COVID news and more 10/8/23

Overall, things are looking a bit better this week. Test positivity is down as are emergency room visits and hospitalizations for COVID. On the CDC wastewater map,  there is a high level of virus in New York State and parts of the northeast, in addition to North Carolina, Missouri, and Nebraska. Of note, Ohio, Louisiana, and Arkansas have not reported data recently. The major variants in circulation continue to be EG.5, FL.1.5.1 and HV.1.

When looking at Biobot wastewater data, we see that the Northeastern U.S. continues to have an increase in COVID cases, but there may be a plateau in virus levels in the Midwest, the West Coast, as well as the Southeast. Rumblings on Twitter said that there may be delayed reporting on Biobot this week.

JP Weiland reports that Biobot wastewater levels showed no further decline this week. He estimates that there are 575,000 new COVID infections a day in the United States at this time and that currently approximately 1 every 57 Americans are infected with SARS-CoV-2. Of note, Jean Fisch also reported on Twitter that SARS-CoV-2 wastewater virus levels have plateaued in Belgium instead of continuing to decrease. We’ll have to see what happens next week.

JP Weiland has put out a new modeling forecast for SARS-CoV-2 through mid November. He expects numbers of COVID cases to decrease until late November despite the growth of HV .1 and FLip mutations. For the last 3 years, a new COVID wave started after Thanksgiving and picked up after the Christmas holidays as many people got together to celebrate indoors without masks. I expect that the same will happen this year. Getting an updated COVID booster and a flu shot soon could help reduce the risks of respiratory viral infections over the holidays. See vaccines.gov for an appointment.

This week the Nobel Prize in Medicine went to Katalin Karikó and Drew Wiseman for their work on mRNA technology that made the development of mRNA vaccines against COVID-19 possible. Dr. Kariko believed that mRNA technology had promise when other scientists didn’t see her vision, which made it hard for her to get grant money. Despite being demoted at her old job four different times, she turned negatives into positives by continuing to move forward. “Don’t focus on what you cannot change,” Kariko says. “Because you are fired, don’t start to feel sorry for yourself. You just have to focus on what’s next because that’s what you can change.” 

Dr. Linsey Marr, an aerosols expert and professor of Civil and Environmental Engineering at Virginia Tech, won a MacArthur genius award. Dr. Marr showed that the SARS-CoV-2 virus is airborne as opposed to traveling only in large droplets that fall to the ground with gravity. Her work helped update public health guidelines to include the need of respirator masks (N95, KN95) to protect against aerosols of the virus and better ventilation in buildings. The work of Dr. Kariko, Dr. Wiseman and Dr. Marr surely helped to save lives during the pandemic.

COVID vaccines

Two days ago, the CDC reported that during January through August 2023, adults age 65 and older accounted for 63% of all COVID related hospitalizations. Of the people that were hospitalized, only 23.5% of them had received the COVID bivalent vaccine last year. It is important that people get the updated XBB.1.5 COVID vaccine this year, especially in higher risk people such as those over age 65, so as to help prevent hospitalizations and deaths from COVID in the coming months. In addition to getting the updated vaccine, the CDC recommends “adopting measures to reduce risk for contracting COVID-19” such as masking indoors and improving ventilation. Finally, the CDC recommends that people over age 65 seek prompt antiviral treatment like Paxlovid if they have a positive SARS-CoV-2 test.

There were several articles this week, talking about misinformation about COVID-19. Katelyn Jetelina and Kristen Panthagani MD PhD wrote a response to the Florida surgeon general's remark that he was “very uncomfortable, recommending the new COVID – 19 vaccine to anyone” as it is “anti-human.” They summarized: 

“Framing public health as anti-human is an incredibly dangerous game to play. Health policy decisions need to be grounded in an accumulation of evidence that provides a comprehensive picture of reality. He [Ladapo] combines legitimate points with profoundly foolish ones, which muddles the picture, creates a sense of false equivalency, and makes it difficult for the general public to discern the truth.”

An article in JAMA this week looked at a poll of 13,000 people and found that 6% (1 in 20) of people with COVID reported using non-evidence-based treatments, such as ivermectin and hydroxychloroquine. In contrast, 7.3% of the surveyed people used an FDA approved antiviral treatment such as Paxlovid.  “Among those using non-evidence-based medications, 30% of individuals using ivermectin and 14% of individuals using hydroxychloroquine reported that they did not receive these interventions from a medical professional, which suggests that studies relying on prescription databases to estimate such use are likely to substantially underestimate their use.” Individuals with greater scores on the American Conspiracy Thinking Scale were more likely to have received non–evidence-based medications. The article also reported that people got misinformation from social media and specific news channels. 

So far, approximately 4 million Americans have gotten the updated XBB .1.5 COVID vaccines in September 2023. This is similar to the total number of people who got the bivalent booster in 2022, so we are on track to have a higher total number of people boosted in 2023. 

The FDA authorized Novavax’s updated 2023 COVID vaccine. A study from JAMA shows that Novavax is about 50% effective against symptomatic COVID infections in the first four months after full vaccination. Novavax relies on an older, protein-based approach which has shown long lasting protection against other pathogens. However, since both the mRNA vaccines and the Novavax vaccine target the spike protein of SARS-CoV-2 they may have more similar responses than differences. Further studies, including head-to-head comparison of mRNA vaccines to Novavax, would be needed to see if there are any differences in protection.

MMR, Measles, Mumps and Rubella, is a safe vaccine that has been used for 50 years. Using 6-proline stabilized spike proteins from 3 different SARS-CoV-2 variants, plus measles and mumps antigens, a group made a “next generation” intranasal trivalent vaccine for SARS-CoV-2. The intranasal “MMS vaccine” given to mice induced strong SARS-CoV-2-specific neutralizing antibodies, mucosal IgA, and systemic and lung resident T cell immune responses that provided broad protection against the three COVID strains. 

Babies have a different response to SARS-CoV-2 than adults. A group tested blood samples and weekly nasal swabs of infants to better understand mucosal and systemic immunity to SARS-CoV-2 after birth and found that infants mount an antibody response that lasts for up to 300 days. Babies have an atypical innate response in blood and do not show inflammatory cytokines, but they do have increased interferon-alpha (IFNα), and other chemokines. Infants also showed a robust upper respiratory tract antiviral and inflammatory response.

A new study in Nature magazine shows that in the common cold coronavirus HKU1, the receptor binding domain of its spike protein remains closed and out of sight from our antibodies in order to evade our immunity. However, with the flip of a “sugar switch” called the “sialoglycan-based primary receptor to domain S1A”, this opens up the previously hidden binding domain and allows the coronavirus to attach to and enter human cells. This study gives “further insight into coronavirus attachment to host cells, with a possible dual receptor usage and priming of entry as a means of immune escape.”

Antiviral treatments

Comparing the antiviral efficacy of molnupiravir to Paxlovid, showed that while both drugs accelerated the clearance of virus in the nose and throat, the antiviral effect of Paxlovid was much better. Another study from Canada shows that Paxlovid was associated with a lower risk of death and hospitalization, but mostly in severely immunocompromised people. In their study, individuals who were not as severely immunocompromised did not see the same benefit.

The New York Times had an article this week about Paxlovid rebound. During the original Pfizer trials of Paxlovid, they estimated that about 2.3% of people who took Paxlovid had COVID rebound infections versus 1.7% of controls. However, another study from July 2023, showed that 14% of people who took Paxlovid had COVID rebound versus 9% in controls who did not take antiviral medications. As Dr. Michael Mina said, “if you test positive again on a rapid test, assume that you’re contagious… and take the necessary precautions: Isolate from other people as much as possible, and wear a high-quality mask if you go out in public or are around household members.” Rebound lasts 3 days on average but can range from 2 to 10 days.

Long COVID

In order to study clotting and inflammation in microvasculature, scientists made human vascular organoids from pluripotent stem cells which they then transferred to mice. With this human organoid-mouse model, they were able to see that the SARS-CoV-2 spike-ECD triggered inflammathrombosis in engineered human vessels and that complement factor D (CFD) mediated microvascular immunothrombosis. With this knowledge, they then tested an antibody to block Complement Factor D (CFD) in monkeys infected with SARS-CoV-2 and found that this protected them against immunothrombosis. This study shows that it may be possible to treat and prevent microvascular clotting in acute COVID infection, and possibly in Long COVID, using a CFD antibody. Further clinical studies in humans are needed to see if this holds true.

For the Long COVID community, Hannah Davis recommends an upcoming PolyBio Symposium on Friday 10/20/23 regarding Long COVID and ME/CFS research. She also posted about an MIT study currently recruiting people with Long COVID to evaluate the glymphatic system of the brain using MRI. 

In non-COVID news, California's CARE Court will allow relatives, health care providers and homeless outreach workers to be able ask state courts to compel certain people with severe mental illness (schizophrenia and other psychotic disorders) to accept treatment. US health officials propose using antibiotic doxycycline as a 'morning-after pill' treatment against sexually transmitted infections in gay and bisexual men and transgender women. 

High triglyceride levels can exacerbate the severity and complications of acute pancreatitis in NAFLD (nonalcoholic fatty liver disease). Science magazine had a review of Metabolic dysfunction–Associated Steatohepatitis (MASH, aka NAFLD) which has the “potential to progress to advanced fibrosis, leading to cirrhosis and liver cancer.”

GLP-1 agonists such as Ozempic and Wegovy were in the news because 250 people have reported to the FDA that they had suicidal thoughts after taking these drugs. In another study that compared GLP-1 agonists to bupropion-naltrexone for weight loss, the use of GLP-1 agonists was associated with increased risk of pancreatitis, gastroparesis, and bowel obstruction but not biliary disease. 

Two-thirds of all surgeons report work-related musculoskeletal disorders from operating often in twisted positions for hours, and 95% of pregnant surgeons had symptom exacerbation.

Husband and wife country music stars Garth Brooks and Trisha Yearwood are building houses this week in Charlotte, North Carolina for Habitat for Humanity in honor of Jimmy and Rosalynn Carter. It’s Fat Bear Week in Alaska and you can vote for your favorite by October 10th. You can see the finalist photos for the UK’s Comedy Wildlife Photo Awards and can vote for the People’s Choice Award here. 

Have a good rest of your weekend,

Ruth Ann Crystal MD

COVID news:

Walgreens positivity rate: https://www.walgreens.com/businesssolutions/covid-19-index.jsp

US Variant tracker: https://covid.cdc.gov/covid-data-tracker/#variant-proportions

CDC COVID data tracker: https://covid.cdc.gov/covid-data-tracker/index.html#datatracker-home

CDC COVID Hospitalizations (blue) and Emergency Room (orange) visits tracker: https://covid.cdc.gov/covid-data-tracker/index.html#trends_weeklyhospitaladmissions_7dayeddiagnosed_00

Weekly ED visits for respiratory illnesses, by age and disease: https://www.cdc.gov/ncird/surveillance/respiratory-illnesses/index.html

US Wastewater Monitoring:

CDC Wastewater Monitor https://covid.cdc.gov/covid-data-tracker/#wastewater-surveillance

Wastewater from NWSS and Biobot in a US

High in New York state, Pennsylvania, N. Carolina, Missouri, Nebraska, etc.

Ohio, Louisiana, Arkansas not reporting data recently.

Biobot wastewater data: https://biobot.io/data/

California wastewater level updates:

–Wastewater SCAN:

https://data.wastewaterscan.org/

  California statewide view https://buff.ly/3YObiul

Davis, San Rafael increasing the most

Sewer Coronavirus Alert Network (SCAN) project by Stanford University: 

Canada risk in different provinces: https://covid19resources.ca/covid-hazard-index/ 

• Click on “Today’s index scores, past scores”

10/5/23 The Globe and Mail: British Columbia, Canada COVID-19 hospitalizations up 58% in two weeks, as infections, deaths also spike https://buff.ly/3rLbTkb

Belgium:

JP Weiland math modeling using wastewater data to predict U.S. cases:

https://twitter.com/JPWeiland/status/1710060572174111039

10/6/23 Nobel Prize winner Katalin Karikó was 'demoted 4 times' at her old job. How she persisted: 'You have to focus on what's next' https://buff.ly/3LRDuHc

Nobel Prizes 2023: https://www.nobelprize.org/prizes/lists/all-nobel-prizes/

10/6/23 YLE: A response to Florida Surgeon General's anti-human remarks https://buff.ly/45oxigO

• This week the Florida Surgeon General said he is “very uncomfortable recommending the new Covid-19 vaccine to anyone” as it’s “anti-human.”

• Katelyn Jetelina and Kristen Panthagani MD PhD respond with real science and why this is a misleading and false statement. They conclude:

  

PolyBio Symposium Friday 10/20/23 https://polybio.org/polybio-fall-symposium-schedule/

10/5/23 PNAS: A next-generation intranasal trivalent MMS vaccine induces durable and broad protection against SARS-CoV-2 variants of concern https://buff.ly/46a5r5n

• MMS= Measles, Mumps and Trivalent SARS-2 nasal vaccine candidate, “built on a platform (MMR) with a 50-y safety record that also protects against measles and mumps.”

• Expected longer duration  with preS-6P.

• Intranasally delivered MMS induced strong SARS-CoV-2-specific neutralizing antibody, mucosal IgA, and systemic and lung resident T cell immune responses that provide broad protection against challenge with each of these three strains.

10/6/23 Science: Mapping SARS-CoV-2 antigenic relationships and serological responses https://buff.ly/3PHerrH

• Immune responses to 21 SARS-CoV-2 variants and 15 groups of human sera obtained from individuals after primary infection with one of 10 different variants or after D614G or B.1.351 vaccination were studied. 

• Prior variant exposure modulates our immunity and ability to fight off new COVID infections.

10/5/23 Cell Stem Cell: Complement factor D targeting protects endotheliopathy in organoid and monkey models of COVID-19 https://buff.ly/48BbaD3

• Longitudinal proteomics reveals aberrant complement patterns in severe COVID-19.

• Human pluripotent stem cells (PSC)-vascular organoid models endotheliopathy by SARS-CoV-2 infection.

• SARS-CoV-2 spike-ECD triggers inflammathrombosis in engineered human vessels.

• Complement factor D antibody reduces inflammathrombosis in the primate COVID-19 model.

Explainer for the above article:

10/5/23 Cell Stem Cell: Fishing for “complements” with vascular organoid models of microvascular disease https://buff.ly/46xWu6h

• "Kawakami et al. (above) develop a SARS-CoV-2 infection-competent, progenitor-derived, human vascular organoid model and uncover a role for complement factor D (CFD) in mediating microvascular immunothrombosis. This model may be applied to conditions where microvascular disease plays a major pathogenic role."

First they made a human vascular organoid from stem cells which they then transferred to mice. With this model, they were able to see that the SARS-CoV-2 spike-ECD triggered inflammathrombosis in engineered human vessels and that complement factor D (CFD) in mediated microvascular immunothrombosis.

With this knowledge, they then tested an antibody to complement factor D (CFD) in monkeys and found that this protected against immunothrombosis. 

10/6/23 CDC MMWR: COVID-19–Associated Hospitalizations Among U.S. Adults Aged ≥65 Years, January–August 2023 https://buff.ly/3Q59bzm

• During January–August 2023, adults aged ≥65 years accounted for 62.9% of all COVID-19–associated hospitalizations.

• Only 23.5% had received the recommended COVID-19 bivalent vaccine.

• "Adults with increased risk for COVID-19–associated hospitalization, including all adults aged ≥65 years, should reduce their risk for severe COVID-19 by receiving recommended COVID-19 vaccinations, adopting measures to reduce risk for contracting COVID-19, and seeking prompt outpatient antiviral treatment after a positive SARS-CoV-2 test result." 

Study looking for people with Long COVID near Boston:

10/4/23 Reuters: About 4 million Americans got updated XBB.1.5 COVID vaccines in September https://buff.ly/3F4bufJ

• This is similar to how many people got the bivalent booster in 2022 and the total number boosted this year is expected to increase.

10/4/23 JAMA: Estimated Effectiveness of a Primary Cycle of Protein Recombinant Vaccine NVX-CoV2373 (Novavax) Against COVID-19 https://buff.ly/3PPZfsu

• In this cohort study of 20,903 adults who started a primary cycle with NVX-CoV2373 (Novavax) in an Omicron-predominant period in Italy, 

• The estimated vaccine effectiveness of Novavax during the first 4 months after full vaccination was: 

  • 31% VE against notified (any including asymptomatic) SARS-CoV-2 infection vs 23% for not fully vaccinated 

  • 50% VE against symptomatic COVID-19.

• Estimated effectiveness waned against infection but remained stable against symptomatic COVID-19 out to 4 months.

10/6/23 Science: Should you pick Novavax’s COVID-19 shot over mRNA options? https://buff.ly/3F8SxJa

• There is limited data and a lack of head-to-head studies so it is hard to compare the 2 types of vaccines.

• Novavax relies on an older, protein-based approach that has shown long-lasting effects against other pathogens, and Topol wondered whether it might produce more durable protection.

• Since both the mRNA vaccines and the Novavax vaccine target the spike protein of SARS-CoV-2, they may give a more similar response.

10/4/23 NPR: This MacArthur 'genius', Prof. Linsey Marr, knew the initial theory of COVID transmission was flawed https://buff.ly/46EWAZs

• The groundbreaking research of Dr. Linsey Marr, an aerosols expert and professor of civil and environmental engineering at Virginia Tech, showed that the SARS-CoV-2 virus is airborne as opposed to traveling in large droplets that fall with gravity.

• Her work helped to update public health guidelines and likely saved lives. 

Dr. Linsey Marr

10/2023 Mayo Clinic Proceedings: Diagnosis and Management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) https://buff.ly/3rMsh3V

• Overlap with Long COVID.

• Recommended blood tests:

  • Complete blood count with differential

  • Comprehensive metabolic panel

  • Ferritin

  • Vitamin D

  • Vitamin B12 and folate

  • Thyroid function testing

  • Erythrocyte sedimentation rate and C-reactive protein

  • Cortisol and dehydroepiandrosterone sulfate ∗

  • ∗Adrenocorticotropic hormone stimulation test and endocrine evaluation can be pursued if cortisol level is markedly abnormal. Insulin tolerance testing may be ordered by subspecialist if adrenocorticotropic hormone stimulation test results are inconclusive.

  • Phosphorus

  • Antinuclear antibody

  • Rheumatoid factor

  • Tissue transglutaminase celiac testing

  • Urinalysis

  • Overnight oximetry

  • If orthostasis symptoms are present, an autonomic reflex screen (including 10-minute tilt table) 

• Treatment- see table:

10/4/23 Nature: Sialoglycan binding triggers spike opening in a human coronavirus https://buff.ly/46Ehbgr

• SARS, SARS-2 (SARS-CoV-2), MERS all have spike proteins that open and close to expose domain S1B that can attach to our cells.

• The receptor binding domain of the spike protein of common cold human coronavirus HKU1 remains closed and is able to evade immunity. The virus has a “fine-tuned sugar switch” (sialoglycan-based primary receptor to domain S1A) which opens up the S1B domains and allows the coronavirus to attach to and enter human cells.

• Insight into coronavirus attachment, with possible dual receptor usage and priming of entry as a means of immune escape.

10/3/23 FDA authorizes Novavax's updated COVID vaccine for fall 2023 https://buff.ly/46gRh2f

9/28/23 Lancet ID: Antiviral efficacy of molnupiravir versus ritonavir-boosted nirmatrelvir (Paxlovid) in patients with early symptomatic COVID-19 (PLATCOV): an open-label, phase 2, randomised, controlled, adaptive trial https://buff.ly/3QaDLYJ

• Paxlovid vs Molnupiravir vs other meds tested in Thailand, Brazil, Pakistan, and Laos.

• Low-risk adult patients aged 18–50 years with early symptomatic COVID-19 (<4 days of symptoms).

• Both molnupiravir and ritonavir-boosted nirmatrelvir (Paxlovid) accelerate oropharyngeal SARS-CoV-2 viral clearance in patients with COVID-19, but the antiviral effect of Paxlovid was substantially greater. 

Estimated treatment effect on viral clearance rate relative to no study drug under a model adjusting for study epoch and virus variant.

10/2/23 JAMA (BC, Canada): Nirmatrelvir and Ritonavir (Paxlovid) and COVID-19 Mortality and Hospitalization https://buff.ly/3ZF4fo8

• n = 6866

• In this study, Paxlovid was associated with lower risk of death or hospitalization in the most clinically extremely vulnerable individuals (severely immunocompromised) but not in less vulnerable individuals. 

9/29/23 Cell: Multi-omics analysis of mucosal and systemic immunity to SARS-CoV-2 after birth https://buff.ly/3Pze0j4

• Immunity to SARS-CoV-2 in infants was studied with blood samples and weekly nasal swabs. Single-cell transcriptomics and epigenomics in the first weeks and months of life were studied.

• Infants and young children:

  • mount antibody responses that last for up to 300 days

  • Have an atypical innate response in blood: no inflammatory cytokines; high IFNα and chemokines

  • upregulation of activation markers on innate cells, no inflammatory cytokines, but several increased chemokines and increased IFNα.

  • Have robust upper respiratory tract mucosal antiviral and inflammatory responses characterized by inflammatory cytokines, interferon (IFN) α, and T helper (Th) 17 and neutrophil markers (interleukin [IL]-17, IL-8, and CXCL1).

• “a snapshot of immunity to infection during the initial weeks and months of life.” 

9/29/23 JAMA: Misinformation, Trust, and Use of Ivermectin and Hydroxychloroquine for COVID-19 https://buff.ly/3PDBEeb

• “Approximately 1 in 20 people with probable COVID-19 reported using a non–evidence-based treatment, and these individuals were more likely to exhibit specific deleterious beliefs and attitudes not captured by political affiliation.”

9/29/23 JAMA: Electronic Data to Track Incidence and Mortality for SARS-CoV-2–Associated Sepsis https://buff.ly/45g1wTa

• Early in the pandemic, SARS-CoV-2–associated sepsis was common (1 in 6 cases of sepsis) and had higher mortality (33%) than bacterial sepsis (14.5%).

• In-hospital mortality rates for SARS-CoV-2–associated sepsis were high (33.4%) at first, but declined over time to 14.9% and ultimately was similar to bacterial sepsis (14.5%).

9/26/23 NY Times: What to Know About Paxlovid Rebound https://buff.ly/3RI23ds

• Pfizer trial estimated COVID rebound 2.3% of people who took Paxlovid vs. 1.7% in controls.

• A study from 7/2023 showed COVID rebound in 14% of people who took Paxlovid vs. 9% in controls.

• “if you test positive again on a rapid test, assume that you’re contagious, Dr. Mina said, and take the necessary precautions: Isolate from other people as much as possible, and wear a high-quality mask if you go out in public or are around household members.” 

• Rebound lasts 3 days on average but can range from 2 to 10 days.

9/11/23 Washington Post: Threads app blocks searches for ‘covid’ and ‘long covid’ https://buff.ly/48yJb6K

• The words “coronavirus,” “vaccines” and “vaccination” are also among blocked words. 

Non-COVID news:

9/29/23 NY Times: A New Approach for People With Severe Mental Illness https://buff.ly/3tfWtVH

• California's CARE Court will allow relatives, health care providers and homeless outreach workers to be able ask state courts to compel certain people with severe mental illness (schizophrenia and other psychotic disorders) to accept treatment.

10/3/23 AP: US health officials propose using a cheap antibiotic doxycycline as a 'morning-after pill' against STDs https://buff.ly/46BnAZH

• Gay and bisexual men and transgender women who took the antibiotic doxycycline within three days of unprotected sex were far less likely to get chlamydia, syphilis or gonorrhea compared with people who did not take the pills.

• Doxycycline reduced the acquisition of chlamydia and syphilis by nearly 80%, and gonorrhea by about 50%.

10/3/23 Healio: High triglyceride levels exacerbate severity, complications of acute pancreatitis in NAFLD (nonalcoholic fatty liver disease) https://buff.ly/3to8RmE

10/4/23 Science: Fibrosis in metabolic dysfunction–associated steatohepatitis (MASH) https://buff.ly/3tlq5B5

• Review of MASH, aka NASH, aka NAFLD (non-alcoholic fatty liver disease)

• “Metabolic dysfunction–associated steatohepatitis (MASH) is a severe form of liver disease that poses a global health threat because of its potential to progress to advanced fibrosis, leading to cirrhosis and liver cancer.”

10/3/23 AP: Lahaina residents deliver petition asking Hawaii governor to delay tourism reopening https://buff.ly/45jkN6g

• The grieving community is not ready to welcome back visitors. Other parts of the island not affected by the fire like Wailea are open to tourists.

10/3/23 American J of Surgery: The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons https://www.americanjournalofsurgery.com/article/S0002-9610(23)00495-6/fulltext#%20

• Two-thirds of all surgeons report work-related musculoskeletal disorders (WRMD).

• Beyond 24 weeks of pregnancy, 89% of respondents continued to operate/perform procedures, 82% worked >24-h shifts and 70% performed repetitive lifting >50 pounds.

• 95% of respondents reported symptom exacerbation by workplace activities during pregnancy and 13% took unplanned time off work as a result.

• Procedural activities can exacerbate pain symptoms for the pregnant surgeon. 

9/28/23 Reuters: Ozempic and Wegovy, other weight-loss drugs scrutinized over reports of suicidal thoughts https://buff.ly/45jsFVm

• 250 people have reported to the FDA that they had suicidal thoughts after taking these drugs.

10/5/23 JAMA: GLP-1 Agonists and Gastrointestinal Adverse Events https://buff.ly/3ZHiB7y

• n =4144 liraglutide, 613 semaglutide, compared to 654 bupropion-naltrexone users.

• Use of GLP-1 agonists for weight loss compared with use of bupropion-naltrexone was associated with increased risk of pancreatitis, gastroparesis, and bowel obstruction but not biliary disease.