David Russler-Germain, MD/PhD
@dgermain21
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Oncology Instructor @SitemanCenter @WUSTLmed | lymphoma/leukemia researcher @LabFehniger | all views 100% my own
St. Louis, MO
Joined January 2009
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Pretty much everyone who knows me knows I'm a big fan of bispecific antibodies for B-NHL. For a summary of key landmarks in this space, emerging evidence and lessons from recent clinical trials, and exciting new directions, check out our review:
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Literally the last paragraph of the article reads:
Breaking News: Pfizer and its partner BioNTech are expected to ask the FDA as soon as Tuesday to authorize its Covid vaccine for children 6 months to 4 years old as a two-dose regimen.
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How do I teach the essentials of DLBCL to my co-fellows?
See this folder for my slide-deck and PDFs of the references. Enjoy!
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I'm prepping a talk and for the first time it dawned on me: why don't I put a QR code at the end that links to a Box drive folder of the PDFs of every reference I cited in the talk? Cool or dumb idea? Seems super obvious now...
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If I had to give future heme/onc fellows one piece of advice not directly related to patient care, it'd be to read at 1+ paper every (week)day. Set aside 30 min to read something from NEJM, Lancet, JAMA, Blood, JCO, or any sub-journal. Save and highlight PDFs digitally.
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So was I last person on earth to learn that NCI-designated cancer centers don’t have to accept Medicaid? Heard from few fellows at ASCO from other institutions (some of which I thought were safety-nets) that their cancer centers won’t treat patients on Medicaid. Help me process…
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I’m honored to receive a 2022 LRF Postdoctoral Fellowship to support my work in
@LabFehniger
on lymphoma mouse models of FL/DLBCL. Many thanks to everyone supporting my physician-scientist training: Todd, Tim Ley,
@nancybartlettMD
,
@KahlBrad
,
@DiPersioLab
, and many others!
We are pleased to announce the 2022 LRF grantee class, with $5.7 million in grants awarded to early career and established scientists working on innovative lymphoma research. Read more about our grantees by visiting us at .
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CART cells are revolutionizing B-NHL treatment. But…
Let’s not sweep under the rug:
(1) ~$400k product, ~$1M “total package”
(2) ~1/4 patients required ICU care
(3) Non-relapse mortality ~10%
We need to acknowledge the downsides to make CART cells cheaper, faster, and safer.
The ALYCANTE trial of axi-cel in transplant ineligible DLBCL patients just out in
@NatureMedicine
88.7% patients over the age of 65
Median PFS 11.8 months
Grade 3/4 CRS 8.1%
Grade 3/4 ICANS/neuro events 14.5%
#lymsm
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I’ve been asked to re-share some of my lymphoma teaching resources from
@WUHemeOncFellow
. So glad people find them useful!
Focused review of RT for DLBCL:
Broad review of DLBCL for first year fellows:
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Recently saw a patient for “new MDS” with Celiac dz, a prior small bowel resection, and was taking two zinc-containing supplements. Negative sequencing and FISH. Copper level below limit of detection, zinc level 3x ULN. IV cupric chloride to the rescue! Normal CBC now!
Copper Deficiency Anemia!
Rare but seen in:
TPN
Postbariatric surgery
Celiac dz
Excessive zinc intake
Menkes disease
Anemia+neutropenia (thrombocytopenia rare)
Variable MCV
Mimic of MDS as dysplasia can be seen in marrow
Cytoplasmic vacuolization erythroid/myeloid precursors
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@VPrasadMDMPH
Be the doctor you want taking care of your family members. Hard for that advice to lead you astray.
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The
@nytimes
does a great job covering legitimate amazingness of CAR-T cell therapy for cancer. But they should follow-up those pieces with a series on how poorly insurance companies are behaving as they delay patients' access to this treatment for months without justification.
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Sometimes I read prominent papers and I think, "What in the world is going on here? Why am I so confused?" Recently, I'm realizing it's because it's easy for authors to obfuscate the data and make plots of p-values instead of actual data. I'm staring at bar charts...of p-values.
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After the polatuzumab ODAC,
@Eddie_Cliff
and I were very intrigued by the POLARIX subgroup analyses.
This led to multiple discussions, and together with
@nancybartlettMD
, we've published our impressions of the polatuzumab COO interaction:
#lymsm
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I couldn’t be more excited to begin my first inpatient attending block on our lymphoma/myeloma service today
@SitemanCenter
@WashUOnc
@BarnesJewish
@WUHemeOncFellow
. Unsurprisingly, I’ll focus my teaching on lymphoma, and we’ll examine a paper-per-day. 1/🧵
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The way I read this study is that patients with more advanced cancer and poorer performance status are more likely to use cannabis. Curious about others’ views on the causality direction here.
#Cannabis
use associated with inferior
#immunotherapy
outcomes
📍Median time to tumor progression 3.4m (95% CI, 1.8–6.0) for cannabis users vs 13.1m (95% CI, 6.0–NA, p 0.0025) for nonusers
📍Prospective study from 2020 of pts w adv cancers receiving immune checkpoint inhibitors
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My 6.5 yo son (1st grade) has formed a 'nice guy gang' (his words) with school friends called 'The Thunderstorms' -- the 'levels' in his 'gang' are 'Intern' to 'Fellow' to 'Professor'. 😜
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@DGlaucomflecken
But what if your in-network ED and out-of-network ICU doctors are doing a patient handoff at the stroke of midnight?!
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Excited to announce my fellowship IIT is officially open: mosun + pola in 1L FL
.
An incredible experience thus far, and journey is just beginning. Massive gratitude to mentors
@nancybartlettMD
and
@LabFehniger
, plus amazing
@SitemanCenter
staff.
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@Plenary_Session
@jcbriscoe1
Why, as a healthcare system, are we (on one-hand) willing to pay for a $100,000 drug that prolongs life my weeks, but not (on the other hand) willing to spend even 1/2 that on the tangible, non-pharmaceutical care a patient may really need and want (and maybe even prolong life)?
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I know my opinion on many matters isn’t all too important, but I feel the need to declare my view that it’s rather disappointing as a trainee to see faculty promoting a parody account of a professor and bashing that person on threads from that parody account. Seriously y’all?
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I knew very little about EBV+ DLBCL (outside of PTLD), and came across this really outstanding paper. Recommended for all lymphoma fellows!
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So meta but so true.
In 20 years, there will be 100s of studies showing masking in schools works, and 100s showing it does not work at all.
This is a product of immense analytic flexibility & motivated reasoning
One person saw all this years ago;
A brilliant article 👇
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This is sad.
I think if a cancer center is refusing to take Medicaid patients, the
@theNCI
should not give them a cancer center designation.
There's no reason the federal government should brand a center when it is failing people who need cancer care the most.
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POLARIX DLBCL abstract published:
pola-R-CHP > R-CHOP (PFS HR 0.73)
OS, CR rate, toxicity profile essentially equivalent.
Practice changing now or show me the K-M curves, full AE data, and cost implications?
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As someone in
#WashUdebate16
audience: pretty much only some middle aged whites "laughing" at "you'd be in jail". Everyone else: mortified.
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This is classic "why Twitter is awesome" -- biotech investor
@AndyBiotech
says one thing, oncologist
@VinayPrasad82
says another. Amazing.
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Every week in my oncology clinic I combat significant vaccine misinformation. This potential approval, and any potential subsequent mandates (heaven-forbid), will be a disaster for drug regulatory credibility.
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Congrats to my amazing wife
@MimiRussler
who matched into AP/NP as part of the PSTP
@wusm_pathology
!
#PathMatch21
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I’m sorry if I offend anyone but I am going to have to say something here. BR+I was NOT safer than the control arm. This tweet is misinformation. An extra 4% of patients had fatal adverse events from adding concurrent indefinite ibrutinib to BR.
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A truly embarrassing graph made by a legitimate organization. Wow.
An analysis looks at how defense spending among the nations with the highest expenditures has changed since 1992 and what may have driven the changes
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All checked-in and headed to
#ASCO22
. Honored to be recognized via YIA this year for our work on lymphoma mouse models and genomics in
@LabFehniger
. See y’all soon!
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This is really fantastic, irrespective of where you fall on the political spectrum.
Is the pandemic a social construct?
@VPrasadMDMPH
says technology, policy, and polarization play a role in the realities of COVID-19.
Listen to the whole conversation here:
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If we are showing an OS “trend” then why omit the HR confidence interval? Not good practice IMO…
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As parent of 6-month and 5-year olds, I’ve vax’d oldest & plan to vax youngest.
But I also think it’s not ideal to grant EUA for vaccine based on outdated viral strain (yes, still partially protective still) that failed to meet the low bar of Ab titers, not a clinical endpoint.
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I keep meaning to write up some reflections on my first year as an independent oncology attending, specializing in lymphoma at academic center. In meantime, spoiler alert: be the doctor you’d want your family member to have. That gives you answers to 95% of questions you face.
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Wow. Probably my favorite abstract thus far at
#ASH22
#lymsm
-- work from
@AshAlizadeh
group shedding incredible light into classical Hodgkin lymphoma biology and prognostication.
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I will humbly argue that we should stick with RCHOP x4 or x3 + RT for true limited stage disease. These patients have 85-90% cure w/ 1L Rx, so even if swapping in Pola offered HR 0.8 improvement, NNT becomes 30-40.
@Eddie_Cliff
@majorajay
This is the algorithm we have used during our discussion on
#DLBCL
w/
@DrCarlaCasulo
.
#lymphoma
#lymsm
#HemeTwitter
#MedTwitter
#OncEd
@CancerNetwrk
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@VPrasadMDMPH
I do not like surrogate endpoints, man.
Of surrogate endpoints, I am no fan.
I do not like them in that trial there.
I do not like them anywhere.
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At the risk of being the uppity and whiny trainee, I have to say it's getting very frustrating seeing the abandonment of intention-to-treat analysis in modern CAR T-cell studies.
1/🧵
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It goes without saying, but
#ASH22
was awesome. I hadn’t been able to go in-person for quite some time, but I think
@ASH_hematology
did a great job facilitating free time before and after sessions for breaks, finding the next session location, arranging private meetings, etc…
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Pro-tip (coming from a fellow, admittedly): take advantage of everyone else socializing on a Friday night and go enter all of your author details for
@ASH_hematology
abstracts. The website is very fast right now!
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To me, NPI = zero sum game. Political leaders have X credits to spend on their choice of policies. It’s quite possible we are putting too much effort into interventions that are marginally helpful (ie we have no clue of effect size). In turn we DON’T do many alternative NPIs…
Its a popular trope to say no one complains about having to/ it doesn't bother anyone to do...
ok, noted, but if someone did a study and showed that doing that thing didn't actually work/ doesn't actually help, then why do it?
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A lesson I’m on both sides of (as a mentor and mentee) and try to share with others: more red ink on a manuscript draft is not a bad thing. Hard to not feel criticized at times by receiving lots of red ink…but trust me, the mentor you get it from cares a lot about your success.
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Generally speaking, key knowledge for fellows taking in-service exams, plus vital to know in real practice.
Key pathobiological point: these are not fusion proteins a la BCR-ABL1; they instead hijack IGH regulatory elements to drive inappropriate MYC/BCL2/CCND1 expression.
USMLE Lymphoma Review
Translocations:
Chromosome 14 = locus Ig heavy chain
+
Partner gene = cell proliferation or inability to die
8 = MYC = ⬆️proliferation
11 = Cyclin D = Cell cycle G1 to S
18 = BCL2 = anti-apoptosis
t(8;14) = Burkitt
t(11;14) = Mantle
t(14;18) = Follicular
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👍🏼⭐️🎉 What many don’t realize is there are patients with good insurance still needing to pay $2000 PER MONTH for their oral cancer drugs right now. A $2000 annual cap is truly a HUGE step in the right direction!
Capping copays for seniors at $2000 per year is huge. Seniors are being crushed by high prescription drug prices.
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If you aren’t mentioning that our insurance system intentionally makes it hard for patients to receive these incredible treatments, your article on CAR-T cell therapies is incomplete. Anyone want to convince me why payers deserve 20+ business days to review cases?
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This sounds like a world I won’t like.
In an interview with
@benthompson
, Zuckerberg says a “killer use case” of the metaverse is wearing augmented reality glasses when you are interacting with people in real life that allow you to continue text messaging people without people in real life noticing
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@AaronGoodman33
In classic
@WashUHeme
“cowboy” fashion, Carl Moore grew vegetables with radioactive iron in the soil and raised chickens and rabbits with radioactive iron in their diets, which he fed to dogs and ate himself for this and other studies:
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If our society journals are going to be 1/3 pharma ads, could they at least enforce a rule that graphics/charts have to be accurate and true-to-scale?
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As usual
@VPrasadMDMPH
doesn't pull any punches discussing precision oncology. This time, joined by
@AaronGoodman33
. This is a must listen, if you're interested in heme malignancies, trial design, drug approval, and/or clinical cancer genomics. 1/🧵
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Key teaching point! Curative potential plummets if you chase the ANC during 1L ABVD. What matters is infection risk, and despite grade 3-4 neutropenia, if no signs/symptoms of infection, power through because infection risk so low (even without GCSF).
Board Review for the Fellows
25 year old with stage 4 classical Hodgkin lymphoma on ABVD. Nurse calls you on day 15 with ANC of 0.1. Patient feels wells. They ask you if you want to delay chemotherapy. You recommend...
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I discussed the evolution of our understanding of DLBCL biology, risk groups, ups/downs of frontline trials, and recent genomic insights for
@SitemanCenter
Oncology Grand Rounds today. PDF of slides: . DM/email for link to archive of references.
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@matthew_mei
Oh, totally. Very aware of the differences in reimbursement between insurers. It just seems like we can't fix poor URM representation on trials (major issue!) while we also refuse to accept insurance plans that serve the most vulnerable.
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These “CAR-T on-study vs RWE” outcomes papers blow my mind. Would love to talk out the issues with anyone interested.
I just heard a myeloma 'expert' compare outcomes from car t phase 2 study with a database of people who didn't get car-t.
Just goes to show you. You can be an 'expert' and literally have no idea what you're talking about.
Thread 🧵
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It doesn’t help when so many
@NCCN
Cancer Centers (who receive massive federal grants for support) don’t accept Medicaid…
This finding of differential access to cell therapies by neighborhood poverty is a common thread in & out of academic centers. Some is likely related to the locations of cancer centers, but insurance availability, quality, and acceptance by centers is a major factor!
#Tandem23
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Daycare for the 1.5 yo was preemptively closed due to impending snow in StL, so she and I are playing at home all day while listening to
@WolverHeme
and
@BloodCancerTalk
— fun and productive!
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@VPrasadMDMPH
I honestly wonder what the college financial calculus is. Precautions appear to mainly appease concerned parents, who pay (most) tuition…? But are the precautions wiping out any college pride from student body, resulting in no eager donors in the future?
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That’s pretty much my top 3 as well!
Oncology fellow Starter pack 😉
#weekendreads
#MedTwitter
#HOFellows
#Oncology
#Oncmedtwitter
#HemOnc
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I know it’s early, but if you are starting to think about
#hematology
#oncology
fellowship, reach out and ask me anything! Happy to share my experiences, connect you with anyone in particular, and elaborate on our amazing “LOI” / fellow-led investigator-initiated trial program!
All (118) of our
@WUHemeOncFellow
in the past 20 yrs wrote a clinical trial as part of their training
✔ 79% proceeded to IRB approval
✔ 65% of IRB studies were published
✔ 45% were first author
✔ 38% journals had IF >10
#MedEd
@WashUHeme
@WashUOnc
@SitemanCenter
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I’ll take it as a compliment that a recent clinic patient suggested I make a YouTube channel explaining AML induction, consolidation, and transplant? 🤷🏻♂️
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@VPrasadMDMPH
@Sensible__Med
I find this spot on. Academic medicine culture is very (and surprisingly) fragile — it’s probably fewer than a dozen people across a division that set the tone, positive or negative. One departure, one retirement, and one wrong hire can demolish a decade of excellence.
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I like
@VPrasadMDMPH
and I like
@Bob_Wachter
. I suspect one gets more flack on Twitter for opinions on post-vaccination behaviors than the other. Recent
@washingtonpost
piece is solid, IMO. And I’ll just leave this screen-cap here...
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In STL, we had double-doc families paying to send their (public) elementary school children to Planet Fitness to sit masked w/ plexiglass shields and do school on iPad, supervised by gym staff, w/ teacher Zooming from home. Meanwhile private schools (even liberal ones) were open.
In the peak pandemic, Palo Alto schools rented out their space to for-profit companies so that people who had to work could drop their kids off to look at laptops in the exact same classrooms that were closed because the teachers unions didn't want to work in person
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Think about that for a second. Imagine as an oncologist (or world-class CRA like Molly) you were a patient on a clinical trial, and you couldn’t read the protocol of the study you are participating in. Call me crazy, but maybe that’d make me less inclined to enroll?
@dgermain21
Not sure if it answers your question, but we're literally not allowed to give patients pages from the protocol--they've requested schemas or entire protocol PDFs before, but if it's not in the ICF (or an approved doc like drug diary/QOL,) we can't give it to them.
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I want to write a children's book about a bear who would tweet opinions about articles based on the credentials of who wrote them, not the content of the articles.
Then the bear stopped reading altogether and life passed him by.
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An important, academic cost-effectiveness study. “Hidden costs” of CAR-T cells are going to crush us if we don’t address them soon. Payors are only going to get tougher if the entire process (including product, and post-treatment supportive care / AE mgmt) costs $1.5M+…
Cost-effectiveness of second-line axicabtagene ciloleucel in relapsed refractory diffuse large B-cell lymphoma
#lymsm
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I was there in the audience. It happened repeatedly, and was obvious intimidation. Very creepy, and premeditated.
Was waiting for a major news org to bring this up. Would love to hear an explanation, because it certainly looks like intimidation.
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Who wants to bet we see some financial maneuvering to get aducanumab in veins for free / cheaply, whether or not insurers pay / patients have co-pays, then we end up with anecdotes of miracles that make us all go 🤦🏻♂️🤦🏻♂️🤦🏻♂️
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It’s almost like some “charlatan” should have chimed in to say, “Hey, folks, let’s get some data and make an evidence-based decision not influenced by politicians…” 🤷🏻♂️
How to lose public confidence?
1. Announce a booster program on Sept 20 for all at 8 months post-vaccine
2. Change it to 6 months, then 5 months, then back to 8
3. Lack of agreement among leadership group
4. Have no US national data
5. Announce the program will be "scaled back"
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We've jumped the shark. GOP AHCA could have some people paying more for healthcare in a year than they earn. Seriously.
"In NE's Chase County, a 62-yr-old earning $18K could pay nearly $20K for coverage under GOP plan." Under ACA: $760.
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@AaronGoodman33
The proper RCT wouldn't be KRD + ASCT vs. observation. It would be KRD + ASCT vs. $500K-1M cash and observation. The 'cash+obs arm' would show OS advantage, IMO.
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“We found no statistically significant difference in overall response rate or rate of MRD negativity between patients receiving KRd versus patients receiving VRd,” would be how I’d have said it… 🤷🏻♂️
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What a blast and a real privilege to join
@GuidoPelaez1
for
@WashUIMRes
Intern Journal Club as the (soon-to-be) faculty discussant! We reviewed the STIL trial of BR vs RCHOP in indolent B-NHL. Lots of things to critique, but definitely a practice-changing trial.
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I suspect nobody cares, but just putting it out there: I’m going to be reducing how many accounts I follow over the next week. A lot of what comes across my feed these days is not the content I’m here for. Lots of personal attacks, bad faith arguments, ad hominem…
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I am printing the paper to read and markup thoroughly this weekend, but regarding ZUMA-7, the primary endpoint of EFS is just as awkward as modified PFS from ECHELON-1, so I hope we can be consistent in how we applaud or critique these trial design strategies.
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Is there anything more “winning at life” as a lymphoma clinician than your all-star pathologist wife calling a sentinel LN bx from a breast work-up suspicious purely by H&E, doing more work up, and it turns out to be NLPHL?
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Did I love doing an MD/PhD? Yes!
Does the MSTP produce many great physician-scientists? Yes!
But is the MSTP the *best* way to train physician-scientists? Maybe?
Is the MSTP right for you? Maybe, but you should understand how and why not everyone ends up 80/20 with an R01.
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@VPrasadMDMPH
The other thing that is frustrating me are the social media photos of 10+ unmasked physicians with arms around each other indoors at restaurants, while the same folks complain online that unmasked college students stood shoulder-to-shoulder at a college football game.
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Honored to be part of this group, which includes my mentor
@LabFehniger
as well! Lots of exciting basic, translational, and clinical follicular lymphoma research is underway.
ICYMI: We announced our 2022 grant class, w/ over $5.7 million awarded across 29 innovative research projects. For more abt. our Career Development Award & Postdoctoral Fellowship Award recipients, visit:
#CancerResearch
#LymphomaResearch
#ResearchGrant
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Another year, another great
@pedalthecause
on Team
@nancybartlettMD
Bikers! 🚴
Always fun riding with fellow
@WUSTLmstp
alum
@ChenLabWustl
!
Thanks to everyone who supported our ride for
@SitemanCenter
!
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Heading home after another fantastic
@lymphoma
scientific workshop, this one focused on follicular lymphoma. These events offer unmatched debate as we get into the nitty-gritty of how to advance the field, and their support of trainees and junior investigators is fantastic. 🙏🏼
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A question that came to mind today: why didn’t CHOP ever catch on in cHL?
Do we know it’s worse than ABVD?
I see these two studies, but I’m curious what more experienced folks can teach me.
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@DGlaucomflecken
"The distal convoluted tubule has fascinated me since AP Biology in 11th grade. I then sought a role as a volunteer researcher..."
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I tell trainees: “If it’ll take you a minute in Excel, it’ll take a hour in R. If it’ll take a week in Excel, it’ll take an hour in R.”
Why spend 4 minutes doing something in Excel when you can do it in R in 4 hours?
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Is myeloma health equity “$900+ per lenalidomide pill for all!”…?
ASH 2022: Bristol Myers Squibb Myeloma Health Equity Forum
#mmsm
#healthtreeMM
#myeloma
#bloodcancer
#ASH2022
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Agreed. And every time we call a drug a “breakthrough” despite its single-digit week improvement in PFS but no OS benefit we shoot
@ourselves
in the foot. We will get worse drugs and lose patient trust.
Physicians desire autonomy
I am surprised that many do not realize that a slew of cancer Tx approvals that cost 20k+++ a month and have no control arm will reduce their autonomy, as payers inevitably push back
A problem of more options, v costly, not tested properly
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I’m excited to read this, but at the same time I can’t help but wonder how/why we’ve done relatively large single-arm ven+FLAG and ven+CLIA studies, but no randomized FLAG/CLIA +/- ven studies…
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I would take open windows over whatever they are spraying any day...
Is there some rule in America that we have to keeping doing things that don't work?
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Just like TKIs for CML, more competition doesn’t bring down the price, eh? Sad :(
Amazing!
Nine approved anti-PD1/Anti-PDL1 inhibitors
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@VPrasadMDMPH
I'm reading a Nature paper. More extended data figures (10) than regular figures (5). Every extended data figure legend has a mistake (e.g. 5f and 5i have same legend, copied by mistake). No methods in actual paper, only supplement. Section on source of key patient data missing.
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@k_vaishnani
@AaronGoodman33
Vanishing bile duct syndrome in setting of Hodgkin lymphoma? Trying to think of why you're showing a CXR...
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I’ve had this moment as well. Patient from out of state self-referred to
@WashUHeme
because of our work on DNMT3A mutations. Coincidentally came to clinic where I was rotating that day, with a printed copy of my JCI paper in-hand!
Patient (email): Just read your article in
@CellCellPress
"A Basophil-Neuronal Axis Promotes Itch". Do you do telemedicine consults?
Me (thinking to myself): Never imagined a patient reading a Cell paper leading to an appointment request. About as translational as it gets!
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Very cool! We actually just reported the first case of donor-derived follicular lymphoma after solid organ transplant!
@obigriffith
@malachigriffith
@KahlBrad
@LabFehniger
#ScienceSaturday
Did you know that in some animals such as
#shellfish
, cancers can spread from one organism to another? This has not been documented in humans (except in rare cases of organ transplantation) and our well developed immune system would reject a cancer cell from
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Lovely. I can take care of you overnight in the ICU at 30, but still need another decade-and-a-half for my research to be funded.
Ave. age of biomedical scientists getting their first R01 is at an all time high of 46. This is bad. Really bad.
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@ManniMD1
@AaronGoodman33
@RichardBaron17
Yes and no. He didn’t say physicians *shouldnt* have hobbies… But, while I eagerly await the full interview, I think it’s interesting that he implied physicians could be too distracted by hobbies to stay up on the latest medical evidence, and that might compromise their skill?
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Shouldn’t people learn “the basics” of HF during medical school and residency? Aren’t the four big diagnoses all IM folks should master HF, MI, PNA, and COPD?
These are great discussion points. Here is a bit more depth. A “HF internist” spends a year after IM training learning the basics of identification of Stage C and D HF, approach to GDMT management, HF co-morbidities, basics of end of life / palliative care, and when to refer
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