904 days left


Lots of news out there. Regurgitating it is not useful. Plenty of websites out there for that. Insight? Not much of that around.

AGN whiffing on Naurex assets is not surprising. Long ago real diligence revealed peptide-based NMDA is a really insane way to try this hypothesis. The data were VERY suspect, which is why Naurex went for remarkably little (~$500m if I recall). Speaking of which, Spravato was approved. Must be administered in a physicians office. It appears they underpriced it. If the average price is $750 and I guess patients will use 6 doses per course average, it is very modestly priced for a last-line option in a very severe patient population. Depression patients just don’t go to the office frequently. Getting out of bed is hard enough! In the real world, ketamine is dosed as needed and not on a fixed-schedule. Could break $1 billion if it gains massive adoption, which seems unlikely. J&J is usually very good at launches but flops happen (Invokana, Intelence).

Despite all the advances in CF (like the VX-445 data the other day), CF patients’ lungs are still badly colonized by bacteria. Who will be their white knight in an age where antibiotic development is persona non grata? See Papers I’ve Read section.

For FCSC, KRYS and ABEO, stay cautious. Data quality is really important and companies will put their findings in the best possible light. Be skeptical of single-center data, non-published or non-presented data, etc.

Some big pharma stocks getting tantalizing: GILD, ABBV.

Papers I’ve Read

Once-Daily Plazomicin for Complicated Urinary Tract Infections. Wagenlehner et al. NEJM 2019.
Needed: Antimicrobial Development. Cox, Nambiar, Baden. NEJM 2019.
Plazomicin for Infections Caused by Carbapenem-Resistant Enterobacteriaceae. NEJM 2019.

Plazomicin looks like a new and useful aminoglycoside. An accompanying editorial laments the lack of choices in antibiotics but, alas, the authors are lying. Plazomicin, sold by AKAO, had a whopper of a first quarter, selling around $500,000. I think Britney Spears’ back catalog did better than that. Trashy, my cat, probably earned more in YouTube revenue. If new antibiotics are needed so desperately, why aren’t you doctors who write these editorials actually prescribing them? AKAO is nearly out of business (give it another quarter or two). So, desperately wishing corporate suicide will not get you far. Torching cash is usually not a preferred method of wealth disposal. For drug companies, the only obvious choice to me is to raise the price of antibiotics, especially last-line agents. Serious treatment-resistant infections are lethal–why shouldn’t they have cancer-like pricing if one’s life is on the line?

Sacituzumab Govitecan-hziy in Refractory Metastatic Triple-Negative Breast Cancer. Bardia et al. NEJM 2019.
These data are incredible. Should be the next Ibrance. What am I missing? Doesn’t that make IMMU a 5x?


I introduced some of my fellow inmates to jazz music. Feels like that Talladega movie with Will Farrell. Sounds like someone is strangling a cat!


905-910 days left


Looks like XON is disappearing. Good riddance to hubris. Soon-Shiong next?

It’s amazing how Sun has bucked the trend in generics. Taro is quite the engine I guess?

Apparently “biotechs” that don’t care about making money and are focused on ‘public benefit’ go out of business. How about that!?

ACAD is still a pretty good short. I think LOE is sooner than it looks for this product and all of the product development costs in the world won’t help it too much. The company needs a new drug. Targeting $300m in 2019 revenue implies +40-50%, which isn’t impossible, or even unlikely, it’s just not a lot relative to the market cap. This is a promotion-sensitive drug, too, where new patients are needed (high turnover).

Congrats to LGND for monetizing Promacta. Smart team!

Microaggresions, Nanobigotry and Picoprejudice – A Critical Review of “Racist Like Me — A Call to Self-Reflection and Action for White Physicians”. Deborah Cohan, NEJM 2019

An editorial written by a white physician, exhorting fellow white physicians to urgently battle their collective alleged implicit bias and racism was published in the New England Journal of Medicine. The author’s self-flagellation is, like most acts of atonement, a subtextual peacocking of virtue and superiority. Even at the outset of her apologia, Cohan comforts herself with her score (not peer-reviewed or in a supplemental addendum) on the implicit-association test, a purported diagnostic for subacute racism. This wavering is no contradiction, but a contrapuntal thrust of her achievements as a truly aware… micro-bigot. From this antecedent, she leaps valiantly with syllogistic ease–noting her ‘mission as a white physician is to be humble and respectful toward my patients… …as a revolutionary act against racism, elitism, and hierarchy’. Nevermind for a minute how we got to elitism and hierarchy: what happened to the Hippocratic oath and common sense? The mission of ANY physician is to be “humble and respectful towards their patients”. Sine qua non, no? Elitism and hierarchy? If treating your “patients with respect is a revolutionary act against racism, elitism and hierarchy”, I guess physicians are the new iconoclasts. Viva la revolution!

Cohan’s desire to fight racism, while honorable, is irrationally metastasing to redefine her role as a physician. There may be tremendous inequality in the world, but a plumber is someone who unsticks toilets and an ob/gyn is someone who delivers babies, examines vaginas, and prescribes birth control. You can try to recast yourself as a champion of equality and race, but you’re not a social sciences philosopher and you’re still doing a job that a computer will eventually replace. What made Dr. Cohan regard herself as Themis for the medical world is not apparent. It takes some gumption to immediately conclude there is an urgent implicit bias-driven racism problem in medicine and that all white physicians “suffer” from this malignant malady, and we need to hear the unlettered Dr. Cohan’s perspective to address it. Urgently.

I think physicians tend to forget the unearned pedestal they blindly climb is largely self-directed. Cohan is not a hem-onc or a PhD or in some field where things are actually happening. In case you haven’t inferred, my view is this pretentious trash shouldn’t be in the NEJM. It most certainly shouldn’t come from a field where the major dilemma is which kind of rFSH works best. Oxytoxics haven’t changed in 100 years–get over yourself, glorified electrician. Model yourself after Virchow. Break barriers in your scientific field. Instead of productive research, we get this unstinting and unsolicited micturition.

Cohan notes she is ‘shaped by the subtle trendils of white supremacy’ that are ‘deeply embedded in our culture’. Poetic and even true perhaps, but if we are all shaped by this undetectable racism, why should we be listening to a white physician’s viewpoint? Why not listen to Phil Ivey, Morgan Freeman or Dwayne Michael Carter who claim racism has had zero effect on their success as black professionals? Racism is a real and ugly thing, but the slippery slope some, largely affluent and white, are chasing is dangerous. There is a Mobiusian inevitability of racism according to this self-abnegating crowd. Progress cannot be acknowledged. I read somewhere that the KKK membership is down 99% from peak. That’s a great thing. But when we need to define implicit bias and microaggression to sustain pangs of guilt, what’s next? Nanoracism? Picoaggressions? The need to implacably advance and define ever-dimishing transgressions is fatuous. It conjures a froward and liverish nerd-hipster hybrid only satisfied with delineating your impiety.

This sort of nouveaux mortification of the flesh is not what Christians had in mind but Cohan adapts it perfectly: “I need to explore the parts of me that are most unwholesome, embarassing, unflattering… …My goal is to dismantle the insidious thoughts…” Sound familiar? The Bible suggests we “put to death what is earthly in you: fornication, impurity, passion.” For me, this evokes an arguably psychotic penance for original sin. Yet here, Cohan is a new self-appointed God, the physician’s original sin is white elitism and her decree-cum-solution is apparently to brag about it all. “As I become aware of my biases, they began to loosen their grip”, Cohan notes. A 12-step program for this “treatable condition” (her words) would be welcomed by fellow San Franciscans.

But the woke police have an ulterior motive. My theory is the genesis of this strange movement is the justification (and guilt) of the movement members’ ordinary intellect coupled with their slightly above average achievements in life. If you’re on television and of minor celebrity (or a doctor), the ‘luck’ you’ve received is really ‘privilege’ and your karmic atonement is necessary lest you upset the balance of power. Forget hard work, natural variability of intellect, or pure luck. Genuflecting to the PC gods allows for your continued place in the slightly above-average and mediocre-at-what-I-do firmament. Acknowledge and accept your “privilege” as your raison d’etre and you may be able to sustain your advantage as you work to undermine and dismantle it. I think most extremely successful people don’t even consider race or racism. Like birthdays and religion, we need a narrative bigger than us to explain why we are what we are. The race boogeyman is convenient for he affluent, pathetic white that need a crutch to lean on and look down over, and a reason to not elevate further. Morgan Freeman notes that we inflate racism to a bigger issue than it is. The problem is people like Dr. Cohan.

Cohan, you are not a racist. You’d be racist if you told a patient of color that you don’t accept Medicaid, pre-judging their income based on skin color. You’d be racist if you refused to treat black patients. You’d be racist if you uttered racial slurs. “I noticed myself sitting farther than usual from a black patient in her hospital bed” is a far cry from a “perpetuating a systemic inequity for patients”. I am truly dumbfounded that a sentient person could write this essay. Instead of implicit bias spreading through health care, may I suggest some form of racist dysphoria is spreading across California, resulting in some bizarre acute sensitivity to a largely imagined collectively guilty conscience. “…health care is not safe for people of color as long as the overwhelming majority of U.S. physicians are white…” How was this published?

The echoes of racism are still alive in the present day. Cohan’s article trivializes real racism by wokesplaining semi-elite guilt. Cohan pathetically shames herself to feel better about the benefits she perceives she’s received from the white patriarchy. If you call a $300,000 round-the-clock job with a ton of debt that you train a decade for ‘privilege’, count me out. I’ll stay here educating inmates who confess their woes come from poverty, not having a father figure around and removing themselves from school to chase a quick dollar selling drugs. The media’s romanticizing of guns and drugs has crippled Black youth and culture. The societal bonds of family and the value of education that have allowed Asian-Americans to out-earn even the “priviledged” white don’t exist in Black culture. Why? I’ll tell you it has nothing to do with white physicians and it is not a problem Dr. Cohan is remotely qualified to assist with. It is heartbreaking to meet man after man here who can barely read and write with the same sad story. “Dad left when I was 6.” “My dad is still locked up.” “I didn’t finish high school–left in the 8th grade.” “Never heard of the Beatles.” I’ll do my tiny part and not selfishly seek attention for actual good deeds.

I’m disgusted that the NEJM and Lancet have becoming stomping grounds for the ultra-progressive agenda. The Lancet has functionally become “Social Justice Weekly with a few clinical trial reports.” I’m a “compassionate conservative”, or really an actual liberal, and I’m trying to read about the latest advances in medicine. The NEJM isn’t the place for some untrained doctor to wax on critical theory.

Closing The Gap — Making Medical School Admissions More Equitable — Talamantes et al. NEJM 2019 – A Brief and Critical Review

Just pages before Cohan’s essay lies this masterpiece lamenting the disparity of minority physicians versus minority makeup of the general population. There is no mention of the Asian minority, interestingly. Nowhere does Talamantes suggest that socioeconomic equality could possibly be a result of cultural differences. No, the answer lies in changing medical school admissions qualifications. Throw away the MCAT, and let’s value “distance traveled” (how far a student has come in light of discrimination or a lack of resources or support).
When it’s you on the operating table, you can take the surgeon with the low MCAT score and higher “distance traveled”. I’ll go with the high scorer and not give race a second thought.

Actual Science Papers I Read

Flight of an aeroplane with solid-state propulsion. Haofeng Xu, Yiou He, Kieran Strobel, Christopher Gilmore, Sean Kelley, Cooper Hennick, Thomas Sebastian, Mark Woolston, David Perreault & Steven Barrett.
Flying with ionic wind. Nature 2018.
These MIT researchers fly a plane that has no moving parts and makes virtually no sound. Ionic winds power this 5kg solid-state system to flight. Incredible!

Clinical Trials I Noticed

Safety, Tolerability and Immunogenicity of NBP607QIV in Healthy Adult Volunteers. SK Chemicals Co., Ltd.
A new flu vaccine player has appeared.

A Study of How Tutin and Hyenanchin, Two Toxins Found in Honey, Are Absorbed and Processed by the Body. Christchurch Clinical Studies Trust Ltd.
Don’t eat too much honey! Apparently glycine receptor modulators are in there!