Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 205

It’s hard to believe that we first learned of Trump’s Covid diagnosis exactly one week ago tinyurl.com/yxq2vbv3. Here are a bunch of hot takes on today’s issues, which continue to move at hyper-speed.

2/ On Trump’s clinical status. Yesterday, his doc reported that Trump's vital signs were stable, including normal oxygen saturation w/o supplemental O2. Today’s videos show no obvious shortness of breath (he completes sentences without stopping for air): tinyurl.com/y3p9l8lh

3) Based on his @FoxBusiness phone-in today tinyurl.com/y5h5brpe, his mental status & judgment seem to be at his baseline (that's the standard we use). Whatever you think about Trump's mind, there’s no new evidence of lack of capacity to do his job based on Covid or meds.

4/ Again, per his doctor’s note yesterday tinyurl.com/y43v9tuu, Trump's fever is gone, which could be true improvement or masking of fever by steroids or antipyretics.

But overall, Trump seems stable. With each day, his odds of survival improve.

5/ As of last Friday, as a high-risk Covid patient w/ high fever and low oxygen who needed hospitalization, he probably had a 1-in-5 chance of dying from this episode. There's no great data to give a precise estimate now, but given stability on day 7, mortality rate is probably…

6/ … now more like 1-in-20.

Note that it is decidedly not zero – many Covid patients (most famously Herman Cain tinyurl.com/yxco3acb) were stable after week 1 and went on to crash in week 2 or 3. Of course, it’s hard to extrapolate from…

7/ … the literature, given that Trump enjoys around-the-clock care in his home, can return to the hospital by helicopter, and has received 3 medications, one of which (monoclonal antibodies) is not available to other patients, outside of a clinical trial.

8/ But the odds – that he will avoid re-hospitalization, the ICU, intubation, and death – are now favorable. His symptom course is harder to predict, partly because we really don’t know what his current symptoms are and partly because…

9/ … his symptoms may be masked by steroids, which will be stopped in a few days (usual course is 10 days; the remdesivir was probably stopped Tuesday after day 5; the monoclonals were a single shot last week). But here too, if he remains asymptomatic…

10/ …through the first 10-14 days, he’s likely to have a fairly benign course overall. Moreover, it’s unlikely, though not impossible, that he’ll have serious symptoms later (ie, be a long-hauler).

On the other hand, whether he'll have long-term heart and lung involvement…

11/ is hard to predict – unfortunately, many patients do, even if they had a mild initial course. For example, this study found MRI evidence of heart inflammation in 60%; it didn't vary by initial severity tinyurl.com/y6plsg97. The clinical meaning of this is not yet known.

12/ We also learned Trump tested positive for antibodies yesterday. That’s likely from the monoclonal antibodies he received tinyurl.com/y59kkjq5; had he not gotten them, it would be early to test + for antibodies (it usually takes 10-14 days). Overall, it doesn’t mean much.

13/ There is no way to prove whether the monoclonal antibodies (actually called REGN-COV2, though Trump calls them “Regeneron,” which is the name of the company) contributed to his benign course so far, though they may have.

14/ He calls it a “miracle cure.” This, of course, illustrates his (mis)understanding of science. Previous Trumpian “miracles,” you’ll recall, included hydroxychloroquine (proven ineffective), convalescent plasma (jury is out), bleach ( ), & the virus itself, just going away.

15/ When he received the antibodies (it’s not clear whether he was hypoxic yet), he probably had an 85-90% chance of surviving this episode, independent of that experimental treatment. This is why we do randomized trials, with active drug in one arm of the study...

16/ … and placebo or “usual care" in the other. If he continues to do well, it could be due to the antibodies, or to the other 2 meds (remdesivir or dexamethasone), or some combo of them, or luck. There’s simply no good way to known when looking at a single patient’s course.

17/ It follows, then, that the President’s course should have precisely zero influence on public policy, including the cost of the drug or its @US_FDA approval prospects. But that’s not the way Trump thinks, nor, in turn, the stock market. tinyurl.com/y3c5w3gy

18/ Turning to next week's debate: the Commission on Presidential Debates announced today it intends to hold the second debate, scheduled for next Thursday, virtually. Trump immediately rejected the decision tinyurl.com/y34jkbjs

19/ The Commission's decision is wise. Knowing when a Covid patient is no longer contagious is tricky: the @CDCgov guideline says it's 10 days after symptoms began, but 20 days for patients with severe symptoms or compromised immunity tinyurl.com/y3e3t3az

20/ Trump’s symptoms began last Thursday, we believe. So next Thursday would be ~14 days. Although he doesn’t have a known immunity problem, he’s now on an immunosuppressant, dexamethasone.

Unfortunately, there is no available test to allow for 100% certainty re: infectivity.

21/ The problem w/ testing is that a negative test can be wrong (so can a positive – late in the illness it can represent dead virus). For a high risk person (Biden, age 77, is) to stand mask-less, 12 ft away from a mask-less patient with recent Covid who is talking loudly…

22/ … for 90 minutes when said patient has even a 1% chance of still being contagious would be far too risky. If I were advising Biden, I would tell him that the right call is to hold the debate virtually, or not at all.

23/ When I first heard of Trump’s diagnosis, I hoped this would serve as a teachable moment for the US – one that might advance the science & change public attitudes in a way that could save many lives tinyurl.com/yynz7mlc. But as @murphymike says, Trump is the "atomic clock":

24/ totally predictable & unchanging. By minimizing the role of health measures (incl masking & contact tracing), downplaying the virus's severity because he (may) be getting lucky, touting unproven therapies & framing himself as a survivor due to his own powers of personality...

25/ (implying that those who died lacked such fortitude; read: losers), he continues his record of Covid-19 failure. The hope that illness would lead to humility & compassion for millions of sickened & 210,000 dead Americans was to ask too much. Now I simply wish him good health.