Vincent Rajkumar Profile picture
Sep 23, 2020 14 tweets 4 min read Read on X
Amazing exchange between @RandPaul and Dr. Fauci.

1) As one of the first people to raise the possibility that not everyone may be susceptible to COVID, and that cross reactive immunity may be protecting some people from severe infection, I agree with those points by @RandPaul
2) I’ve also been on record that seroprevalence underestimates the proportion of people who are immune & that we may be closer to herd immunity in prior hotspots than the 5-10% seroprevalence indicates. But that number (~2 times seroprevalence) is still far short of herd immunity
3) Having said here are 3 comments I disagree with.
-The comparison of NY to Sweden is not correct.
-The statement that flattening the curve does not reduce number of deaths is not correct
-We are doing as well as S. America & so mitigation strategies don’t help is not correct
Sweden as Dr. Fauci pointed out did not do anywhere as well as Denmark, Finland, or Norway—its neighbors. Those are the comparators. Sweden also had warning that NY didn’t have. So we cannot compare. Both Sweden and the US have done equally badly in terms of deaths per million.
Flattening the curve will spread CASES over time and so the area under the curve for cases may be similar whether you flattened or now. But not DEATHS. In fact, the whole idea of flattening the curve is to reduce high number of deaths that occurs when the system is overwhelmed
In fact NY, NJ and the east coast were hit BEFORE the flattening happened. The high death tolls there reflect what happens when the curve is NOT flattened. There is a lag between issuing mitigation orders and flattening to occur. Same thing happened in Lombardy.
We made a lot of mistakes. I have catalogued things we could have done better in hindsight. An earlier recommendation for universal masks would have helped. And a uniform bipartisan recommendation on that. We have fared really badly compared to most developed countries.
The reason why S. Korea, Vietnam, Japan, Taiwan, and China have done so well is far less likely to be related to cross reactive immunity but rather related to strict border control for entry into country, testing, tracing, masks. They followed the science. We didn’t.
I agree that it’s possible that S. America, Africa, India, Pakistan have lower mortality because of cross reactive immunity from prior corona viral infections. But we likely have much less cross immunity. So if we had less social distancing like them, we would have 400,000 deaths
Some links. On susceptibility and cross reactive immunity.
On seroprevalence being an underestimate. @JoshuaPCohen1 google.com/amp/s/www.forb…
What could we have done better to reduce mortality. 10 factors in this list.
*now = not

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More from @VincentRK

Dec 31, 2023
My year end endorsements.

1) @costplusdrugs — where you can get >2000 prescription meds at lower price than almost any other pharmacy in America. Has revolutionized the generic prescription drug market. @mcuban costplusdrugs.com
Image
2) @PayorDieFilm — the story of lives lost due to the high price of insulin in America. Likely contributed to why all 3 big insulin manufacturers have now cut the price of insulin by >70-80%. @scottaruderman @NSmithholt12

Watch on @paramountplus @mtvdocs Image
3) Inflation Reduction Act provisions to cap Medicare Part D copays.

For 2024, the out of pocket max for Part D drugs that a patient pays in copays is capped to a max of ~$3250. A huge relief to many.

This cap goes down further to $2000 in 2025.
Read 7 tweets
Dec 15, 2023
Updated treatment approach to newly diagnosed myeloma based on new #ASH23 data.

Explanation for changes in thread. #MedTwitter 1/ Image
What’s changed?

I’m ok with quadruplet induction for standard risk based on the 2 phase IIIs at #ASH23

Better PFS and MRD-
Limited duration induction.

OS will take a long time to emerge and risk/benefit is reasonable to incorporate Quads.
2/ Image
Which Anti CD38?

Either Daratumumab or Isatuximab are ok as the AntiCD38 antibody to add to VRd for the Quad

Decide based on cost and access.

We had data on both at #ASH23
3/ Image
Read 11 tweets
Oct 2, 2023
Two days ago I did 60 ABIM MOC questions in Heme and Onc (against my will).

Almost all were esoteric/ irrelevant questions. Rare things that doctors rarely see. #MedTwitter

What’s my opinion?

1/
I spend a lot of time in medical teaching and writing. I write for UpToDate for 20 years, and all of the major Hem Onc textbooks.

In my opinion, the MOC questions are useless for routine Hem Onc clinical practice. Useless to assess “walking/ essential knowledge”.

2/
What’s worse: Every 3 or 4 questions that I spent time and answered, I would get a note that it was a “test question”. No answer was given at the end, making it a complete waste of time and making me an unwilling partner to test questions for the ABIM. @DavidSteensma

3/
Read 6 tweets
Aug 11, 2023
US physicians almost unanimously oppose ABIM MOC. #MedTwitter

We have raised our voice in despair. What can we do to make change happen?

1) Urge our professional organizations to support us. More than words, we would like action.
2) Continue the pressure on social media.
3) Support the petition started by @AaronGoodman33

>12,000 have already signed.

change.org/p/eliminate-ab…
Read 13 tweets
Jul 31, 2023
Top 10 reasons why ABIM MOC should be abolished. #MedTwitter

10. It’s a bad life experience that physicians almost unanimously don’t like.
9. The questions asked in the MOC LKA or MOC exam are not what we face in practice. They are often vague zebras or designed to trip people up. (Experts get questions in their own field wrong)
8. MOC depresses morale. When you take a profession where people are committed to life long learning, do plenty of hours of CME each year, and force them to a multiple choice test every 3 months: You know what it does to morale.
Read 11 tweets
Jul 21, 2023
Myeloma drugs — Dosing and schedule

What I do in practice #MedTwitter

1. Dex: 40 mg once a week age <70; 20 mg if age >70 or frail

Stop Dex at around one year if good response.

Days 1-4, 8, 15, 22 schedule for 1st cycle only in cast nephropathy; or VDT-PACE type regimen
Velcade:

Once a week and SQ is my default.

Twice a week for 1st cycle only in acute in cast nephropathy, or with VDT-PACE type regimen
Revlimid:

25 mg standard. But reduce starting dose to 10-15 mg for the following groups: elderly, frail, patients with body weight less than 60kg, renal failure, and patients of Asian or South Asian descent.

Maintenance dose: 10 mg max.
Read 11 tweets

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