Wednesday, July 29, 2020
I had numerous comments on mentors yesterday. It gave me a moment to reflect on my training, and I contemplated how often I felt "imposter syndrome" along the path of my education (and still do, TBH). One of the ways my best mentors mentored was not to feed that feeling, but rather look for ways to empower and elevate. Of course, supportive coaching was more atypical 20 years ago. Medical training, in general, is known for intellectual hazing. But, there is a value to imposter syndrome, especially in medicine. When used at the right "dose," self-doubt keeps you sharp – "What am I not thinking of?" "What data do I need to better understand these events?" "What is the best next step in this complex, time-dependent array of options?" All questions that are answered best when you have a suspicion that you still have a lot to learn.
I often wonder how those without some modicum of self-doubt navigate the world. What self-reflection and outcomes measures are used to evaluate their actions? It is a short walk from certainty to hubris to adverse outcomes.
----Latest Data
http://ourworldindata.org/coronavirus-data-explorer?yScale=log&zoomToSelection=true&time=2020-04-16..&country=USA~GBR~CAN~BRA~AUS~IND~DEU~FRA~ITA~SWE&deathsMetric=true&dailyFreq=true&aligned=true&perCapita=true&smoothing=7
FT data - the second graph down now has state-level data - I suggest setting it to cases, per million, linear, and add your state to the highlighted list.
https://ig.ft.com/coronavirus-chart/?areas=usa&areas=gbr&cumulative=0&logScale=1&perMillion=0&values=deaths
The NY Times has hotspot map is an excellent quick glace of rolling 2-week case change: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
State Details:
https://public.tableau.com/views/Coronavirus-ChangeovertimeintheUSA/2_Corona?:display_count=y&:origin=viz_share_link
Rt data: https://rt.live/
COVID risk by US county: https://globalepidemics.org/key-metrics-for-covid-suppression/
Estimate your risk of exposure to a COVID positive person based on your county and the size of gathering: https://covid19risk.biosci.gatech.edu/
Each of the above sites reports its source data. Please review sources like https://covidtracking.com/ to understand the quality of that data.
-----
I have been part of a few discussions on why the hospitalizations and fatalities seem fewer than in the initial March flair of COVID in NY, NJ, etc. I am not sure I understand the trends we are seeing, but there are numerous hypotheses as to what is going on. I missed the Atlantic's roundup of those on July 7, but offer it now since I think it is still applicable. I would point out the typical times to hospitalization is ten days from symptom onset, and the typical time to death is ~ 25-30 days from symptom onset. While the current spike in cases may still be lagging, it does seem the death/hospitalization rates are muted.
https://www.theatlantic.com/ideas/archive/2020/07/why-covid-death-rate-down/613945/
Some new tests are coming on the market, including saliva-based PCR-based testing. It is apparent how the sensitivity and specificity of the various PCR and antibody testing are dependent on the time point in the infection and the prevalence of the virus in ones' local community. It is an excellent time to review:
On Jun 7 Bob Wachter (well-known UCSF physician) published this comprehensive guide to understanding COVID testing:
https://medium.com/@Bob_Wachter/interpreting-covid-19-test-results-a-bayesian-approach-df058dad2ade
A lab company (selling a product) offers this very simplified, but helpful graph to understand the relative timing of the different tests:
https://thenativeantigencompany.com/wp-content/uploads/2020/03/SARS-CoV-2-RNA-Antigens-and-Antibody-Levels-1.png
Here is a reasonable overview of saliva testing, which has a dependency on when you test (appears to be ideal 6-12 days after symptom onset). It will be interesting to see if the convenience and safety (no more sneezing with swabs!) come at the price of sensitivity and specificity. But, the ease and ability to repeatedly test are a real advantage.
https://www.colorado.edu/today/2020/07/22/new-covid-19-test-returns-results-45-minutes-without-nasal-swab
and
https://news.berkeley.edu/2020/06/30/uc-berkeley-launches-trial-of-saliva-test-for-covid-19/
Pfizer and BioNTech are running studies on a different vaccine. This article is mostly a press release but points to the volume of activity and interest in vaccine development.
https://www.statnews.com/2020/07/27/pfizer-biontech-pick-covid19-vaccine-begin-pivotal-study/
you can put It in context with the STAT news vaccine tracker
https://www.statnews.com/feature/coronavirus/drugs-vaccines-tracker/
There is a disturbing group of very compromised doctors endorsing HCQ. Unfortunately, some of our political leaders seem to support their very, very data-free beliefs. Please arm yourself against friends and family who invoke logical fallacies that imply there are "balanced sides" to the arguments they are offering. There are not. There is a mountain of real, well-studied data on HCQ. And the more you dig on this group, the more compromised and agenda-driven they appear. Scary.
https://gizmodo.com/who-are-americas-frontline-doctors-the-pro-trump-pro-1844528900
And in case you need one more roundup of HCQ data:
https://medium.com/@gidmk/hydroxychloroquine-probably-doesnt-work-for-covid-19-60012de28e1a
One last discussion of note. I found this twitter thread and links to articles discussing the relative safety of air travel (compared to trains or buses). It is an interesting discussion, but I WOULD NOT DRAW ANY CONCLUSIONS OR CHANGE CURRENT TRAVEL PLANS BASED ON IT.
https://twitter.com/nataliexdean/status/1288310352548110337
Infographic of the day #1: tips on purchasing a punching bag
https://visual.ly/community/Infographics/health/what-look-when-choosing-punching-bag
This feels like it should be a metaphor, but it is really tips on buying a real punching bag. Hmm.
Infographics about infographic of the day #2 – Big Texas Squares
A delightful blog I came upon about representing data
https://junkcharts.typepad.com/junk_charts/2020/07/everything-in-texas-is-big-but-not-this-big.html
Bonus Round ---Remembrance of Things Past edition (sans a Proust!)
One of the more difficult parts of being a nephrologist is the volume of patients who pass away. It is not surprising, having kidney disease is a risk factor, and in my dialysis population, 5-10% of the patients will pass away per year, even with the best care. On my office wall, I save funeral notices and pictures of my patients. It is an excellent reminder of the various conversations and stories they tell me. I was surprised to find a similar archive recently. The Digital Library of Georgia offers the Atlanta Funeral Programs Collection. It is an archive of funeral programs – things that are often discarded or tucked away and forgotten. But when presented like this, a great reminder of just how rich and diverse people are.
https://dlg.usg.edu/collection/aarl_afpc
Teddy Roosevelt is on my shortlist of famous historical people with whom I'd like to have lunch. I suspect he is on a lot of people's list. Either way, I offer, for your pleasure, a collection of TR's letters to his children. It reminds you of how human prominent personalities can be.
https://www.artofmanliness.com/articles/theodore-roosevelts-letters/
Clean hands and sharp minds, team
-Adam
I had numerous comments on mentors yesterday. It gave me a moment to reflect on my training, and I contemplated how often I felt "imposter syndrome" along the path of my education (and still do, TBH). One of the ways my best mentors mentored was not to feed that feeling, but rather look for ways to empower and elevate. Of course, supportive coaching was more atypical 20 years ago. Medical training, in general, is known for intellectual hazing. But, there is a value to imposter syndrome, especially in medicine. When used at the right "dose," self-doubt keeps you sharp – "What am I not thinking of?" "What data do I need to better understand these events?" "What is the best next step in this complex, time-dependent array of options?" All questions that are answered best when you have a suspicion that you still have a lot to learn.
I often wonder how those without some modicum of self-doubt navigate the world. What self-reflection and outcomes measures are used to evaluate their actions? It is a short walk from certainty to hubris to adverse outcomes.
----Latest Data
http://ourworldindata.org/coronavirus-data-explorer?yScale=log&zoomToSelection=true&time=2020-04-16..&country=USA~GBR~CAN~BRA~AUS~IND~DEU~FRA~ITA~SWE&deathsMetric=true&dailyFreq=true&aligned=true&perCapita=true&smoothing=7
FT data - the second graph down now has state-level data - I suggest setting it to cases, per million, linear, and add your state to the highlighted list.
https://ig.ft.com/coronavirus-chart/?areas=usa&areas=gbr&cumulative=0&logScale=1&perMillion=0&values=deaths
The NY Times has hotspot map is an excellent quick glace of rolling 2-week case change: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
State Details:
https://public.tableau.com/views/Coronavirus-ChangeovertimeintheUSA/2_Corona?:display_count=y&:origin=viz_share_link
Rt data: https://rt.live/
COVID risk by US county: https://globalepidemics.org/key-metrics-for-covid-suppression/
Estimate your risk of exposure to a COVID positive person based on your county and the size of gathering: https://covid19risk.biosci.gatech.edu/
Each of the above sites reports its source data. Please review sources like https://covidtracking.com/ to understand the quality of that data.
-----
I have been part of a few discussions on why the hospitalizations and fatalities seem fewer than in the initial March flair of COVID in NY, NJ, etc. I am not sure I understand the trends we are seeing, but there are numerous hypotheses as to what is going on. I missed the Atlantic's roundup of those on July 7, but offer it now since I think it is still applicable. I would point out the typical times to hospitalization is ten days from symptom onset, and the typical time to death is ~ 25-30 days from symptom onset. While the current spike in cases may still be lagging, it does seem the death/hospitalization rates are muted.
https://www.theatlantic.com/ideas/archive/2020/07/why-covid-death-rate-down/613945/
Some new tests are coming on the market, including saliva-based PCR-based testing. It is apparent how the sensitivity and specificity of the various PCR and antibody testing are dependent on the time point in the infection and the prevalence of the virus in ones' local community. It is an excellent time to review:
On Jun 7 Bob Wachter (well-known UCSF physician) published this comprehensive guide to understanding COVID testing:
https://medium.com/@Bob_Wachter/interpreting-covid-19-test-results-a-bayesian-approach-df058dad2ade
A lab company (selling a product) offers this very simplified, but helpful graph to understand the relative timing of the different tests:
https://thenativeantigencompany.com/wp-content/uploads/2020/03/SARS-CoV-2-RNA-Antigens-and-Antibody-Levels-1.png
Here is a reasonable overview of saliva testing, which has a dependency on when you test (appears to be ideal 6-12 days after symptom onset). It will be interesting to see if the convenience and safety (no more sneezing with swabs!) come at the price of sensitivity and specificity. But, the ease and ability to repeatedly test are a real advantage.
https://www.colorado.edu/today/2020/07/22/new-covid-19-test-returns-results-45-minutes-without-nasal-swab
and
https://news.berkeley.edu/2020/06/30/uc-berkeley-launches-trial-of-saliva-test-for-covid-19/
Pfizer and BioNTech are running studies on a different vaccine. This article is mostly a press release but points to the volume of activity and interest in vaccine development.
https://www.statnews.com/2020/07/27/pfizer-biontech-pick-covid19-vaccine-begin-pivotal-study/
you can put It in context with the STAT news vaccine tracker
https://www.statnews.com/feature/coronavirus/drugs-vaccines-tracker/
There is a disturbing group of very compromised doctors endorsing HCQ. Unfortunately, some of our political leaders seem to support their very, very data-free beliefs. Please arm yourself against friends and family who invoke logical fallacies that imply there are "balanced sides" to the arguments they are offering. There are not. There is a mountain of real, well-studied data on HCQ. And the more you dig on this group, the more compromised and agenda-driven they appear. Scary.
https://gizmodo.com/who-are-americas-frontline-doctors-the-pro-trump-pro-1844528900
And in case you need one more roundup of HCQ data:
https://medium.com/@gidmk/hydroxychloroquine-probably-doesnt-work-for-covid-19-60012de28e1a
One last discussion of note. I found this twitter thread and links to articles discussing the relative safety of air travel (compared to trains or buses). It is an interesting discussion, but I WOULD NOT DRAW ANY CONCLUSIONS OR CHANGE CURRENT TRAVEL PLANS BASED ON IT.
https://twitter.com/nataliexdean/status/1288310352548110337
Infographic of the day #1: tips on purchasing a punching bag
https://visual.ly/community/Infographics/health/what-look-when-choosing-punching-bag
This feels like it should be a metaphor, but it is really tips on buying a real punching bag. Hmm.
Infographics about infographic of the day #2 – Big Texas Squares
A delightful blog I came upon about representing data
https://junkcharts.typepad.com/junk_charts/2020/07/everything-in-texas-is-big-but-not-this-big.html
Bonus Round ---Remembrance of Things Past edition (sans a Proust!)
One of the more difficult parts of being a nephrologist is the volume of patients who pass away. It is not surprising, having kidney disease is a risk factor, and in my dialysis population, 5-10% of the patients will pass away per year, even with the best care. On my office wall, I save funeral notices and pictures of my patients. It is an excellent reminder of the various conversations and stories they tell me. I was surprised to find a similar archive recently. The Digital Library of Georgia offers the Atlanta Funeral Programs Collection. It is an archive of funeral programs – things that are often discarded or tucked away and forgotten. But when presented like this, a great reminder of just how rich and diverse people are.
https://dlg.usg.edu/collection/aarl_afpc
Teddy Roosevelt is on my shortlist of famous historical people with whom I'd like to have lunch. I suspect he is on a lot of people's list. Either way, I offer, for your pleasure, a collection of TR's letters to his children. It reminds you of how human prominent personalities can be.
https://www.artofmanliness.com/articles/theodore-roosevelts-letters/
Clean hands and sharp minds, team
-Adam
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