2/ Quick review of @UCSFHospitals, 20 pts, 5 on vents – both lowest since June (Fig on L). San Francisco: 53 cases/day, also lowest since June. 91 deaths, w/ only one death in Sept. Case positivity rate 2.15%. 62 pts in SF hospitals (Fig R). Overall, we continue to do quite well.
3/ On to this week’s grand rounds. @ 6:15, @PeterHotez began by illustrating the value of vaccines; tens of thousands of lives have been saved between 2000 and 2017 by vaccinating children (Figure).
Today marks a half-year of Covid. We’re increasingly told that "it’s vital that we remain vigilant.” But what exactly does that mean?
So today: how to make sound decisions about risk in the face of uncertainty, longing, frustration & fear.
2/ I’m in Florida, where I’ve come to see my 90 & 84 year-old parents. Once I arrived I had to decide how to act with my frail mom & dad (pic: brief suspension of 6ft rule). I’ve been obsessing about whether to make the trip for months & recently decided to take the plunge. Why?
3/ I’m sure I’m not alone – all of us are having to make nuanced risk-benefit decisions re: Covid, nearly constantly. Do I see friends? Inside or outside? Visit family? Send my kids to school? Wear masks? It’s exhausting.
And, for 99% of us, this isn’t what we do for a living.
Nice to re-start our Covid grand rounds today. Available here: tinyurl.com/yyw5myns. We covered a range of epi issues (the shape of the pandemic, changing mortality rate of Covid) and highlighted a novel new therapeutic approach: AeroNabs.
2/ @UCSFHospitals: continued good news, with fewer hospitalized pts (23, w/ 7 on vents), lowest since June (Fig on L). Test positivity 2.7%: 4.7% in pts w/ symptoms (down); 0.9% in pts w/o (a bit up) (Fig R). Sx/Asx ratio usually ~10:1; not sure what 5:1 ratio means. Prob a blip.
3/ SF: daily case rate down to 68, half of the peak in July (Fig on L). Total of 88 deaths since March; more on this amazing # later. SF case positivity rate 2.1%. SF hospitalizations also going in right direction: 65 total, also ~half of peak in July (Fig R).
If @nytimes report is correct that diagnosis in vaccine recipient is transverse myelitis (TM), then level of concern goes up tinyurl.com/yygkas9s Why? First, biologic plausibility: an immunologically-mediated attack is what we worry about re: vaccine side effects (1/4; Thread)
Second, transverse myelitis is fairly unusual, with estimated 24 cases/million in U.S. (if you include transverse myelitis that turn out to be initial presentation of multiple sclerosis, and not just isolated transverse myelitis, which is even rarer) tinyurl.com/y4dugqg7 (2/4)
Via back-of-envelope math, over 2 months, among 15,000 people (approximate # that have been vaccinated; ~half of 30K in the trial; the other half get placebo), the baseline expectation is that 0.06 pt would get TM in absence of vaccine. So concern re: cause & effect is real (3/4)
Ending 2 weeks off in (totally) smoke-free & (relatively) Covid-free New Hampshire. As I resurface, I’m reminded of the scene in Hamilton in which Jefferson, after 5 yrs in Paris, asks “What’d I miss?” tinyurl.com/y5a87hna Answer: plenty.
2/ I’ll start with an update on local numbers, then segue to the most meaningful events and trends since mid-August. I’ll focus on 3 biggies: the phase of the pandemic, testing, & vaccines. Of course, in today's world, you can’t talk about any of it without talking politics too.
3/ Beginning with @UCSF and SF: things are looking pretty good. @UCSFHospitals, 28 cases, 6 on vents (Fig L). While not matching our lows of May/June, big improvement from last mth. Case positivity rate also down by ~50% (Fig R): 5.65% in pts w/ symptoms; 0.65% in asymptomatic.
We’re only 6 months into Covid in the U.S., a little early for déjà vu, but I’m definitely experiencing it – the calm-before-the-storm feeling I had in May, as the numbers fell in the Northeast and we thought that we were over the worst.
2/ Today, after SF updates, I’ll lay out my thinking about what the next few months may have in store, including the prospects of another surge. I’m worried that September will be mellow – just as May was – and we’ll let our guard down… only to be slammed again in October.
3/ @UCSFHospitals, 30 pts, 6 on vents (Fig L). Test positivity rate 2.6%; 9.1% in pts w/ symptoms; 1.15% in pts w/o (Fig R). All of these numbers are up a bit in the last month. We have plenty of capacity, but it would be good to come down from these too-high plateaus.
Today, 150 days since I began my Covid tweets, I’m going to do something odd: write the speech that Trump should give. I have no faith he’ll do so, but it’s worth recognizing how little it would take to change course & save lives. Here goes:
2/ My fellow Americans:
3/ It’s been six months since the coronavirus – the virus that causes Covid-19 – first entered our country. In that time, the disease has killed more than 160,000 of our fellow citizens, sickened millions, devastated our economy, & exposed a number of fault lines in our society.
Grand rounds today: . As we hit Covid’s 6 month mark in the U.S., we’re desperate for innovative approaches. Today, I decided to focus on 3 impressive ones – across a range of disciplines: testing, epi, & narrative.
2/ First, local updates. Things are still OK @UCSF, SF, & CA. @UCSFHospitals, 29 pts, only 5 on vents (Fig) – lowest vent # in about a month. Interestingly, @ZSFGCare (our county hospital) has more Covid: 38 pts, 14 vents. In March/April, UCSF & ZSFG tended to run about even…
3/ …so this is likely another sign that Covid is hitting underserved populations more heavily, since ZSFG is city’s safety net hospital. SF is averaging 91 cases/d, down ~30% from peak last mth (Fig on L). Hospitalizations up a bit @ 94 (Fig R), but still well below peak of 114.
Happy Friday. Today I’ll begin with a deeper-than-usual dive into our local situation: SF, @UCSF, and CA. I’ll follow with a few observations from my recent stint caring for patients on the wards @UCSFHospitals.
2/ @UCSF & SF trending better. @UCSFHospitals, 29 pts (lowest since July 27), 9 on vents (Fig L). Fig R is admits/discharges, showing more d/c’s. Avg length of stay is 8d for non-ICU pts, 22d for ICU pts, which explains lag between less virus in community & fewer hosp pts.
3/ Overall @UCSF case-positivity rate is 2.4%. Rates in pts with Covid symptoms (6.55%) & without (0.57%) both falling. Latter # is my quick-&-dirty way of estimating the odds that a person on a SF elevator with me is infected. Not quite at May levels (~0.3%), but getting closer.
Medical Grand Rounds today, available here tinyurl.com/y5qo5kp7. Today, a far-ranging discussion with @ashishkjha, one of the smartest, most thoughtful people I know in healthcare, and a great communicator on all-things-Covid.
2/ I hope you'll find the time (70 minutes) to watch it – I’ll provide a few highlights below but I do this mostly to whet your appetite. Just a chat, no slides, so it would be fine to listen to it as a podcast.
I’ll start today w/ a few local updates, mostly pretty good news.
3/ @ucsfhospitals, 34 pts, 7 on vents. Steady fall in hospitalizations last 4d (Fig on L). Might be blip but seems real.
Case positivity rate also good (Fig R); down to 6.7% for pts w/ symptoms (~9% last mth) & 0.6% for asymptomatic (1.1% last mth). My conclusion: less virus.
San Francisco is experiencing a surge, so it might seem odd to focus on what SF has done –& continues to do– right. But w/ all the news about California’s surge, SF’s remarkable success story is in danger of being forgotten. It shouldn’t be.
2/ Yesterday, SF’s health director (& my former resident) Grant Colfax offered gloomy projections (“as many as 1800 deaths by the end of the year”) & committed to opening new hospital beds in the city tinyurl.com/y54xq89s. While it’s Grant’s job to paint worst-case scenarios…
3/ … if I were a betting man, I’d take the “under” on that one. SF remains the best performing major city in the U.S. w/ Covid. Even as we’ve let things slip since Memorial Day, we're still doing relatively well, compared with other parts of the nation, and to the rest of CA.
UCSF Medical Grand rounds today, available here tinyurl.com/y2tpw3h4. If there could be such a thing as a “classic” set of topics in a pandemic that’s only 6 months old, today was it: Updates in testing, treatments and vaccines.
2/ Very brief local updates today to save room for grand rounds:
@UCSFHospitals, 35 pts, 9 vents. Possibly plateaued but significantly up over last few weeks (Fig L). SF hospitalizations also up, 112 today (R). Deaths still just 58 since March.
3/ Grand rounds. First, Chaz Langelier on testing. @ 7:00, 193 Covid tests approved by @US_FDA (Fig on L), incl. at-home tests: you swab your own nose (studies show it's as good as fancier deep swab), send it off, & get a result, hopefully (but not always) in few days (Fig R).
2/ ... and Adrienne Green, @UCSFHospitals CMO. While @UCSF is having a bump, it's benign compared w/ ATL, MIA, & HOU. 30 Covid pts @ucsfhospitals, 9 on vents (Fig). Test positivity down a bit; asymptomatic rate – was 0.3% for mths – had risen to 1.1%, but now 0.68%–hopeful trend.
3/ SF numbers also fairly stable, w/ cases down a bit (Fig on L; though might be testing or reporting lag. But at least it’s not surging & might be improving.) SF hospitalizations flat, ~100 (Fig R). Bay Area continues to outperform rest of CA; things are much hotter in SoCal.
This isn’t normally my long-thread day, but I started on hospital wards today so this’ll be my biggie this week. I’ll also tweet Grand Rounds Thurs – we’ll discuss surges in the south & west, w/ speakers from Miami, Atlanta, Houston & @UCSF.
2/ No big changes in # 's today. @UCSF: 30 pts, 9 vents (Fig L). In SF, cases down a bit (R); city’s test + rate only 3% (vs CA 7.2%, U.S. 8.5%). 99 pts in hospitals. Overall, pretty stable.
We hit 1000 deaths in a day today in U.S., 1st time in July. So many were preventable.
3/ Today's topic: I was asked yesterday when life might “return to normal.” It’s a complex question, w/ many knowns, lots of known-unknowns, & some unknown-unknowns. But I’ll give it my best shot. Since I’m human (and thus want my old life back) I might be biased toward optimism.
I usually don’t post on Mondays, but there’s been enough concerns about the numbers that I’ll do a brief update. Bottom line: SF, Bay Area & CA all fairly stable, maybe plateaued. Elsewhere (particularly the southern states): not so good.
2/ At @UCSFHospitals, 31 pts, 8 on vents. Down from peak of 36 pts over the weekend – too early to declare a trend, but we’d been marching upwards for the prior 2-3 weeks, so hoping it is. Test positivity rate unchanged, overall 2.1%; still about 1% positive in asymptomatic pts.
3/ SF also dipping down a bit, with rolling average of 76 new cases per day. Similar to our @UCSF hospital census, this is ~three times the June daily totals, but lower than 80s-90s of last week. Given the shortage of tests, this could be due to less testing – too soon to tell.
@UCSFHospitals: 29 pts, 8 vented (Fig L). Sadly, 1 more death, so 2 in last 3d (after none for ~1 mth). Test positivity stable at 2.1%; asymptomatic rate ticked up to 1.1% (highest I can recall); rate among pts w/ symptoms down to 5.65% (R).
2/ In SF, slow uptick in cases, now 80/d, up from ~30 in June. Even w/ bump, SF remains low in per capita cases & deaths (Fig). Note that Miami now tops NYC in cases per 100K, & PHX, LA, ATL, HOU are closing in. Deaths are still way behind NYC, but starting to rise, as predicted.
3/ As for surging states, CA has plateaued a bit, AZ is down but still huge #. Relentless surges in TX & FL. And GA has earned its place on this graph by virtue of both its surge & the fact that Governor Kemp has decided to double down on boneheadedness tinyurl.com/yb68nlfs
Grand rounds today, here: tinyurl.com/y5ut4435. As I said in my intro (@ 1:00), we covered perhaps the most important topics in the world today: how SARS-Co-V-2 spreads & what can be done to prevent it.
2/ I went thru the numbers yest, & no big changes: tinyurl.com/yyfp92bh@UCSFHospitals 28 pts (down 2), 9 on vents (stable). SF: 77 new cases/day, sl. up (Fig L). Hospital pts=99, most ever (R). Note: mostly non-ICU – ?healthier pts, better Rx? Not sure why, or if it’ll last.
Not a full-fledged thread tonite, but the numbers are changing quickly enough @ucsf, in SF, and in CA (and concerning enough) that I thought I'd update them for folks who are following closely...
2/ @ucsfhospitals, we're at 30 patients, 15 in ICU, 9 intubated (Fig). 30 is higher than our previous peak in mid-April. It's not straining our capacity...but we have re-uped our Command Center. A few from elsewhere (4 from San Quentin) but mostly home-grown. Worrisome trend.
3/ Also @ucsfhospitals: test positivity rate is ~2% overall; 6.4% in pts w/ Covid symptoms; 0.9 in pts w/ no symptoms. Both a bit lower than last wk, but 2x last mth's %s. As I said before, I follow asymptomatic % as rough guide to chance that avg person in SF has active virus.
It's been a wild week, with terrible news about new cases, overwhelmed hospitals, and deaths. Plus boatloads of new info on wide-ranging themes. So this’ll be a potpourri thread, covering a few areas that seem most interesting and dynamic.
2/ Still lots of interest in the end of the “California Miracle.” I wrote this piece in today's @TheAtlantictinyurl.com/ybaoq9yf on how California went astray. My key point: California let its guard down, in spite of good governance. Complacency may be our biggest threat.
3/ Interesting Bloomberg @business piece on why CA, a blue state, hasn’t been criticized (as red states have) for its surge tinyurl.com/ydcwkzan Reasonable point – one could make similar unfairness claim that TX never got the credit CA got for crushing the curve in March-May.
Medical Grand Rounds returns today: @YouTube here tinyurl.com/y99b6csl We cover the state of the pandemic, opening the schools, and the San Quentin prison outbreak. My summary below, after a brief update on our local situation.
2/ Local update: not great. @UCSFHospitals, up to 25 patients, 10 vented. (Some were transferred from Imperial County & San Quentin.) Our highest # s since mid-April. Test positivity rate quite concerning: up 3x (for both symptomatic & asymptomatic pts) over past few weeks.
3/ In San Francisco, cases have stabilized a bit, averaging 43/day (Fig on L). SF hospitalizations up to 76 (Fig R), highest since early May. As with patients @UCSF, some are transfers from other counties, but most are from SF.
I’ve done a ton of media in past few days (eg, @NPR: n.pr/3inIcfK) re: how CA fell off the rails. As I’ve thought hard about that, my answer is different from the one I would have given a few weeks ago. That’s today’s theme.
2/ First, the # ‘s. At @UCSFHospitals, 21 pts, 8 on vents, 2x early June (Fig on L). In SF: cases mildly up (43/d), hospital pts 70 (from ~30 two wks ago); but half the bump is from out-of-SF transfers (Fig R). So SF getting worse but I wouldn't call it “surge,” at least not yet.
3/ In CA, though, surge is an apt term, w/ >7K new cases yesterday (vs. ~2500 new cases/d in early June), hospitalizations up 56% in last 2 weeks (now 5200 hospitalized pts in CA) (Figs L & R). Test positivity rate up to 6.9%, from ~4.5% two weeks ago. All bad and scary numbers.