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Vincent Rajkumar Profile picture
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20 May, 6 tweets, 4 min read
Monoclonal Gammopathy of Undetermined Significance (MGUS) is present in ~5% of the population age >50. MGUS carries a lifelong risk of the cancer multiple myeloma at a rate of 1% per year.

Should we screen for MGUS? iSTOPMM trial will answer this question nature.com/articles/s4140…
iSTOPMM has enrolled more than 80,000 people living in Iceland, 40 years of age and older. The trial asks 2 questions: Does screening provide benefit? Does intensive follow up of MGUS provide benefit. @SaemundurMD @sykristinsson
Here is an excellent thread by the first author @SaemundurMD on the iSTOPMM trial.

@IMFmyeloma @BindingSiteHaem @BrianDurieMD @sykristinsson
High Risk Populations: MGUS is twice as common in Blacks, and in first degree relatives of people with myeloma. The @PromiseStudy @IreneGhobrial @DanaFarber is trying to determine whether screening for MGUS will be of particular value in high risk populations.
In the small subset of very high risk populations, specifically Blacks with one affected first degree relative with myeloma, & all others with 2 affected first degree relatives, I think we must screen now before the results of trials are available. @Nature nature.com/articles/d4158…
In all others, we should wait for the results of iSTOPMM and @PromiseStudy

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Vincent Rajkumar Profile picture
22 May
Why are prescription drug prices so high in the US?

Let us start with insulin as an example. Insulin is the Achilles heel. If we understand insulin, we understand why it's so hard to fix our broken system.

1/ Existence of a vulnerable population needing a lifesaving medicine Image
2/ Monopoly

3 companies control the market for insulin. In a monopoly with significant regulatory and legal barriers to entry of competing products, the seller can set the price however high they want.

Here, the monopoly is not over a luxury item, but a lifesaving medicine.
3/ Patent Evergreening:
Making patent life extremely long & preventing competition.

Covert: By making newer version of a drug and patenting it (see insulin below)

Overt: Filing multiple new patents on same drug to stretch patent life, pay for delay schemes, lawsuits. Image
Read 18 tweets
Vincent Rajkumar Profile picture
21 May
Finally we have important data that shows that neutralizing antibody levels are highly predictive of protection from symptomatic COVID. @NatureMedicine @Nature nature.com/articles/s4159… Image
20% of convalescent titer gave 50% protection from symptomatic disease.

Just 3% of convalescent titer was able to give 50% protection from severe disease.

mRNA vaccines and Sputnik V look really good. Blue is proportion protected from symptomatic COVID. ImageImage
The observed efficacy with the various vaccines aligns very well with the predicted efficacy from neutralizing antibody titers.

Pfizer/BioNTech, Moderna, Novavax, Sputnik V looking very good. Image
Read 5 tweets
Vincent Rajkumar Profile picture
20 May
3 reasons why I'm worried the pandemic in India is different:

-Rapidity with which the disease seems to progress
-High transmissibility in family contacts
-Severe disease & deaths in young people

I wish we had hard numbers. This my opinion based on following events closely.
Qualitatively the way COVID has behaved in India in the last 2 months is very different from India's first wave. It is therefore prudent to assume we are dealing with one or more extremely bad variants.

Of the variants listed below, B.1.617 is the one of major concern in India.
Implications:

1) We have to monitor and determine efficacy of vaccines, especially mRNA vaccines, against B.1.617 variants.

2) It is in the best interests of all nations with resources to help with huge amounts of vaccines ASAP to prevent the rise of even more serious variants.
Read 4 tweets
Vincent Rajkumar Profile picture
19 May
The 4 COVID variants considered variants of concern by the WHO.

Of these, B.1.617 worries me the most. This is the variant that is sweeping across India. It appears more contagious, and likely more virulent.
who.int/docs/default-s…
Here is an update on how B.1.617 is becoming more dominant in India. @MohanaBasu @ThePrintIndia google.com/amp/s/theprint…
There are 3 subtypes of this variants. B.1.617.1, B1.617.2, and B1.617.3.

Preliminary studies suggest it is more contagious. Although the vaccine induced neutralizing antibody activity appears lower, it is still more than enough to neutralize the virus. google.com/amp/s/www.cnbc…
Read 6 tweets
Vincent Rajkumar Profile picture
18 May
Just heard that it only costs $3 per dose for Pfizer and Moderna to make their COVID vaccine. But they sell it for $15-40 to the world.

Given the amount of publicly funded research that went into development of these vaccines, & the current crisis, this is unacceptable.
I'm ok with profits. But not on this scale, where it places many countries at huge financial and public health crisis. google.com/amp/s/www.nyti…
Moderna had $1.7 billion in sales, and $1.2 billion in profit. google.com/amp/s/www.mark…
Read 8 tweets
Vincent Rajkumar Profile picture
17 May
This drop in confirmed COVID cases in India is an illusion. First, due to limited testing, the total number of cases is a huge underestimate. Second, confirmed cases can only occur where you can confirm: the urban areas. Rural areas are not getting counted. @BDUTT
The daily confirmed deaths in India had exceeded 4000. At no time in the pandemic did any country exceed 3500.

The 4000 deaths are also a huge underestimate. Last year deaths were probably undercounted by a factor of 2 or 3. Now probably 10.
Although a nationwide lockdown would have been ideal, this has not happened. However most states have instituted lockdowns. This is less that ideal (since strictness varies a lot) but will help bring true cases and deaths come down in 2 weeks.
Read 6 tweets

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