(Right after finishing this article, I received an email sent from Sermo with a message of “Love your contribution to Sermo”, when I opened the email, there he was; it was from the “Founder and CEO” of Sermo.)
If my writings on Sermo caught the eyes of the “Founder & CEO” of Sermo, shouldn’t you read it? I’m trying to exhaust all your excuses of not reading it. The following is part of the email.
jerkaty:
Catching up on Sermo this weekend, I was struck by several of your comments and your post on the ACCORD trial [the very last of this article] That sort of contribution is the very essence of what makes Sermo so powerful. I think we are seeing what can happen when physicians are able to come together in a place to gain a collective voice. . . . .
Any rate, thanks again for all your great contributions. It really is so critical for this community. As always, if ANYTHING at all we can do to make your experience on Sermo better in any way, please do not hesitate to contact me, either by PM, or directly (my contact info is below). [he listed his email, office # and cell phone #]
PS Based on the success of the Tumor Board, we are expanding the clinical case conference series. Please let me know if you might be interested in moderating a case in your specialty. It is great to get the real time feedback from colleagues and help educate. It is pretty painless, as a member of the Sermo team will walk you through the technical steps and we do provide a stipend for each case.
-------------------------------------------------------------------------------------------------------------- My article (called posting in Sermo), “ACCORD vs. ADVANCE: compare and contrast, NEJM June 12, 2008” made it to the Sermo cover page for a day or two, so I do have that 15-minute fame, even though no one knows who is jerkaty [in Sermo, only user name is used] I walked with a halo above my head for a day or two; somebody please knocks my head, otherwise, I may even begin to think I am really the one the Sermo CEO think who or what I am. Like the dog in the cartoon said, “On the internet, nobody knows you are a dog!” {OK, enough self-promotion. Here begins the article, the real stuff}
I’ve been busy reading and writing in Sermo, known as MySpace or Facebook for physicians (currently there are over 70,000 registered users), neglecting my blog. I haven’t found my 25th hour of the day yet, so the solution is to transport some of my writings in Sermo to this blog.
Thanks to Jo, I was introduced to Sermo over one year ago, it was not a ‘love at first sight’, I stayed as a reader only all along until recently when I began to write. It is much easier to write for my peers as I can write as I please; I can write CVS without worrying about the confusion about the drug store chain (by the way CVS is Customer-Value Service). I can write GLP-1 or DDP-4 inhibitor and feel no need to explain anything.
The format of Sermo is a user (physician only) posts an article with question (called posting)—medical or otherwise—and everyone is free to comment. Anonymity encourages more candid expressions (only user name is used, although one can always reveal him/herself if one so chooses and some do)
Reading through what I have written on Sermo, you may learn a thing or two about medicine along the way, and get an idea that doctors are not just talking about the boring medicine only.
Human papillomavirus vaccine is not the first cancer vaccine
In the posting of Gardasil [human papillomavirus vaccine] redux, one wrote “Have heard no bad commentary . . . the value of this first-ever cancer vaccine is enormous.” and the other wrote, “Perhaps the most important vaccine ever developed. the first human vaccine to prevent cancer.” (I highlighted) so I wrote,
In his Autobiography in nobelprize.org, Dr. Baruch Blumberg (1976 Nobel Prize in Medicine) wrote,
“HBV vaccine is the first ‘cancer vaccine’, that is, a vaccine that prevents cancer. . . . The second ‘cancer vaccine’ – against Pappiloma [Papilloma] virus that causes many cases of cancer of the cervix – has been successfully tested and will probably be widely deployed within a few years.” [Dr. Blumberg wrote this Addendum in August 2006]
Thus Gardasil is not the ‘first-ever’ cancer vaccine, however, its enormous value remains the same.
I used Dr. Blumberg’s writing to dispute that Gardasil is not the first cancer vaccine; who dares to argue with a Nobel laureate? In fact, right after I wrote that, a doctor wrote, “Beat me to it, JerKaty! [my user name] Thanks for making that point.” By the way, Dr, Blumberg (or somebody’s typo) misspelled ‘papilloma’ as ‘pappiloma’.
“Short words are best and the old words, when short, are best of all.”
A retired pathologist who now devotes to writing wrote a short essay using all simple, one-syllable words, and in the end he quoted Churchill, “Short words are best and the old words, when short, are best of all.” I have quoted this many times, so I wrote a comment quoting Thomas Jefferson and Mark Twain,
“The most valuable of all talents is that of never using two words when one will.” - Thomas Jefferson
“Damn the subjunctive. It brings all of our writers to shame. As to the Adjective: When in doubt, strike it out.” - Mark Twain
Untimely death of Tim Russert
There are several postings about Tim Russert, all sad, particularly the one “Thoughts about Tim Russert on Father Day”; his recent two best sellers were all about his father now known as “Big Russ.” I wrote a comment on the one titled “Tim Russert had died” in which cause of his death was mentioned.
Sadly “Big Russ” survived Tim; it was not supposed to be that way. Sadly Dr. Thomas Sydenham (1624-1689) was right when he said, “A man is as old as his arteries.”
In a posting, “Too bad about Tim Russert”, unanimous comments by virtually all doctors indicated Tim was well liked and respected, so I posted a comment using the lines from Macbeth (toward the end of the play)—Ross is a nobleman of Scotland, not to be confused with Tim’s dad, “Big Russ”.
For “Big Russ”
Ross
Your cause of sorrow,
Must not be measured by his [Tim’s] worth, for then
It hath no end.
Macbeth Act 5 Scene 8
plaque rupture leads to sudden death
Many of the acute heart attacks occur in the setting that the coronary stenosis (the narrowing of the lumen of the coronary artery) is less than 50%. The sudden plaque rupture (plaque is the build-up along the lining inside a coronary artery lumen, causing partial occlusion) leads to bleeding, which in turns causing the complete blockage with the blood clots. How much narrowing of the artery lumen the plaque causes is important, what's more critical is how stable the plaque is. The resultant acute myocardial infarction (heart attack) may cause ventricular tachycardia/fibrillation—a serious cardiac rhythm disturbance, often leads to sudden death, sadly as was the case for Tim Russert.
According to Russert’s doctor, this was how this well liked news man was taken away from us, as there was a freshly formed blood clot seen inside the blocked coronary artery.
Postings and comments are not allowed to be edited
In Sermo, the postings and comments are not allowed to be edited; this rule makes sense, as one would comment about your comment, and if you change yours, the chaos come. I came across a posting of “Is there any way to edit your original post?” my comment is,
Think twice before your fingers fly. Your typos will be forgiven by your peers and equals. Unlimited comments to a given post is one way to correct the comment that you regret. And for one to stumble onto your “much to be desired” comment in the sea of Sermoan comments is like finding a needle in a haystack. It is well hidden.” {the one reads or writes in Sermo is called “Sermoan.”}
Sermo, a place to keep updated in medicine, a place where doctors learn and teach
I began to bookmark (keep as my favorite) certain doctors. There is an oncologist who diligently wrote excellent summaries of his attending to scientific sessions everyday during the recent ASCO [American Society of Clinical Oncologists] annual meeting at Chicago (May 30-June 3).
A new friend of us, Dr. Engyen Huang, a radiation oncologist at 高雄長庚醫院 in Taiwan, also attended this meeting (more more than 32,000 attendees every year). Dr Huang came to Pittsburgh with Dr. Yur-Ren Kuo, who returned to UPMC for a talk before going to Springfield, Illinois for his lectures; we had a nice get-together at Dr. C.C. Lin’s apartment, along with Dr. Ishun Huang’s family. These doctors are all cream of the crop physician scientists from Taiwan.
I wrote a comment in this oncologist's posting to show my sincere appreciation to his time and effort, whoever or wherever he is.
A radiation oncologist friend of mine came to ASCO from Taiwan, and thanks for your report, I can enjoy the same staying home. Are you considering being a medical journalist as a sideline? khagan [his user name]
Herceptin—the poster drug of clinical medicine reaps the benefit of basic science research
The same doctor [khagan] wrote “More crumbs from ASCO day 3” one item he mentioned was about Herceptin, the following is my comment; unfortunately, this is a doctor-to-doctor talk.
The story of the synergy of lapatinib and trastuzumab (Herceptin) in treating HER2+ metastatic breast cancer is encouraging. Both biologicals block epidermal growth factor receptors, albeit with distinct mechanisms, as khagan pointed out “more complete blockade of the her 2 pathways makes a difference.”
Prior to Herceptin, her 2+ is a dread. MDACC experience has shown that, with Herceptin, her 2+ metastatic breast cancer can behave as if they were her 2 negative.
We begin to reap of what Stanley Cohen sowed long ago when he worked to elucidate epidermal growth factor pathway.
Thanks, khagan, you’re the source of my oncology update for a non-oncologist.
MDACC is (University of Texas) M.D. Anderson Cancer Center. When the subject is oncology, to say MDACC is enough. I did write an article in my blog talking about Stanley Cohen, but few may appreciate him as much as I do.
My posting attracts some attention
I wrote a posting of “Relistor & Entereg: mu-opioid-receptor antagonists” on June 2. A posting needs to ask question so the reader can respond. (Again this is doctor-to-doctor talk)
Wyeth’s Relistor (methylnaltrexone) was recently approved for the treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care. This will make it an off-label use for those who legitimately require opioids so they do not have to ‘live with pain’ and who are not considered receiving palliative care.
GlaxoSmithKline’s Entereg (alvimopan) was recently approved for treatment of post-op ileus in “partial large or small bowel resection surgery with primary anastomosis.” This will make it an off-label use for patients who undergo any other abdominal surgeries and who also receive opioids.
What is your opinion about the potential off-label uses of these two peripherally-acting mu-opioid-receptor antagonists?
Yesterday (6/14/08) I came across a posting "Methylnaltrexone (Relistor) for opioid induced constipation", and it was posted by a "Sermo client", which means by Wyeth or company paid by Wyeth. A posting by “Sermo client” is usually for opinion survey research.
At the end, it directed readers to the other Sermo posting, when I clicked and it turned out to be the one I posted on June 2. Wyeth even 'stole' my off-label use question. One never know who is reading one’s posting in Sermo, in this case, it is the people from Wyeth or its representatives. (Companies, Wyeth in this case, has to pay Sermo for such service and privilege.)
Be aggressive in controlling diabetes: To be, or not to be, that is the question . . .
Based on ACCORD study, I wrote an article “Be aggressive in controlling diabetes: To be, or not to be, that is the question . . .” in my blog on February 14, 2008 and the controversy continues; the June 12 NEJM issue published both ACCORD and ADVANCE trials, both of which can be considered landmark studies and yet yielded conflicting results.
I wrote another posting in Sermo, lengthy though it may be, but I have done my best, considering the 28 pages of the two studies and 6 pages of the two editorials in NEJM, let alone the complexity and the controversial nature of the issue. (This is the one posting attracted the attention of the Sermo's founder & CEO, Dr. Daniel Palestrant.)
ACCORD vs. ADVANCE: compare and contrast (NEJM June 12, 2008)—[title of the posting]
10,250 vs. 11,140 type 2 patients, follow-up 3.5 vs. 5.0 years, 1/3 had prior CV events, randomized to intensive- vs. standard-therapy, but the similarities stop there.
Both achieved a similar median HbA1c (6.4% vs. 6.5%) in the intensive-therapy groups, but the paths led to this goal differed. So may be not the goal, but how to reach that goal counts.
Management of non-glycemic risk factors (BP & lipids) differed.
TZD (rosiglitazone used almost exclusively) were heavily used in ACCORD and sparingly used in ADVANCE, although TZD was exonerated as a contributing factor to excess death in the intensive-therapy group by ACCORD.
ADVANCE showed reduced combined macrovascular and microvascular events in the intensive-therapy group (18.1% vs. 20.0%), this primary outcome was not evaluated in ACCORD.
In ACCORD, more people died in the intensive-therapy group (257 vs. 203 patients), among them, 115 were definitely non-CVS death, 86 were listed as “unexpected or presumed CVD”. But, in ADVANCE, no difference of death (CVS or otherwise) between two groups.
ADVANCE confirmed what we’ve already known that intensive glycemic control reduces microvascular complications (9.4% vs. 10.9%), and this was primarily attributed to the reduced nephropathy (4.1% vs. 5.2%), but not retinopathy.
Severe hypoglycemic reactions were more common in the intensive-therapy groups of both studies, and this might even directly or indirectly contribute to death. Hopefully this may put pressure to the various formularies to relax their restriction of uses of ‘incretin mimetic’ (Byetta) or DDP-4 inhibitor (Januvia), which may be less prone to cause hypoglycemia.
Be aggressive in controlling type 2 diabetes: To be, or not to be, that is the question with no answer, at least not yet.
I’m hoping patients wouldn’t ask this question, otherwise, they may be more confused than before they come to the office. How are you going to explain to patients in 5 minutes or 10?
Janet and K went up to Maine to see Paula and Steve, and brought back a precious gift for me from Steve: Richard Feynman’s Six Easy Pieces, which was part of “Feynman’s Lectures on Physics” (synonymous to classic) to undergraduates at Caltech in early 1960s and was reproduced in 6 tapes, complete with a book by Addison Wesley.
Thanks to Steve’s thoughtfulness, as Janet told me, and like Charlie Brown, I am going to have some ‘heavy reading’ in days to come, plus the fact that I also checked out Feynman’s QED: The Strange Theory of Light and Matter from Carnegie Library two weeks ago.
Alan Alda (of M*A*S*H fame) devoted a chapter, “Pass the Plate, Mr.Feynman”, in his Things I Overheard While Talking to Myself; in which he told the tale of his infatuation with science in general and with Richard Feynman in particular.