Ebola

–New cases are leveling off, but still occurring. Regardless, we’ll give a few more weeks to confirm that overall trend. The Ebola Sudan specific vaccines seem to be perpetually about to arrive in country “next week”–we’ll see when they actually get there. Meanwhile, Uganda is still doing well with contact tracing and quarantines of contacts to minimize spread, along with more community outreach to keep people informed. Still no obvious threat of a massive explosion of cases. There is still some risk of cross border spread, but nothing I would consider elevated beyond the usual “It’s super easy to hop onto a plane to anywhere in the world these days” risk.

Coronavirus

–China is still having problems, with officially acknowledged cases still increasing. With the Zero COVID policy still very much in force, this is creating lots of social media fodder for mass testing mandates and at least partial lockdowns. This morning there were videos everywhere of riots at the Foxconn factories, who do an enormous amount of work for Apple iPhones, as workers protest low wages and severe COVID restrictions to keep the factories running.

Elsewhere, Italy’s numbers have taken an odd pop, and if anything is concerning for a bona fide winter wave, that will be the one to watch. Otherwise, despite the still ever present “new variant increasing percentage of cases!” headlines, the confirmed cases of COVID in the US remain level and low with a recent, ever so slight uptick. That said, early indicators are moving -slightly- in a bad direction for first time in months. So we’ll still be mindful and watching.

–Overall, it is still -very- possible to catch COVID. I still hear of at least a case every other week or so.

–As far as the “triple pandemic” being touted in headlines of COVID, flu, and RSV (+/- other cold viruses), again, I think the headline coverage has largely been alarmist. If you are vaccinated for the flu (and everyone should be–pediatric versions are absolutely available and a great idea), and some combination of vaccinated/recovered from PCR positive COVID, your chances of hospitalization are pretty low. Some of the most alarmist “data”, especially for pediatric cases, such as that put together for the state of Oregon by a third party they contracted which was claiming something like a 40%+ hospitalization rate for any of flu/COVID/RSV, has gotten sued because it is so obviously wrong versus actual hospitalization numbers.

But to show you what they are talking about, this tracker from the CDC shows “influenza like illness” which will cover a wide variety of viral illnesses, including COVID and even potentially more severe cases of common cold from RSV or other common cold agents:

The black line and red triangles are this year’s season. The two highest peaks are the 2017-2018 and 2019-2020 seasons, both pre-COVID. The pink line at the bottom is the lockdowns running rampant over flu and cold viruses as we discussed before. Yes, they simply removed COVID from counting as influenza-like illness for the purposes of this charting during the pandemic years, and it’s not clear to me if those are back to being counted as influenza like illness to account for at least some of this year’s rise.

Regardless, what you’re seeing is brisk cold/flu activity, likely across the board from a combo of SARS-CoV-2, influenza and cold viruses–and it also appears to be earlier than usual.

As for confirmed flu, here is this year’s data (albeit with no historical comparison):

So yes, brisk flu season start so far. The flu that is circulating is the combination of H and N that was expected, and is thus covered well by the current vaccine. So again, good time to get the vaccine. Maybe with your turkey.

But with vaccines available and effective acute treatments for COVID (even if you catch flu at the same time, which yes, is possible, but not as likely as catching one or the other at a time), this is not a new pandemic requiring draconian public health responses.

–Speaking of acute treatments for COVID, lot of electrons spilled this week on court hearings over the FDA and Ivermectin. Again, the best phase 3 study out there, the ACTIV-6 study, we covered before but as a short reminder shows at best only a trend to benefit with early treatment of ivermectin, and not statistically significant. I would say that is inline with other results of smaller or less rigorous studies that were back and forth over ivermectin effectiveness. I also want to re-iterate that ivermectin, in the doses described for use in COVID, has a long and glorious history of safety, coming from its primary use treating several nasty parasitic infections.

The main e-outrage seems to stem from the FDA’s lawyers, in court, trying to argue that the FDA never recommended AGAINST the use of ivermectin, and only officially stated that it should be given in the context of a clinical trial. While this is technically true (and thus perfect for the lawyers to latch on to), much of the uproar has been over the FDA’s definite messaging discouraging off label use of Ivermectin to treat COVID. A common citation in the outrage articles is a social media message from its official account that went viral stating “Ivermectin is for horses, y’all.” Which managed to simultaneously ignore ivermectin’s FDA label for treatment of certain parasitic diseases in humans while definitely seeming to discourage use of ivermectin in treatment of COVID–all from an official FDA source.

At best, review and approval of statements that are, or could be reasonably construed as official FDA policy, were lacking at the FDA.

I don’t have a real strong opinion on which way the court case goes, to be honest, and we have more proven options than ivermectin to treat COVID now anyways. But I do think it is evidence that the FDA may need to tighten up its shop a bit.

–In other blasts from updates past, there is a new meta-analysis out looking at the risk of developing diabetes after COVID infection. I think they did a very solid job with it. For those less familiar, a meta-analysis can be thought of as combining a bunch of papers written about a similar topic to increase the total number of cases involved, and get the best version of the “overall picture.” Done well, meta-analyses are very useful. But much depends on how similar the combined studies actually, and the decision for what counts as close enough to include, and what is considered too dissimilar to include. Done poorly, the authors can inadvertently, or even deliberately, bias towards including studies with one conclusion and excluding those with a different conclusion.

But this was done well, and I don’t see any screaming suspicion of bias. You can find the full meta-analysis here.

The long story made short is that while new onset diabetes after recovering from COVID isn’t common (it’s still pretty rare), it does happen and does appear to be associated with COVID.

Now, Hypothetical Reader, before you freak out on me jus-….

Yeah, exactly. Let me just explain the results a little bit that will put them more in context for your actual risk.

The risk of new onset diabetes (diabetes first diagnosed within 3 months of overcoming COVID) was elevated across all age groups and both genders. Which you would expect, if the virus itself was correlated and especially if the virus was causal. The risk was also higher (relative risk of 1.17) than risk of new onset diabetes in patients with ANY upper respiratory infection, and had a relative risk of 1.82 versus the general population. Again, this is consistent with SARS-CoV-2 being a little better at causing a tip over into diabetes.

However, this is a risk the authors calculated as 15.53 new diabetes cases per 1,000 person-years.

Said in English, if 1,000 people who caught COVID were followed for 1 year, about 1.5% of them would get new onset diabetes. Compared to general population risk of ~0.8%. So higher risk if you get COVID, but you are NOT destined to get the diabeetus if you catch COVID, and the vast majority won’t. People catching older cold viruses will fall in the middle of that 1.5-0.8% risk, for the record.

Is this something your doctor should pay attention to after you catch COVID? Yes. Is it something -you- need to lose a lot of sleep over? No.

We mentioned previous studies showing that the risk of developing new onset diabetes is highest in those with severe COVID. That held up in the meta-analysis. Their relative risk was higher. Surprisingly, mild to moderate COVID also had a slightly increased risk of new onset diabetes, but only slightly.

I think it’s still an interesting question as to whether those who do tip into new onset diabetes were those with other pre-disposing conditions, such as obesity. The authors of the meta-analysis do too, but state that they didn’t have enough data at that level to know (not enough of the included studies including things like BMI).

–In other health and COVID news, bordering on “socioeconomic”, hospital systems across the country are feeling inflation’s gravity as well, and alarms are starting to sound about potential financial collapse. You can read more here:

https://www.beckershospitalreview.com/finance/health-system-cash-reserves-plummet.html?utm_medium=email&utm_content=newsletter

I would argue that years of investment driven by the short term financial interest of an expanding “health administrator” class are to blame, coupled with callous HR that has skyrocketed physician and nursing burnout (since there is only so long you can really battle a system increasingly designed to work against you and your patients). But regardless, it’s happening.

Weird, I know, recalling “Plandemic” and other more conspiracy minded coverage highlighting all that sweet, sweet bonus money that hospitals were supposedly raking in for calling everything possible a COVID case and death… But this is happening, I assure you, both from that article and anecdotally.

–In other news, heard from an endocrinologist I trust a lot and am pretty close to that the US endocrinology board is formally concerned over the pass rate for this year’s fellows taking the board exam in endocrinology. More fellows than usual failed–and this is the class that would have been starting endocrine fellowships when COVID was first hitting. Unclear if the increased fail rate on the first pass is related to seeing fewer of the less common endocrine issues as hospitals were all or partially shut down, or going remote for patient visits for huge stretches, or even if some of these fellows were conscripted into COVID units during parts of the pandemic. All of that undoubtedly happened. But there is now formal wonder what the pandemic effects were on parts of medical education…

Socioeconomic

–Just a couple quick early points, because again, there are only starting to be echoes of the pandemic in it, and the crises happening now were longer in the making and only arguably catalyzed by pandemic response choices. First of course, is watch the weather, as Europe will get its first truly cold days of the season in the next couple of weeks. The UK has already been warning of possible power shortages. And remember–if it gets bad this year, next year stands a good chance of being worse. Also watch food, because the constraints on fertilizer we talked about -this- year won’t really start to be felt until next year as well.

–Second, investigation confirmed that “foreign objects” and explosive residue were found on the Nord Stream pipelines. I know, I too am surprised that was not like 10 years ago, and only feels that way. But they still have not listed any suspects and for continued control of geopolitical tensions, trying to keep WW3 from breaking out, I doubt that will be forthcoming any time soon. Of course, the ones who did it know. And the relevant people in the right offices likely know who the short list is.

–Third, the FTX scandal has proven to be “The Moment” for some, and you can read the short thread here. This of course has been a major theme of this section through the pandemic, and sorry for flogging the dead horse some more. But it’s also worth mentioning I’ve had a few readers quietly contact me with their own experiences of “The Moment”, where the coverage by media they previously thought was doing a pretty good job was just so off on a subject they knew well. For some, so off they could not believe it was not deliberate in service of a schismogenic narrative.

And once you have seen, there is no going back.

On the FTX scandal itself, and why coverage that minimized just how criminal this was became The Moment for the guy in the thread, a really good short summary video by Coffeezilla can be found here on YouTube (worth the 10 minutes, and he’s great for business scam coverage of all kinds in general). The Vox interview with the now disgraced founder and CEO of FTX is also very much worth your time.

And then this thread, which starts funny because it’s all true and ends with the perfect punchline:

https://mobile.twitter.com/EpsilonTheory/status/1593027618399719424

If you are normal, and thus unfamiliar with the history of that punchline, quick primer here.

–Maybe it’s just me, but I’m getting that feeling in the zeitgeist again. Or maybe it’s not just me, because the small but noticeable signs, like increasingly impatient and selfish drivers out there on the road with you, are getting noticed. That specific one popped up on Twitter in the past couple of weeks. The post underneath it reminding everyone that there is an above average chance that someone you are encountering today is on edge, and barely holding it together.

I can see and sense that again in the grocery store. Even over zoom calls.

And I get it right. There’s been another just exhausting election season in the US. There’s economic malaise everywhere. Scandal upon scandal, crisis upon crisis, and some are very real and quite serious. But they don’t seem to end, and it’s not immediately obvious how we get through. Meanwhile, the tides of schismogenesis ride high, because at least there’s a tribe, right? But I’m not sure how real that feels to as many any more either. When those tribes are increasingly defined by how threatening and evil the other is, and not a positive message of who they are and where they are really going, I think it’s tough to maintain momentum. And I wonder if part of the increasing rhetoric and vitriol, the reason the zeitgeist seems more exhausted and frustrated, is you just can’t sustain that over time. “Vote for our team because it will suck less” is still choosing an option that sucks. Constantly avoiding a negative is not a positive motivation for an action.

I think we would all rather be “for” something.

I also think there is greater agreement, in the broad strokes, of what we are “for” that gets lost in what we are told we are against, and must be against.

And I think more are starting to wonder how much of it is real, and how much is just The Moment from up above, where it was all narratives that were weaponized to you and hit all your confirmation biases. And now you’re defending a tribe that deep down, you’re not even sure has the way out of all of this, because you started defending that tribe awhile ago, and what would it mean for you, about you, if you couldn’t do it anymore?

I think that’s why you’re seeing more and more who used to be associated with one tribe now breaking away. But where do they go when they leave?

I think the zeitgeist is losing hope.

But I don’t think it should.

Because there is still movement forward, when you look. I haven’t been able to train jiu jitsu as often as I would prefer over the past month due to other commitments, but I’ve been struck at how those times I have made it in, it’s been like walking in the bar in “Cheers.” Felt the same way at my daughter’s maintenance belt testing this past weekend. And even though gathered at a memorial service for a former co-worker, running into my old crew from the pandemic, it was like I hadn’t left 5-6 months ago. And the other moments recently that took one’s breath away.

All to say, in my usual rambling way, that the holidays are upon us. Starting tomorrow in the US, but soon enough everywhere. I know people are hurting. I know mountains are falling into seas, and the powers in the heavens are being driven from the courses. I’ve had a few tell me as much this past year. More often, in fact, that at any point during the pandemic. So as friends and family gather, remember that a few, maybe even you, are at the limit.

So I’m going to challenge you, not so hypothetical readers. Yes, getting this challenge out before Thanksgiving -is- the reason for the “early” publication date of this update : )

I’m going to challenge you in the full expectation that you will succeed. After all, you are my readers, and thus by definition the smartest, kindest, best-looking AND most humble people of all.

When the usual bullshit starts this holiday season–and it will–remember this challenge, and step back from yourself and moment for just a second. Where there is rancor, where there is argument, where there is schismogenesis and grief, remember this challenge.

And remember instead your favorite memory of those involved. Forget what they are saying, what political points are being made (as if anyone is keeping score, or they will decide anything), forget what misdeeds and bad patterns from the past are re-surfacing for just one moment, and remember instead before all of this happened what their best was, and when you saw it.

Second part of the challenge? Tell them.

Yes, even say “remember when (you were at your best)”. “You are best at…” “You are a great…” Just be sincere, and speak with the still small voice.

And yes, right in the middle of their polemic screed or argument. Right in the middle of it.

For one, they will haz a confuse. For two, having been recently reminded of the cost and consequence of not saying what should be said when the opportunity is there, you won’t make that mistake. You’ll go out on your shield. And for three, if it’s really the sign that they are at the limit, as so many are these days, you will show them (and maybe yourself) by your words and the action of your words that all is not lost. Not yet.

It’s passion, it’s pain. Sometimes it’s healing. Sometimes it’s catharsis. Sometimes it’s Leonard Cohen’s “Hallelujah.” And when the last night falls, as it does for us all, this is what you will miss.

We play for stakes eternal, brothers and sisters. Play like a champion these holidays. Your real team needs you.

Clear your eyes.

Clear your heart.

Can’t lose.

–(with apologies, Whitney. That version fits the vibe better.)

–Your chances of catching coronavirus are equivalent to the chances that you should check out this interactive article on the history of helmet stickers used by the football teams of Michigan and Ohio State. Just well done “and now you know” content.

–Your chances of catching Ebola are equivalent to the chances the Norwich City faithful will be raising the “U-S-A!” chant for their number 24, Josh Sargent, on Friday.

<Paladin>