F. Perry Wilson, MD MSCE
@fperrywilson
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Director, Clinical and Translational Research Accelerator @Yale . Columnist @medscape . How Medicine Works and When It Doesn't in bookstores now!
New Haven, CT
Joined October 2014
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Two years ago, I started writing "How Medicine Works and When It Doesn't" to help people understand the insidious nature of medical misinformation.
That's how it started. It's not where I ended up. (thread)
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This is crazy.
After 2 years of cancer treatment in the US, 42% of patients have depleted their entire life's assets. Unacceptable.
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Folks, we need to talk about this Vitamin D trial. I have no stake in this game - take Vitamin D if you want but this pre-print is super sus. (THREAD)
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Brief thread on that "masks in schools" article in
@nejm
. It's a very well done article that I think many people have not actually read...
1/N
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My lab does not do unpaid internships. Not for students, not for post-grads, not for anyone. Neither should yours. The sample of individuals who can survive a summer (much less a year) without pay is a very specific, privileged group.
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1/ A student just asked me why, if the p-value for a study is 0.04, we can't say the study has a 4% chance of being a false positive. First off, we definitely can't, even under idealized conditions - here's a brief thread as to why.
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Seeing a patient in the ICU now with DKA and shock because he couldn't afford his insulin. So, yeah, the system is broken.
The amount we are spending to save his life is orders of magnitude more than what it costs to make insulin.
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Data keeps emerging that suggests GLP-1RAs like
#Ozempic
curb all sorts of appetites... not just appetite for food. Brief thread on some new findings...
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Proud to report I've had a paper accepted in the New England Journal of Landscaping.
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Does it seem like your hospital patients are getting more... complicated? They are!
🧵
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Twitter account pretending to be an Antifa movement forgets to turn location sharing off...
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So please, read skeptically. Pre-prints have been a boon in COVID times but this study is just... not well done. Be aware. (/END)
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This just happened.
Me: hey kids I have some good news. That grant I was working on for a while got a good score.
My daughter: well I have some bad news. Bees are going extinct.
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I get frustrated with peer-review too, but this is why it's so important. This is super basic stuff - you don't call your study a randomized trial when it's a cluster randomized trial. And peer-reviewers would 100% have asked them to go back and redo the stats.
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And again, is there harm from Vitamin D? Minimal honestly. The harm from promotion of studies like this is tweets like this that try to dissuade people from getting vaccinated and doing other protective measures.
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OK - 8 wards, 5 randomized to Vitamin D, 3 to usual care. (Why not 4 and 4?? - but whatever). So this is actually a CLUSTER-randomized trial. That means you need to use CLUSTERED statistics to analyze it. They do not.
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Masks are annoying, but missing school is more annoying and these 12,000 extra kids would be out of school for a week+. Not to mention the (small but real) risk of more severe covid complications, long covid, MIS-C, etc. (11/N)
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AI in Medicine is suffering from what I would like to call "The Cassandra Problem"
🧵(1/17)
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Well we finally got an Ozempic vs. Mounjaro head-to-head (kind of)... Brief thread to break down the weight-loss-drug showdown...
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I am thrilled to announce that my new FREE online course "Understanding Medical Research: Your Facebook Friend is Wrong" is now LIVE on
@coursera
.
This is a course for everyone, and it's designed to be a lot of fun. Come join us!
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In other words, the confounding is in the wrong direction - if anything it makes these results stronger than reported. (8/N)
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I'm a realist - I get that we are not masking again right now. That's ok - but let's also be real about the benefits. Masking probably avoids absences. And kids need to be in school (in person) as much as possible. If (when?) cases tick up - we should remember that. (13/N).
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This is all pretty compelling data that masks averted some infections. Authors calculate ~12,000 extra infections in unmasked districts, roughly 1/3rd of total in the study period. (10/N)
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The "stay masked districts" had kids with lower SES, more minority kids, and (critically) had larger classroom sizes. All these factors would suggest a *higher* COVID rate in those districts. (7/N)
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OK but maybe kids in the unmasked schools tested more to compensate? Classic ascertainment bias? Second author
@EpiEllie
clued me into this figure in the supplement. Kids in the masked schools got tested *more*. Again, this suggests true effects even larger than observed. (9/N)
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I've spent every Thanksgiving for the past 40 years with my parents, and if you think some virus is going to prevent me from doing that this year...
You're absolutely right. Because I love them and want to keep them safe.
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I need to tell you a story from the early days of the pandemic.
April 2020. COVID was spiking in CT. 450 out of the 1000 beds in our hospital were COVID patients. The ICUs were full - and two extra floors were converted to ICUs to make room. I was seeing kidney consults.
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Hi. My name is Perry and I'm a nephrologist who gives lasix to people with heart failure and AKI.
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The authors could solve this, btw, by releasing a de-identified dataset (including the ward number) for this study. We could analyze it in about an hour at least for topline results using appropriate stats.
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Absolutely fascinating
@JAMA_current
paper this week suggesting that Cerebral Amyloid Angiopathy may actually be infectious. (Thread)
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#fauciatyale
"When you're communicating science, the goal isn't to show everyone how smart you are, it's to make people understand you".
Preach.
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It took me a while to figure out why this was, then I saw in the text that INDIVIDUALS were not randomized, WARDS in the hospital were.
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Why do cancer diagnoses spike at age 65?
Simple - it's when people (finally) get reasonable health insurance (via Medicare).
Of course these cancers were there before that magic age. Untreated.
If only there was a way to extend Medicare to more people...
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In other words, some hospital wards take different patients than others (different risk factors, etc). This is why we see this really weird finding in Table 1:
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I wrote in more detail about this study for
@Medscape
here:
And the primary article is here:
/Thread
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Are women better doctors than men? A new study, appearing in
@AnnalsofIM
suggests, well, yeah. Kind of.
(Thread)
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If my patient from April 2020 had received a vaccine, he'd be alive (and running) today. But he didn't have that chance.
We do.
/end
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This is a big problem. But there is more. It seems that, even if the wards were randomized, the PATIENTS weren't randomized to the wards.
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Is this a perfect study? Of course not. It's one state. It's observational. And no one study is ever definitive. Also, the magnitude of effect seen by delaying masks by 1 or 2 weeks seems larger than I would expect (but exponential growth is weird). (12/N)
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The first clue something is up is that the randomized groups aren't the same size:
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I believe that RNA therapeutics will completely transform medicine. Imagine a future where, instead of taking medications daily, you take a shot maybe once a year. That future is, basically, here.
🧵
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Baseline vitamin D levels dramatically lower in the "non-treated" group. Why? Preseumaby because different types of people got admitted to the wards than were randomized to usual care.
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A million tweets echoing the headline "
#sucralose
is toxic to your DNA" but, like, has anyone read the actual study this is based on? Let's dig in. (thread/)
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You'd expect people with low levels of Vitamin D to do worse - that has been shown multiple times - perhaps because higher Vitamin D levels are associated with less comorbidities.
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OK let's do this.
In one place - ALL the randomized trials of
#Hydroxychloroquine
for
#COVID
.
5 peer-reviewed RCTs. 1 large RCT still in pre-print, but deserves recognition.
All negative.
I don't know what else to say at this point.
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DAMN. Red line is cumulative cases in placebo. Blue is cumulative in vaccine group. Separation at 14 days which, interestingly, is BEFORE dose 2. But don't get carried away, the overall benefit occurs here after dose 2. Still - might be partial protection with 1 dose. 5/
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They know when these various districts lifted their mask mandate. A bunch did right at the end of Feburary 2021 (1) when the state mandate was lifted, a bunch a week later (2), a bunch a week after that (3), and 2 (Boston / Chelsea - Black) held out for the full time study. 3/N
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The setup is starightforward. Cowger et al have access to data on 300,000+ students and teachers COVID tests in 70+ Eastern Mass public school districts. (2/N)
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Flautist undergoing brain surgery plays during the operation. This ensures she doesn't lose critical function.
#GoodMedicine
Credit u/tmrmrk.
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So, on the surface - the districts that stayed masked longer did better. But... (5/N)
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Here's their Kaplan-Meier curve. It doesn't make sense. What do they mean by 'cumulative hazard' of mortality? What units are these? The overall mortality was 10% by their report.
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The rates of COVID were pretty similar before the Mandate was lifted (prior to the dotted line) but diverge thereafter. Some noise around the Omicron wave when so many people were infected. (4/N)
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The paper is presented as a randomized trial of vitamin D supplementation in hospitalized patients with COVID. Interesting and important question! And the results appear dramatic:
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The emerging picture here is that these drugs don't work by simply slowing gastric emptying or something, they work on cells in the brain, curbing reward systems that have long been entrenched. They are sort of "anti-consumption" drugs.
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If true, this would be one of (if not THE most) effective treatments for COVID. But there are problems...
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A study suggesting pasta consumption can reduce BMI is a great example of Simpson's Paradox.
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I know what you're thinking. This isn't a randomized trial. Those districts that stayed masked are likely different than the ones that didn't. You're right! But maybe not in the way you think. (6/N)
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19/ I hope this helps someone! Let me know.
I get it now!
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I still don't get it.
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Desperate for a COVID-19 treatment, we are forgetting the science-based principles that make modern medicine the greatest human achievement of all time.
We can use this crisis to reaffirm those principles.
Here's how (and how it informs the use of HCQ).
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So basically the job of medicine is getting harder. It's just harder now than it was 20 years ago. So... does it make ANY sense that hospitals are staffing so poorly? Could taking care of MORE patients who are MORE complicated lead to MORE burnout?
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4 years of college. 4 years of medical school. 3 years of residency. 3 years of fellowship. 6 years on faculty
@yale
.
Still no idea how offsides works in soccer.
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This week, we have an interesting article in
@JAMA_current
which finds that adding three biomarkers that are clearly associated with cardiovascular disease to an existing risk equation does NOT improve the predictive ability of that equation. How does this happen?
🧵
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But the idea that only people with comorbidities die from COVID is simply not true.
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25,000 patients. Randomized trial. Vitamin D supplementation has no effect on cancer or cardiovascular endpoints.
The observational studies were positive because vitamin d is a biomarker of a healthy lifestyle, not a panacea.
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If only there were some way to determine if HCQ was truly effective. Maybe some kind of system where some people would be given the drug, and some people wouldn't, maybe at random?
Yeah I guess that's crazy. Let's just rely on the experience of whoever is on the news tonight.
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Excited to share our new study in the Journal of Hypertension examining the effect of IV antihypertensives on hospitalized patients with severe htn. Outstanding work from
@lama_ghazi
on this.
Brief thread (1/N)
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Girl, are you a p-value of 0.001? Because you are highly significant to me.
#StatsValentines
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In a society plagued by overconsumption, this could lead to a monumental social shift. We may be at the beginning of the Ozempic era. Literally.
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13/ The realization here is that the more untrue hypotheses are tested, the higher the rate of false positive studies. Here's how this looks graphically:
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All in all, this is REALLY encouraging data. I'll be very surprised if the EUA isn't granted on 12/10. And given this - I would 100% get this vaccine myself.
13/
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Remember the bizarre, fatal melioidosis outbreak in four states with no clear source?
Well yeah it may be due to *aromatherapy room spray*
Did not see that one coming.
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A bit of good news!
As of this morning there are 0 patients with covid in the Yale New Haven ICU.
This is a beatable virus.
But it takes collective action.
Let's continue to be careful and take it seriously.
@GovNedLamont
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My experience with one major journal since the start of my research career. It's not always obvious, but it's important to take stock and realize that you're getting better as time goes on.
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Thread to discuss our new RCT (ELAIA-1) appearing in
@bmj_latest
that showed some unexpected results in the world of electronic alerts for acute kidney injury.
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Put simply: we're asking vaccinated people to wear masks to make sure that the unvaccinated people don't get infected so quickly they break our hospitals.
That's basically it.
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Tried to get holiday photos taken and accidentally got "generic white guy running for Congress".
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Honored to be with these giants of science communication,
@RealDoctorMike
and
@CaulfieldTim
to discuss medical misinformation at Atlantic Health!
Fun fact: combined, Dr. Mike and I have over 25 million social media followers.
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And maybe we should remember that a lot of the people in positions of authority in the healthcare system - even the doctors up in the c-suite - may not have taken care of patients for 20 years. They may not understand what modern medicine really looks like...
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Best thing that has happened to me recently. My niece is on a plane and texts me this picture of a random person reading my book!
Thank you random passenger!
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They aren't the splashiest articles, but studies keep suggesting Ozempic has these "off-target" effects. Here's one showing the drug reduces alcohol intake...
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I feel so damn impotent. Seriously, what can I, as an individual, do here? I can vote, sure. I can give money to good organizations. I can tweet that this doesn't have to happen. But nothing changes. So what can I do? Just hug my kids? Seriously. Tell me what I can do.
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Can you recognize the sound in this video? It may blow your mind (thread)...
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Whoa.
Excess deaths in NYC in NYC over time. 32,000 total deaths between March 11 - May 2, which is 24,000 (!) more than expected. Suggests a substantial undercount of COVID deaths.
VIA
@CDCgov
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As a med student, I'd always get butterflies walking into clinic. I figured they would go away as I got older. They haven't. Not because I'm nervous but because this is probably the closest thing I have to a sacred space.
#doctoring
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The great thing about clinical research is the flexibility it affords you. Like, do I want to stay up late writing this grant OR should I get up early to write this grant?
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I've definitely noticed this phenomenon in American diet culture of late.
But high-protein diets may not be all they are cracked up to be. Why? A new study in Nature Metabolism puts the blame squarely on a single amino acid: leucine.
🧵
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And I keep seeing people doing *exactly* what I was doing. Rationalizing these deaths, these bad outcomes, to make themselves feel safer.
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Today, I received a safe, highly effective vaccine against the
#coronavirus
.
For the past year, we've been fighting this disease that has devastated so many lives.
Now, science is giving us the tools to end it.
#VaccinesWork
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Can someone explain why "hospitalized, in an ICU" is the highest priority for testing? Those people can be treated empirically (treatment is largely supportive care / isolation anyway).
Highest priority should be health care workers. This seems obvious to me. What am I missing?
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The good news is we have vaccines now - a defense against this new thing. Vaccines make you safer - we have data to show that - no mental gymnastics or rationalizations necessary.
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Seeing an interesting question coming up here - should we just give as many people as possible dose 1 of the Pfizer vaccine and not worry so much about dose 2? Let's do some stats. Thread/
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Because let's face it. COVID IS scary. It is a NEW thing. A NEW pathogen. One we are still learning about. And it's easier to go about your day if you can convince yourself that, even if you get infected, you'll be fine.
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18/ Yes, this is Bayesianism. But I didn't want to say that til the end. I'm not wading into that debate. I just wanted to talk a bit about why p=0.04 does NOT mean 4% this study is wrong.
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