Vincent Rajkumar Profile picture
Sep 13, 2020 11 tweets 5 min read Read on X
As I predicted a month ago the number of new COVID cases has decreased in the US. From a high of 70,000 per day to 35,000 per day now. It will likely continue to decrease for some more time.

This is due to many factors, but great national leadership is not one of them.

1/
Why are cases decreasing even though most of us are still susceptible?

2 reasons:
— Increasing proportion of persons at high risk of getting COVID (eg., jobs where u can’t social distance) have already had COVID
— Effect of masks & distancing

2/
But the proportion of people who have been exposed is very low even in hotspots. Less than 10%. Does this mean >90% of us are still susceptible? And if so, why are cases decreasing?
jamanetwork.com/journals/jamai…

3/
While we have to assume that we are all susceptible and continue to take preventive measures, seroprevalence studies likely underestimate the proportion of people who have been exposed to COVID. See article by @JoshuaPCohen1 @Forbes google.com/amp/s/www.forb…

4/
But even if we do some rough math, and double the seroprevalence we will still have only estimated 10-15% of population as having been exposed to COVID, far lower than what is needed for true herd immunity, but yet cases are decreasing, even in many hot spots. Why?

5/
Which brings us to the big question. Are we all equally susceptible to COVID? Or do some people have cross reactive immunity in which cases the disease is so mild that while you may get a PCR positive result, it doesn’t actually lead to symptoms or permanent seroconversion?

6/
An important caveat:

-What happens in Europe happens a month later in the US. In Europe there is a 2nd wave. Our cases can go up dramatically. We have to be careful & continue masks and social distancing because that may reduce viral dose and thereby the severity of COVID
7/
As cases come down leaders will naturally try to take credit. Or my worry is that they may tell people to relax. But to be clear the drop in cases is happening because of reduction in susceptible population and due to behavioral changes, specifically masks. @jeremyphoward

8/
The number of daily cases now is higher than I thought it would have been at this point. But the trend is there.
My feeling is that the drop in cases will be transient and we will have another peak in late fall. But my hope is that the drop in mortality is more enduring.

I also recognize that COVID has a lot of long term consequences. So it’s important we do everything to keep cases down

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More from @VincentRK

Aug 24
Why are prescription drug prices are far higher in the US that other developed countries.

I’ll break it down. A full 360.

1/ We don’t negotiate prices at launch of a new drug. Others do. Image
As a result, we spend billions on common drugs that other countries spend a fraction of the price on.

Some drugs we pay 10 or 100 times more!! Image
2) Generic and biosimilar entry, adoption, and utilization is slower in the US, and there are many barriers.

Timely and adequate free market competition is critically important for lowering price. Image
Read 21 tweets
Jul 8
FDA approval doesn’t necessarily mean standard of care.

Thread.
1/
For example FDA approved Dara VMP for frontline therapy in myeloma in 2018.

Literally no one used the regimen in the US.

Literally no one felt the regimen was standard of care in the US.

Before or after approval!
Why?
FDA adjudicates a sponsors submission on whether a given drug/regimen has met the burden of proving safety and efficacy.

Standard of care in clinical practice is a different standard: judgment of risk/benefit of available alternatives, and assessment of trial design/end points.
Read 13 tweets
Jun 25
Cure is a simple word. But there is confusion when it comes to cancer. What cure is in cancer, and what we should aspire for?

When can we say that a given type of cancer is curable?
Thread
1/
There is a difference between when we can say a particular cancer is a curable type versus whether individual patients with a given cancer can be considered potentially cured.

They are not the same.
2/
To call a cancer curable we must be able to treat the cancer for a finite duration, stop all therapy, and know that a certain % of patients will never relapse

Early stage solid tumors, Hodgkin lymphoma, DLBCL, ALL, AML are curable. Real cure. The definition of curable cancer
3/
Read 13 tweets
Jun 1
The 4 big myeloma randomized trials to watch out for @ASCO #ASCO24

1. Isa-VRd vs Isa-Rd newly diagnosed
2.Isa-VRd vs VRd (IMROZ)
3.DREAMM8 Bela-Pd vs Pd
4.Ven Dex vs Pom Dex (Canova)

See thread for why they are important.
1) The Triplet vs Quad trials with will define role of quads in elderly patients with newly diagnosed myeloma. They also provide frontline phase III data with Isatuximab— and a choice between Dara and Isa. For some patients Isa will be more cost effective. @Myeloma_Doc #ASCO24
2) Belantamab will make a comeback.

Corneal toxicity is low with reduced frequency dosing. The drug works very well. And in many patients with refractory myeloma belantamab may be safer and easier to do than bispecifics. We need options. #ASCO24
Read 12 tweets
May 31
Just out: Updated mSMART recommendations for treatment of relapsed refractory myeloma. #MedTwitter @MayoMyeloma

1/ CART is now included as an option for second or higher relapse. msmart.org/mm-treatment-g…
2/ Even though CART (cilta-cel) is approved for first relapse we are NOT including it in our main algorithm. Reserved only for special circumstances in this population. We have a long track record with standard triplets, and we are concerned about CART side effects. Image
3/ The current approach for second or higher relapse continues to define 3 specific types of Triple Class refractory. This makes it easier for clinicians to consider options. Image
Read 6 tweets
Apr 23
To my followers who wonder what MOC is, and why many doctors are tweeting about it. Thread.

1) Maintenance of Certification (MOC) is a redundant requirement thrust on US physicians by a private organization. We resent it.
2) MOC is causing frustration and burnout. Over the years, ABIM certification and MOC have become entrenched and institutions and insurers require it and will not accept any other alternative.

I am advocating on behalf of my colleagues in the US for change. To end MOC.
3) MOC requires us to pay fees imposed on us by a private organization and take multiple choice question tests irrelevant to our practice.
Read 8 tweets

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