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Heme Doc

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Posts posted by Heme Doc

  1. 1 minute ago, Heme Doc said:

    sorry to hear about this.  
     

    I assume this is adenocarcinoma of the GE junction.  I’m Assuming you have only locally advanced disease and hopefully not distant disease.  At MD Anderson, for something along those lines, you’d probably get concurrent chemo (likely FOLFOX) and radiation (likely protons, although I have no idea how they get insurance to agree to pay for that).  Assuming a good response on follow up PET scan, you’d then look at potentially surgery (esophagectomy).  But I’m just some dope who slept at Holiday Inn last night.  I mostly know about blood stuff.    

    Oh and post surgery there might be a role for immunotherapy (Checkmate 577 trial).  
     

    Disclaimer:  I’m not a GI oncologist but watch a lot of TV doctor shows

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  2. 5 hours ago, Sbbruin said:

    Well, other than my wife, and my doctor, you fuckers are the only ones to know.  I had an endoscopy last Thursday as I have had increasing difficulty swallowing food.  The scope showed a stricture (narrowing of the esophagus near the stomach that he stretched out.  As a matter of course, like a colonoscopy, they took a few biopsies.  I got a call last night from my GE.  I got the cancer.  He's not an oncologist, so doesn't want to try to paint to much of a picture, but it's in the esophagus, so likely esophageal cancer.  That's not a good cancer.  Referred me to a top thoracic oncology surgeon at City of Hope.  Haven't yet connected.  Until the tests are done, really won't know the stage or any of that.  I've been literally having an out of body experience the last 18 hours.  Like it's somebody else.  But it's me.  Not sure how to process it.  Of course all I can think about is my family.  Son is graduating HS in a week.  I don't want this to fuck him up, so may wait to tell the kids until afterwards.  And he's planning on spending his first year of college in London.  I don't want this to fuck it up.  And, well, they really need me around.  

    I'm having lunch with a few buddies today, one of which has brain cancer that is terminal.  He and I have been friends since we were kids.  I'll be driving him home.  He'll be the 2nd person I tell.  Figured he can relate.

     

    sorry to hear about this.  
     

    I assume this is adenocarcinoma of the GE junction.  I’m Assuming you have only locally advanced disease and hopefully not distant disease.  At MD Anderson, for something along those lines, you’d probably get concurrent chemo (likely FOLFOX) and radiation (likely protons, although I have no idea how they get insurance to agree to pay for that).  Assuming a good response on follow up PET scan, you’d then look at potentially surgery (esophagectomy).  But I’m just some dope who slept at Holiday Inn last night.  I mostly know about blood stuff.    

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  3. 7 hours ago, Anastasis said:

    Maybe that is not what he is saying, but that is what I hear. 

    Maybe the idea of “original antigenic sin”?  But I doubt he’s smart enough for that.  I don’t have time to explain it to you peons.  Google it if you like.  But it’s been shown to not be a concern with SARS-CoV-2

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  4. 3 minutes ago, NameAlreadyInUse said:

    Except we do put those mandates on smoking and alcohol in government by prohibiting those not of a certain age from partaking, and private companies also provide both carrots and sticks for weight loss and smoking/alcohol cessation.  This doesn't feel like a completely black/white issue to me and it's frustrating to see so many people try to argue black/white so emotionally, when the answer lies in the gray.  We are never going to be able to properly define the gray if the people yelling for black and the people yelling for white can't quit publicly tantruming long enough for the conversation to even happen.  

    I agree about it being a gray area.  I don’t pretend to have all the right answers.  I hope you don’t feel like I’m throwing a tantrum.  Just trying to have respectful dialogue.  I’d lean more towards the carrot/stick approach above.  Companies can give reduced insurance rates or other perks for employees to get vaccinated.  I’m fine with healthcare workers being mandated to get the vaccine.  I do wish there were carve outs for exceptions for those previously infected (although I’d still advise them to get vaccinated).  

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  5. 2 minutes ago, Sawbonz said:

    I think the problem many docs and other healthcare professionals have with mandates goes back to our medical ethics training and the concepts of autonomy vs paternalism and beneficence vs non maleficence I’m kind of done with this thread but y’all should read up on those concepts if you are unfamiliar 

    Physicians are good at taking multiple choice standardized tests.  It’s how many of us think.  “Here’s a problem.  Pick the one best solution”.  COVID, unfortunately, is not like that.  COVID reminds me of a test question in medical school…

    After the test, friends and classmates all gathered to discuss how we thought we did.  “What did you answer on question 7?”  Everyone had a different answer.  Each person convinced their answer was correct…

    But it turns out they screwed up the test and left off the correct answer choice.  We ALL answered wrong but were convinced we were right.  There’s some deeper meaning there, probably.

  6. 5 minutes ago, Anastasis said:

    If we had a vaccine that conferred sterilizing immunity would that change your assessment?

     

    It is kinda wild to me that vax development and testing seems to have fallen off.  Where are we with nasal administration and variant updates?  The mRNA tech's primary advantage is that once you are comfortable with the tech, we should be able to rapidly deploy updates.  We need the same amount of urgency to get to vaccine 2.0 as we had to get the first roll out. 

    Yes, it probably would.  In a case where vaccine confers sterilizing immunity, much less risk of transmitting to others and harming them.  
     

    GREAT question about new vaccine development.  I don’t know what the deal is.  

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  7. 13 minutes ago, Dahobbs said:

    Yeah, this is what I've been saying over and over in this thread. People are conflating the scientific analysis and the policy analysis. They aren't the same thing. Science can inform policy decisions, but generally isn't going to decide them. Other factors have to be considered too. Unfortunately everyone gets too caught up in the phrase "follow the science" without realizing that the science only takes us so far. Science tells us vaccines work and are very low risk. But that isn't going to tell you anything about the economics of issuing mandates, the potential downstream consequences of giving government the power to determine individual health choices, or the possibility that such policies will inflame divisions in a society. Unfortunately, people will often cloak arguments under the veil of science and say that whoever disagrees, whether it be for or against a certain policy (e.g., vaccine mandates), is failing to follow the science. But science can't make these decisions for us. They are inherently political question that must go through a political analysis, which yes, includes the science as one input among many.   

    VERY well said.  Full agreement here

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  8. 19 minutes ago, Captainant said:

    Someone who is unvaccinated and needlessly consuming and constraining our extremely limited medical resources is absolutely harming other people. It's not a direct matter of transmissibility, but we're all on the same boat. Care providers shouldn't be forced to choose between unvaxxed Joe MAGA or someone who is fully vaxxed but facing a health issue they have no control over. 

    I agree with you that the unvaccinated disproportionately utilize resources and this results in indirect harm to others.  But I disagree that mandates are an ethical solution to the problem.  We do not mandate other behaviors which disproportionately utilize healthcare resources (weight loss for obesity, smoking/alcohol cessation, flu vaccinations, etc).  

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  9. 3 hours ago, Neonmoon said:

     

     

    Okay, so let's discuss the Peter Attia article since both of you are relying on that as your basis for being anti-mandate. 

    First let's start out with Attia's points, if I am wrong summing it up, let me know

    He agrees that the relative risk reduction (RRR) of death is between 84% and 88%, regardless of age, and overall, the risk of death among people who were vaccinated was infinitesimal. So that's good. Vaccines are good. 

    So his argument against is

    1. Vaccines do not provide complete protection to the vaccinated. They are not 100% effective at preventing infection, hospitalization, and death. In fact, although vaccines significantly reduce risk of detectable infection in the few months after vaccination, this protection drops precipitously once circulating antibodies decline, though protection against severe infections and death persists. Now, we have Novel therapeutics, fluvoxamine, and sophisticated critical care. 

    2. Omnicron is less virulent. 

    3. Natural Immunity. The null hypothesis around this point, at the outset, should be that natural immunity is indeed as good as vaccine immunity, pending data to prove that assumption false.

    4. Vaccines don't prevent transmission. It seems that they only slightly reduce the risk of transmission, and that vaccinated and unvaccinated persons with detectable infection have the same viral loads, despite the reduction in disease severity for the former group. Using a metric called the secondary attack rate (SAR), it’s possible to look at infection rates in household contacts stratified by contact vaccination status and index case vaccination status, and based on such analysis, it seems that vaccination only slightly prevents transmission. Vaccination does not reduce the peak viral load in the infected (though it does appear to reduce the duration of viral shedding, which may translate to the reduction in SAR).

    He sums his position up like this

    We have a virus that is far less lethal than the one that started the pandemic two years ago.
    We have very effective vaccines that reduce the severity of illness and death by about 90%.
    We have ample treatments to further reduce severity of illness in death (in vaccinated and unvaccinated alike) by another 90% or so.
    We have better methods of providing in-hospital care to the infected.
    For all their benefits, vaccines are not very effective at preventing transmission.

    The impact of vaccine mandates

    An unvaccinated person cannot board a plane or a train, let alone go into a restaurant, gym, or skating rink. A Canadian friend of mine, this week, was prohibited from seeing a medical doctor for a corneal abrasion because the doctor refused to see unvaccinated patients. What they are not, however, is a monolithic tool to be used as a sword against our citizens, rather than a shield against a virus.

    What is the scientific evidence to support vaccine mandates today?  If this were really about science, why would we not allow previous infection, which confers all the benefits of vaccination, if not more, the same rights?

     

    My rebuttal

    1. Vaccines do not provide complete protection to the vaccinated

          - Vaccines significantly protect against sever infection, hospitalization and death. Seat belts don't protect you 100% but we mandate those. 

    2. Omnicron is less virulent

            - Delta is very deadly. We can't make decisions based on best case scenario variants. What if another variant develops that is deadlier than Delta? 850,000 people have died in the US. We mandate vaccinations against Rubella. 1,000 pregnant women lost their babies, 2,100 newborns died, and 20,000 babies were born with congenital rubella syndrome. Yet we still require it even though most people won't be affected. We have a long history of taking harmless vaccines so other people don't die. Just because you don't give a shit about X number of people dying, doesn't mean it's okay. 

    3. Natural Immunity.

             Vaccines work better than natural immunity because there is no risk associated with dying to obtain a vaccine as opposed to natural immunity. Just because you want to take your chances with the virus doesn't mean that's a good idea, especially when it will negatively impact others. The more people that are vaccinated, the less chance the virus has to spread and infect others. 

    4. Vaccines don't prevent transmission.

             No shit. But as he says, they do "slightly reduce the risk of transmission. Vaccination does not reduce the peak viral load in the infected (though it does appear to reduce the duration of viral shedding, which may translate to the reduction in SAR)." They reduce transmission

    5. I will add Legal

          - Vaccine mandates are legal. See Jacobson v Massachusetts, 197 U.S. 11 (1905)

    6. Impact of Mandates

         - There is no impact other than learning how selfish people are. It is a choice. People are choosing to lose their job, lose access to sports, theatre, etc. People are choosing to lose access to the public because they are too fucking selfish to take a harmless vaccine to protect the public. Fuck them. 

    7. What is the scientific evidence to support vaccine mandates today?

          - He already listed all the scientific evidence to support that getting vaccinated is better than not being vaccinated. He ignores all the data on previous deaths. He makes the assumption that only less virulent variants will remain. He admits vaccines reduce transmission.

    8. If this were really about science, why would we not allow previous infection, which confers all the benefits of vaccination, if not more, the same rights?

        - This one is bit more complicated as the science backs previous infection providing good immunity. So I would agree they should be given the same rights as vaccinated. The problem with this is two-fold. Logistics and Policy. Logistically, we would require everyone have a vaccine pass (which still seems to be a bugaboo with the same people advocating for anit-mandates), and the vaccine pass would have to be updated with a confirmed infection test, and then given a time period of how long that immunity lasts. Of course vaccinated immunity has scientifically been proved to last longer than natural immunity. So we would need to update each vaccines pass with the require timelines. Policy, it would send the wrong message. If you want to take your chances with the virus, then go for it. 

     

     

     

     

    Thank you for the thoughtful reply.  I wasn’t relying on the article for my feelings on usefulness of mandates.  I just used it as a jumping off point for discussion around certain aspects of vaccine mandates.  

    I stand by my previous post that mandates of current vaccine formulations against the current circulating variant (and likely future variants) have little value. 

    To me, the ethical case for vaccine mandates requires that vaccines significantly reduce harm to others.   I think we both agree that current vaccines do a relatively poor job at stopping transmission to others with Omicron and also with waning immunity.  I agree that vaccines do slow transmission some (especially if boosted), but not enough to mandate them (in my opinion).  Preventing indirect harm to others is another way mandates might be beneficial, by improving hospital capacity.  I have previously laid out some problems with this reasoning. 

    I think we would both agree that the main benefits of vaccination are primarily protection for the individual, particularly against severe outcomes.  We do compel other activities for individual safety (seatbelts being an example you mentioned).  But there are important differences between seatbelts and vaccinations.  Further, we do not compel other interventions which would be of benefit to the individual or society (weight loss, restrictions on food/alcohol, or yearly flu vaccines to name a few).  The primary goal of a mandate with current circumstances, to me, is to compel as many people as possible to get vaccinated.  I fear we have reached the end of that usefulness.  If you ain’t been vaxxed yet, you’re probably not going to.  

    I can’t speak as much to the legalities of mandates.  I know there’s been stuff in the Supreme Court, but I’m no lawyer.  

    In an unrelated note — on the topic of the power of these vaccines…my wife went in today for her very last cycle of pretty potent immune suppressive adjuvant chemo.  She has been on chemo since late Sep and got her COVID booster just before starting chemo.  SARS Ab level is STILL off the charts > 2500 as of last week.  Still not had COVID throughout the surge and being on chemo the whole time.  

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  10. 13 minutes ago, PenelopeWitherspoon said:

    I mean that vaccine mandates have caused more vaccine uptake which has allowed NYC to not get back to the dire days of March/April 2020 from a hospitalization or death perspective even though The case counts are at 400% of any other time during the pandemic.  It has allowed NYC to largely get back to normal.

    I’ll drink to that!

  11. 6 minutes ago, jimmyjazz said:

    I get the observation of hospital load, and what you state isn't too different than what I've seen reported in the press, but there are apparently some regions that are being slammed.

    Case counts are primarily a function of measurement and reporting, and not necessarily disease permeation.  

    I just think it's premature to speak of "opening up" when we are currently losing more Americans per day than we have, on average, throughout the pandemic.  If messaging is so important, then let's not gloss over that hugely important point.

    It sucks to have so many people still dying.  Omicron is infecting almost everyone who hasn’t been vaxxed/boosted or previously infected.  And the unvaccinated are the ones dying, almost exclusively.  So I think you’ve got a lot of people who are vaccinated saying “fuck those folks who are dying, they could have protected themselves and prevented this, but they didn’t.  Why should I have to limit my activities to protect those assholes who wouldn’t protect themselves”?

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  12. 2 hours ago, Neonmoon said:

    By all means, elaborate 

    See my post above replying to PW.  

    Did you read the article posted by Immaculate Vibes?  Were there specific things in the article you felt were incorrect?  

  13. 4 minutes ago, Heme Doc said:

    What do you mean by “work”?  Do you mean “increase vaccine uptake with the end goal of decreasing death/hospital burden”?  I suppose I’d agree with this.  Although losing some hospital staff due to the mandates exacerbates hospital burden.  

    But those people who want vaccinations have already gotten it.  Mandates, at this point, I fear, only serve to harden resolve of those who refuse the vaccine.  

    I do not believe mandating injections of current vaccine formulations to enter certain venues, school, or participate in society substantially decreases transmission with our currently circulating variant.  Boosters probably do help with this issue somewhat.  

    To me, there’s 2 ethical reasons to mandate a vaccine.

    1.  The vaccine protects the individual from falling ill and prevents that person transmitting the disease to those at risk.  Current vaccinations absolutely prevent most death and hospitalizations but clearly do not do a great job of providing sterilizing immunity and protecting those around us from getting COVID.   In short, this argument says, “my vaccine protects you”…this is not the case (unfortunately).  Your vaccine protects you from severe illness/death.  Maybe not a lot more than that.  

    2.  Mandating vaccination prevent hospital overload and allows for continuation of normal healthcare delivery (delays in surgery or care due to overburdened hospitals are bad for everyone).  While on the surface, this seems reasonable enough, Ethically, I find this problematic as well.  We do not mandate other medical treatments for this reason (flu or pneumonia vaccinations, for example).  We do not compel people to significantly change behavior when hospitals are at capacity (as often happened in winters even pre-COVID).  We don’t shut down liquor stores, limit driving, or stop other activities that add to hospital burden when they’re already full.  

    I hope I’ve been clear in the above.  I always aim for respectful discourse/discussion.  I don’t pretend to have all the answers.  

    I find COVID to be much like many cancer problems I deal with.  Complex, often without simple solutions, where intelligent, caring people with the best of intentions can sometimes disagree on the best course of action.


     

     

    And I love your posts about NYC.  Makes me want to hop on a plane almost every time

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  14. 23 hours ago, scottsins said:

    2nd CARES results just in.

    For reference, I had Moderna #2 on 2/26.
    First CARES result was drawn on 9/3. The “S Protein” value was 412.

    Received Moderna booster on 10/26.

    Second draw was December 9th: 113

    I must have lupus or something?

    You have AIDS

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  15. 1 hour ago, Judge Roybeanbag said:

    Got my results today.  Ugh, only 100 for S AB level.  2nd Pfizer shot back in first week of April.  After doing some research it appears that a medication I take, Takhzyro, can fuck with lab results on blood tests, particularly as it relates to clotting and protein levels.   I figure I'm going to get a booster anyway though since the first 2 shots didn't kill me.

    For those of you at home, this always makes me feel like Richard Gere after a dose:

    Takhzyro is a fully human IgG1 monoclonal antibody made in recombinant Chinese Hamster Ovary cells.

    Get a booster.  I’ve never even heard of this weird med you’re on, and I love me some weird drugs.   I had to look it up.  

  16. 5 hours ago, dcar00 said:

    it has and always has been marginal effect.  the mask does prevent people from talking as much and generally you reflexively keep distance which can help.   for people 15 and older I'm in the it doesn't really do much but OK whatever camp(it should probably be an N95 or nothing though).  the bigger problem in my opinion is doing it to the elementary and middle schoolers especially if teachers are vaccinated.

    Completely agree.  Badly need cluster RCT of cloth masking in schools.  I’d eat my house there’s zero benefit

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