Day: August 13, 2023

Patients who take blockbuster drugs like Wegovy or Ozempic for weight loss may face life-threatening complications if they need surgery or other procedures that require empty stomachs for anesthesia. This summer’s guidance to halt the medication for up to a week may not go far enough, either. 

Some anesthesiologists in the U.S. and Canada say they’ve seen growing numbers of patients on the weight-loss drugs who inhaled food and liquid into their lungs while sedated because their stomachs were still full — even after following standard instructions to stop eating for six to eight hours in advance. 

The drugs can slow digestion so much that it puts patients at increased risk for the problem, called pulmonary aspiration, which can cause dangerous lung damage, infections and even death, said Dr. Ion Hobai, an anesthesiologist at Massachusetts General Hospital in Boston. 

“This is such a serious sort of potential complication that everybody who takes this drug should know about it,” said Hobai, who was among the first to flag the issue. 

Nearly 6 million prescriptions for the class of drugs that include Wegovy and Ozempic were written between January and May in the U.S. for people who don’t have diabetes, according to Komodo Health, a health care technology company. The drugs induce weight loss by mimicking the actions of hormones, found primarily in the gut, that kick in after people eat. They also target signals between the gut and the brain that control appetite and feelings of fullness, and by slowing how fast the stomach empties. 

In June, the American Society of Anesthesiologists issued guidance advising patients to skip daily weight-loss medications on the day of surgery and hold off on weekly injections for a week before any sedation procedures. Dr. Michael Champeau, the group’s president, said the action was based on anecdotal reports of problems — including aspiration — from around the country. 

It’s not clear how many patients taking the anti-obesity drugs may be affected by the issue. But because the consequences can be so dire, Hobai and a group of colleagues decided to speak out. Writing in the Canadian Journal of Anesthesia, they called for the drug to be stopped for even longer — about three weeks before sedation. 

That accounts for how long semaglutide, the active medication in Wegovy, remains in the body, said Dr. Philip Jones, a Mayo Clinic anesthesiologist who is also deputy editor-in-chief of the journal. 

“When 90% of it is gone, which is after three weeks, hopefully everything should go back to normal,” Jones said. 

Champeau and Jones both acknowledged there’s not enough evidence to say for certain how long semaglutide should be held to make anesthesia safe. Many patients won’t see providers far enough in advance to stop the drug three weeks before procedures, Champeau noted. 

Aspiration occurs in one of every 2,000 to 3,000 operations that require sedation, and almost half of patients who aspirate during surgery develop a related lung injury. But case reports show recent patients on semaglutide had problems even when they stopped food as long as 20 hours before their procedures. 

“There’s nothing that says if you fast twice as long, it will be OK,” Champeau said. 

Among the several reports detailing potentially serious problems was one of Hobai’s patients, a 42-year-old man in Boston who recently began taking Wegovy, had to be intubated and suffered respiratory failure that put him in intensive care. He aspirated food that remained in his stomach despite fasting for 18 hours. 

In Chapel Hill, North Carolina, a 31-year-old-woman on a low dose of Ozempic had fasted for 10 hours before a routine endoscopy prior to bariatric surgery last fall. The procedure had to be stopped because solid food remained in her stomach and she was at high risk for aspiration, the report said. 

Since then, doctors have seen dozens of similar cases as use of the weight-loss medication has grown, said Dr. Elisa Lund, an anesthesiologist at the University of North Carolina at Chapel Hill School of Medicine. “It has exponentially increased,” she said. 

Hobai is completing a retrospective study of almost 200 patients taking semaglutide. While it’ll be published later this year, the work so far appears to confirm a small study from Brazil, he said. In that study, about a quarter of patients taking semaglutide had residual food in their stomachs during procedures requiring sedation — even after stopping the drug for 10 days. 

The American Society of Anesthesiologists advises doctors who are in doubt to treat patients who haven’t paused the drug as if they have full stomachs, which can mean using different types of sedation protocols or delaying procedures, if possible. Jones added that research is urgently needed to update guidelines for doctors and patients. 

Novo Nordisk, which makes Ozempic, Wegovy and similar drugs, said the firm’s clinical trial and post-marketing safety data did not show that the medications led to aspiration. But the drugmaker noted that the medications are known to cause delayed emptying of the stomach and that the labels warn of possible gastrointestinal side effects. 

Stopping the medications for three weeks can cause problems, too. Patients with diabetes will need another way to control their blood sugar and those seeking to lose weight may regain some, Hobai said. 

Hobai suggests that people using Wegovy and similar drugs tell their doctors before sedation and discuss the risks and benefits. 

“If you’re taking this drug and you need an operation, you will need to have some extra precautions,” he said. 
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For a vast number of book writers, artificial intelligence is a threat to their livelihood and the very idea of creativity. More than 10,000 of them endorsed an open letter from the Authors Guild this summer, urging AI companies not to use copyrighted work without permission or compensation.

At the same time, AI is a story to tell, and no longer just science fiction.

As present in the imagination as politics, the pandemic, or climate change, AI has become part of the narrative for a growing number of novelists and short story writers who only need to follow the news to imagine a world upended.

“I’m frightened by artificial intelligence, but also fascinated by it. There’s a hope for divine understanding, for the accumulation of all knowledge, but at the same time there’s an inherent terror in being replaced by non-human intelligence,” said Helen Phillips, whose upcoming novel “Hum” tells of a wife and mother who loses her job to AI.

“We’ve been seeing more and more about AI in book proposals,” said Ryan Doherty, vice president and editorial director at Celadon Books, which recently signed Fred Lunzker’s novel “Sike,” featuring an AI psychiatrist.

“It’s the zeitgeist right now. And whatever is in the cultural zeitgeist seeps into fiction,” Doherty said. 

Other AI-themed novels expected in the next two years include Sean Michaels’ “Do You Remember Being Born?” — in which a poet agrees to collaborate with an AI poetry company; Bryan Van Dyke’s “In Our Likeness,” about a bureaucrat and a fact-checking program with the power to change facts; and A.E. Osworth’s “Awakened,” about a gay witch and her titanic clash with AI.

Crime writer Jeffrey Diger, known for his thrillers set in contemporary Greece, is working on a novel touching upon AI and the metaverse, the outgrowth of being “continually on the lookout for what’s percolating on the edge of societal change,” he said.

Authors are invoking AI to address the most human questions.

In Sierra Greer’s “Annie Bot,” the title name is an AI mate designed for a human male. For Greer, the novel was a way to explore her character’s “urgent desire to please,” adding that a robot girlfriend enabled her “to explore desire, respect, and longing in ways that felt very new and strange to me.”

Amy Shearn’s “Animal Instinct” has its origins in the pandemic and in her personal life; she was recently divorced and had begun using dating apps.

“It’s so weird how, with apps, you start to feel as if you’re going person-shopping,” she said. “And I thought, wouldn’t it be great if you could really pick and choose the best parts of all these people you encounter and sort of cobble them together to make your ideal person?”

“Of course,” she added, “I don’t think anyone actually knows what their ideal person is, because so much of what draws us to mates is the unexpected, the ways in which people surprise us. That said, it seemed like an interesting premise for a novel.”

Some authors aren’t just writing about AI, but openly working with it.

Earlier this year, journalist Stephen Marche used AI to write the novella “Death of An Author,” for which he drew upon everyone from Raymond Chandler to Haruki Murakami. Screenwriter and humorist Simon Rich collaborated with Brent Katz and Josh Morgenthau for “I Am Code,” a thriller in verse that came out this month and was generated by the AI program “code-davinci-002.” (Filmmaker Werner Herzog reads the audiobook edition). 

Osworth, who is trans, wanted to address comments by “Harry Potter” author J.K. Rowling that have offended many in the trans community, and to wrest from her the power of magic. At the same time, they worried the fictional AI in their book sounded too human, and decided AI should speak for AI.

Osworth devised a crude program, based on the writings of Machiavelli among others, that would turn out a more mechanical kind of voice.

“I like to say that CHATgpt is a Ferrari, while what I came up with is a skateboard with one square wheel. But I was much more interested in the skateboard with one square wheel,” they said.

Michaels centers his new novel on a poet named Marian, in homage to poet Marianne Moore, and an AI program called Charlotte. He said the novel is about parenthood, labor, community, and “this technology’s implications for art, language and our sense of identity.”

Believing the spirit of “Do You Remember Being Born?” called for the presence of actual AI text, he devised a program that would generate prose and poetry, and uses an alternate format in the novel so readers know when he’s using AI.

In one passage, Marian is reviewing some of her collaboration with Charlotte.

“The preceding day’s work was a collection of glass cathedrals. I reread it with alarm. Turns of phrase I had mistaken for beautiful, which I now found unintelligible,” Michaels writes. “Charlotte had simply surprised me: I would propose a line, a portion of a line, and what the system spat back upended my expectations. I had been seduced by this surprise.”

And now AI speaks: “I had mistaken a fit of algorithmic exuberance for the truth.”
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Postal worker Eugene Gates Jr. was delivering mail in the suffocating Dallas heat this summer when he collapsed in a homeowner’s yard and was taken to a hospital, where he died.

Carla Gates said she’s sure heat was a factor in her 66-year-old husband’s death, even though she’s still waiting for the autopsy report. When Eugene Gates died on June 20, the temperature was 36.6 Celsius and the heat index, which also considers humidity, had soared over 43.3 Celsius.

“I will believe this until the day I die, that it was heat-related,” Carla Gates said.

Even when it seems obvious that extreme heat was a factor, death certificates don’t always reflect the role it played. Experts say a mishmash of ways more than 3,000 counties calculate heat deaths means we don’t really know how many people die in the U.S. each year because of high temperatures in an ever-warming world.

That imprecision harms efforts to better protect people from extreme heat because officials who set policies and fund programs can’t get the financial and other support needed to make a difference.

“Essentially, all heat related deaths are preventable. People don’t need to die from the heat,” said epidemiologist Kristie L. Ebi, who focuses on global warming’s impact on human health as a professor at the University of Washington.

With a better count, she said, “you can start developing much better heat wave early warning systems and target people who are at higher risk and make sure that they’re aware of these risks.”

Currently, about the only consistency in counting heat deaths in the U.S. is that officials and climate specialists acknowledge fatalities are grossly undercounted.

“Deaths are investigated in vastly different ways based on where a person died,” said Dr. Greg Hess, the medical examiner for Pima County, Arizona’s second most populous county and home to Tucson. “It should be no surprise that we don’t have good nationwide data on heat-related deaths.”

Many experts say a standard decades-old method known as counting excess deaths could better show how extreme heat harms people.

“You want to look at the number of people who would not have died during that time period and get a true sense of the magnitude of the impact,” Ebi said, including people who would not have suffered a fatal heart attack or renal failure without the heat.

The excess deaths calculation is often used to estimate the death toll in natural disasters, with researchers tallying fatalities that exceeded those that occurred at the same time the previous year when circumstances were average.

Counting excess deaths was used to calculate the human impact of a heat wave in Chicago that killed more than 700 people in July 1995, many elderly Black people who lived alone. Researchers also counted excess deaths during the COVID-19 pandemic to provide more complete information about deaths directly and indirectly related to the coronavirus.

But as things stand now, the Centers for Disease Control and Prevention reports just 600 to 700 heat deaths annually in the United States. A study published last month in the journal Nature Medicine estimated more than 61,000 heat-related deaths last summer across Europe, which has roughly double the U.S. population but more than 100 times as many heat deaths.

Dr. Sameed Khatana, a staff cardiologist at the Philadelphia VA Medical Center and assistant professor at the University of Pennsylvania’s Perelman School of Medicine, has said deaths in which heat contributed significantly to fatalities from causes like heart failure should also be considered.

Khatana participated in research published last year that counted excess deaths in all U.S. counties. The findings suggested that from 2008 to 2017 between 3,000 to 20,000 adult deaths from all causes listed on death certificates were linked to extreme heat. Heart disease was listed as the cause of about half of the deaths.

After the Pacific Northwest heat wave in summer of 2021, the Canadian province of British Columbia reported more than 600 deaths due to heat exposure while Oregon and Washington each initially reported a little more than 100 such fatalities.

“It’s frustrating that for 90 years public health officials in the United States have not had a good picture of heat-related mortality because we have such a bad data system,” said Dr. David Jones, a Harvard Medical School professor who also teaches in the epidemiology department at the Harvard T.H. Chan School of Public Health.

There is no uniformity among who does the counting across U.S. jurisdictions. Death investigations in some places might be carried out by a medical examiner, typically a physician trained in forensic pathology. In other locales, the coroner could be an elected sheriff, such as the one in Orange County, California. In some small counties in Texas, a justice of peace might determine cause of death.

Utah and Massachusetts are among states that do not track heat-related deaths where exposure to extreme heat was a secondary factor.

The CDC, which is often several years behind in reporting, draws information on heat deaths from death certificate information included in local, state, tribal and territorial databases.

The CDC said in a statement that coroners and others who fill out death certificates “are encouraged to report all causes of death,” but they may not always associate those contributing causes to an extreme heat exposure death and include the diagnostic codes for heat illnesses.

Hess, the Arizona coroner, said determining environmental heat was a factor in someone’s death is difficult and can take weeks or even months of investigation including toxicological tests.

“If someone was shot in the head, it’s pretty obvious what happened there,” Hess said. “But when you find a body in a hot apartment 48 hours after they died, there is a lot of ambiguity.”

Hess noted that Pima County this year began including heat-related deaths in its tally of environmental heat fatalities. Maricopa County, home to Phoenix, America’s hottest big city, for years has included heat-related deaths. Clark County, Nevada, home to Las Vegas, now also considers deaths in which heat was a contributing factor.

Maricopa’s Public Health Department counted 425 “heat associated” deaths last year, including those where heat was a secondary factor, such as a heart attack provoked by high temperatures.

It reports there were 59 heat-associated deaths confirmed this year through Aug. 5, with another 345 under investigation. The latest count follows the hottest month in Phoenix on record, and a record 31 consecutive days that hit 43.3 Celsius or higher.

Dallas, which regularly sees summer highs above 37.7 Celsius, sweltered through an excessive heat warning this month and also grapples with oppressive humidity.

Carla Gates, whose mail carrier husband died, noted cities worldwide now must learn to deal with extreme weather. She said her spouse, with 36 years on the job, tried to protect himself by taking a chest filled with ice and several bottles of cold water on his rounds.

“Our climate has changed,” she said. “And I don’t think it’s going back to how it was 20 years ago. So we’re going to have to get used to it and we’re going to have to make some adjustments.”

Now she wants to honor her husband by pushing legislation to ensure people working outside are better protected from the heat. Gates noted that the day her husband died he was in an old mail truck without working air conditioning.

“I don’t wish this on anyone, anyone to get a phone call that their loved one died working, doing something that they love in the heat,” she said.
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