis for pain relief. I am hopeful we will start to see more and better data, especially considering recent reports of the FDA recommending the removal of cannabis from the list of controlled substances. The Medscape article discusses some of the fascinating politics and problems behind cannabis science.
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehad834/7500071
and
and
https://www.nytimes.com/2024/01/12/health/marijuana-fda-dea.html
There is a large industry of consumer-focused "health screening" companies using ultrasound and MRI equipment to look for "early" asymptomatic diseases. There are anecdotes (often found on these companies' marketing materials) of individuals who detected some intervenable disease ("This MRI saved my life!"). However, population data indicates that consumer-driven screening is far more likely to generate increased healthcare costs and find benign or minor abnormalities that cause concern and a cascade of further testing. The New Yorker published a very thoughtful article on the trade-offs of the direct-to-consumer full-body scan industry. (To be clear, evidence-based age- and demographic-appropriate screening tests balance the good and bad - the probability of finding actual disease vs. false positives (e.g., colonoscopies after age 45). However, no data suggests wide-scale full-body imaging is cost-effective or clinically valuable.)
https://www.newyorker.com/science/annals-of-medicine/will-a-full-body-mri-scan-help-you-or-hurt-you
Infographics
https://informationisbeautiful.net/visualizations/timeline-of-the-far-future/
A few observations from a Timeline to the End of the Earth:
1) In 22,500 AD, the real estate market near Chornobyl will boom.
3) Check out the projected release date for George R.R. Martin's next GoT book in about 700,000 years.
4) Earth is only safe for another few billion years. Consider that in any investment strategies regarding point #1. We should encourage Elon to focus on Space X, so we have options.
Things I learned this week
Thanks to a colleague, I learned that there is a border crisis in North Dakota and Minnesota. We are on the cusp of an invasion of feral Canadian super pigs. Weaponized Canadian bacon is unsettling - conflating something good with destruction - the intellectual equivalent of horror movies and first-person shooter games made with (the now public-domain) images of Winnie the Pooh and Mickey Mouse.
and
https://en.wikipedia.org/wiki/Winnie-the-Pooh:_Blood_and_Honey
and
https://www.thegamer.com/horror-steamboat-willie-parodies-mickey-mouse-boomer-shooter-steam/
A loyal reader suggested Bill Bryson's book The Body, and I am overwhelmed learning a deluge of new (to me) medical ephemera. I thoroughly enjoy dry British snark applied to medical and scientific writing. For instance, Bryson taught me that Clemson University food safety researcher Paul Dawson publishes data on "the five-second rule," double dipping (like chips and salsa), and the bacterial transfer associated with blowing out birthday candles. Who knew there was data to fuel elementary school lunch table topics? Let me apologize in advance for inadvertently stoking germaphobic reader paranoia.
and
"Blowing out the candles over the icing surface resulted in 1400% more bacteria compared to icing not blown on. Due to the transfer of oral bacteria to icing by blowing out birthday candles, the transfer of bacteria and other microorganisms from the respiratory tract of a person blowing out candles to food consumed by others is likely."
https://www.ccsenet.org/journal/index.php/jfr/article/view/67217
Living with A.I.
The Danish researcher Mushtaq Bilal wrote a practical and tactical article on using A.I. tools for academic research. If you are not fluent in Danish, I suggest using Google Chrome's translation functions to read Bilal's advice.
Google published data on their latest medical LLM. Google compared humans vs. their LLM in performing medical consultations with patient actors via a chatbot. The Google LLM demonstrated appropriate clinical patient conversations while displaying empathy. This study followed the medical LLM matching clinical accuracy of trained physicians in 300 New England Journal of Medicine clinical case files.
https://twitter.com/GoogleAI/status/1745843740822933517
and
https://arxiv.org/abs/2401.05654
Google's A.I. tools are accumulating the skills needed to offer front-line patient interviews and a reasonable diagnosis and plan for typical diseases. While most patient interactions are not via chatbot today, it does not take much imagination to see where this trend is heading [like A.I. avatars offering real-time telehealth with, for now, a clinician doing the final approval of diagnosis and treatment plan].
A.I. art of the week
"Draw a picture of a person seeing a physician via telehealth on a large monitor in the style of Tomioka Tessai art."
https://drive.google.com/file/d/16nLRM6V79rwBhLPn2TsigNGbLGJKQ2oG/view?usp=sharing
A recent trip to the Smithsonian National Museum of Asian Art inspired this one. I am amused that the average of "doctors wearing stethoscope" is interpreted by DALL-E as all stethoscopes having a bell and ear pieces on both ends (look at the image's shoulders).
Clean hands and sharp minds,
Adam
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