Latest twist in "aspirin for primary prevention" story (rec: don't do it) hits home.… When I was in med school, I told my dad (age 52) to take an ASA daily. He was a stressed-out guy, heart attacks were common, & early evidence on ASA was supportive.(1/8)🧵
A few months later, I got a call that he had passed out on the train. The cause: a huge upper GI bleed. I felt terrible – I was pretty sure that my aspirin had caused his bleed. This was, in essence, my first prescription, and I'd nearly killed my father. I rushed home. (2/8)
The GI doc let me watch as he performed dad's endoscopy, expecting to find stomach inflammation or an ulcer. I heard the doc gasp when he found a large polyp at the stomach-esophagus junction – it was clearly not what he expected to see. Turns out it was a stomach cancer. (3/8)
Stomach cancer is usually deadly, in part because it grows stealthily for months, usually spreading before it causes symptoms. This one bled early – almost certainly due to my little aspirin. Dad had an 8-hour surgery to remove half his stomach and part of his esophagus. (4/8)
Despite the serendipitous early diagnosis, the cancer had already spread to a lymph node. His life expectancy was a year or two; the chance of cure was probably around 10%. He retired from work and got his affairs in order. (5/8)
As it happened, he was one of the lucky ones – he turned 91 this year (that's him at his grandson's wedding a few years back; sadly he's bed-bound now and nearing the end). (6/8)
It's now clear that when used for primary prevention (in pt who hasn't yet had heart disease or a stroke), the risks of aspirin outweigh benefits – it shouldn't be used this way. But if dad hadn't been on that aspirin, he likely would have died of his cancer 40 years ago. (7/8)
Moral of the story: who knows? Mostly humility – medicine is such a funny, unpredictable business. And clinical trials – which give us crucial answers to how to manage groups of patients – sometimes obscure individual stories. And sometimes it's better to be lucky than good.(8/8)

• • •

Missing some Tweet in this thread? You can try to force a refresh

Keep Current with Bob Wachter

Bob Wachter Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!


Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @Bob_Wachter

20 Aug
Covid (@UCSF) Chronicles,Day 521
I can't resist one more thread on boosters. I see lots of debate on data: about antibody levels, infections vs severe infctns, etc. I don't see much about the big issue: the tension between 2 perspectives – that of individuals vs. society.(1/25🧵)
It's particularly tricky when talking about a global pandemic since (as we've learned, painfully) no person is an island: individual behavior impacts the collective & vice versa. In pandemics, there's also the matter of who comprises the collective: just domestic or global?(2/25)
For those who don't follow healthcare closely, you've stumbled into a longstanding tension in health policy, one that maps pretty well to two different and (mostly) fraternal fields: clinical medicine and public health.

As a physician (though one with public health... (3/25)
Read 25 tweets
19 Aug
Lots of criticism of new booster plans, much of it re: how much of ⬇efficacy # s are due to confounding vs truly ⬇effectiveness. To me, it seems incontrovertible that vax effectiveness is ⬇significantly, though amount of drop – particularly vs severe cases – is unclear.(1/7🧵)
I'm in support of the new booster plans. This is anecdotal, but in past week I've heard of 2 fully vaxxed people in 70s who died of Covid. With Delta & waning vax effectiveness, this will happen. Even if failure to wear masks contributed to the cases, that'll happen too. (2/7)
We can make two types of errors here: acting too early and acting too late. Given that it'll take 4-6 months to roll out boosters to 200M people, I think we need to skate to where the puck is going. To my reading, the evidence we have regarding waning vax effectiveness... (3/7)
Read 7 tweets
4 Aug
Covid (@UCSF) Chronicles, Day 504

To me, the most confusing time in the pandemic was May 2020, as we exited lockdown and nobody quite knew what they should & shouldn’t do (clean the mail? touch the dog?).

But now is giving May 2020 a run for its money. (🧵1/25)
Today, a smorgasbord of some of the most confusing issues: Delta, masking, vaccine efficacy, vax mandates, boosters.

Bottom line is that my thinking has changed. Six months ago, I felt like I understood all of the key variables when it came to the virus & vaccines. And… (2/25)
…when I learned that a variable had changed w/ Delta, I assumed nothing else had.

But now I see that it’s best to assume that nearly every parameter is different – usually for the worse. That creates cognitive vertigo, but it matches the facts on the ground. (see below.)(3/25)
Read 25 tweets
30 Jul
The CDC document that was discussed in @washingtonpost today… is now on line:…
The WashPo shared it with me before publication for reactions, and I'm quoted. Some thoughts follow. (1/13)
My overall view: we knew much of what's in here, but there's some new information & analysis. In some cases it's brand new, in others it clarified something we knew before. In virtually all cases, the new stuff's a bit worse than I expected. Here are the key findings: (2/13)
1) Delta is much more infectious than the original: they estimate an Ro of 5-9, vs. the 2-3 for the original, which makes Delta "as transmissible as chicken pox." We've been estimating Ro of ~6 for Delta, or ~2x as infectious as original. It may be a bit worse than that.(3/13)
Read 13 tweets
26 Jul
Covid (@UCSF) Chronicles, Day 495

When I began my tweets 494d ago, it was before we had reliable local, US, or world data. So I focused on data from @UCSFHospitals. Today, we’re awash in data, yet I find my hospital's data still provides a unique lens into our situation. (1/20)
So today, a few data points from @UCSF, with my interpretation. They reinforce the case that the combo of Delta & relaxed behavior is leading to a powerful & worrisome upsurge that requires a change in approach. I knew things were bad, but it’s even worse than I thought. (2/20)
What’s particularly noteworthy about @UCSF experience is that it’s in a city w/ the nation’s highest vax rate. And cases are rising fast in our employees, of whom 93% are vaxxed. (Special thanks to Ralph Gonzales, Bob Kosnik & @SaraMurrayMD for some of the data.) Here goes:(3/20)
Read 20 tweets
15 Jul
If you're wondering how bad Delta really is, even in highly vaccinated SF (76% of >age 12 fully vaxxed) & still w/ a lot of masking (most folks in stores), we're seeing a pretty steep Covid uptick. Daily cases up 4-fold (10->42; Fig L), hospital pts doubled (9->19; R)(Thread 1/4) ImageImage
Uptick mirrored @UCSFHospitals: Covid inpatients (we were at ~3 pts two-wks ago) now 13 (Fig L). Overall test positivity rate was well below 1%; it's now up to 2.6% (Fig R). Even more worrisome, test positivity rate in asymptomatic pts was ~0.15%, now up 6-fold to 0.9%. (2/4) ImageImage
I don't have vaccinated/unvaxxed breakdown for SF & UCSF – I assume most severe cases are in unvaxxed. But even for vaxxed, w/ more Covid in air expect more breakthru cases. As for me, I'm back to double-mask in stores. Still indoor dining but might abort if trends continue.(3/4)
Read 4 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!