Archive for May, 2020

 

May 29 2020

Guest Blogger: Jeff Toretsky, MD

by at 7:30 am

With gratitude to Dr. Weiner for sharing this venue, my best wishes for his challenge that he faces today with his father. I hope it goes well.

Gratitude Started with a Hemoglobin of 2.4

When you wake up after sleep and take that first big breath, are you grateful for being alive another day? Most of the world’s religious traditions have created prayers for this monumental activity, waking up and breathing. With a hemoglobin of 2.4, normal being greater than 11, that first morning breath needed to circulate oxygen became a challenge for a recent patient of our team.

In Judaism, a prayer that one can say upon waking is called Elohai Neshama — literally, “My God, the soul that you placed within me.” Elohai Neshama continues: “the soul that you placed within me is pure. You created it, You formed it, You breathed it into me, and You preserve it within me… All the time that this soul is within me, I am thankful before You…”

I am constantly thinking about gratitude these days. On many days I share this gratitude with others, especially when I talk with friends outside of medicine about what I do all day long. As the Division Chief for Pediatric Adolescent and Young Adult Hematology/Oncology, I lead a team that has maintained a full schedule of patient care since COVID-19 infections began rising. Our patients range from literally birth through their early 30s. The spectrum of diseases includes severe hematologic problems, like anemia with a hemoglobin of 2.4, to cancers of the oral cavity. Fortunately, to date, none of our patients have been infected with COVID-19. I am grateful that patients put their trust in the care that our team provides.

I lead a team that includes nurses, social workers, administrative staff, clergy, child life specialists, pharmacologists, and other physicians. Everyone on this team has personal stresses from the impacts of COVID-19, whether it is from the illness itself or the uncertainty in the world. Yet, I have heard many compliments of our team sharing how team members kept patients calm through adversity or organized a complicated sequence of medications. One of our social workers was recently recognized as Associate of the Month, a significant honor bestowed by MGUH (look for Heather’s picture on the hospital wall in June). I am most grateful for this amazing team for showing incredible professionalism in a stress-ridden world.

My gratitude for our patient coming through a narrow place in her life, because of a dangerously low hemoglobin, led to this blog post. Just this week, I opened my email to find a video that was prepared by our patient and her father. When patients or their families write a note of thanks for their medical care this kindness is never solicited, not required, but always touching. In the case of this very special thank you, the father happens to be a composer/musician and the patient an excellent violinist. It is with gratitude, and their permission, that I share this video.

May you stop for a minute today, take a deep breath, and be grateful. Know that I will.

— Jeff Toretsky

P.S. I am also grateful that Betsy has remained married to me for 32 years, as of today.

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May 28 2020

Life in the Time of Corona(virus) – Day 74

by at 8:18 am

We are headed up to Philadelphia today to visit my father. It will be a difficult trip, as I described in my blog yesterday. On top of this, the drive, which we have made countless times, carries with it all manner of challenges.

Traffic should not be all that terrible, but there are only a few available rest stops along the way. It is hard to not think of each indoor public space as a potential killing zone, however banal it appears. When we get to my father’s house, there will be additional practical challenges. There has been a virtual parade of care providers in and out of the house — visiting nurses, aides, physical and occupational therapists, some family members. We head into this potential viral incubator with some trepidation, armed with gloves, masks, wipes and, of course, love.

It will be a long day. We should be at the house by 11 a.m. or so, and will hit the road by 8 p.m. It will be hard. But, in the end, it will be a good day. We are doing what we should do, what we feel we must do. On this day, just this day, cancer, and hopefully coronavirus, will have to take a back seat. After all, this is one of the last times I will get to be a son. I treasure that opportunity.

Stay safe and be well.

Lou

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May 27 2020

Life in the Time of Corona(virus) – Day 73

by at 7:30 am

I heard that our inpatient numbers of COVID-19 patients have gone up just a tiny bit, but the severity of the case load seems to be on the wane — the high flow oxygen unit at the hospital is being decommissioned. So that’s the good news for the day. I do think we will have COVID-19 inpatients for a long time though. I get a real sense of a need to find responsible ways to socially distance without strict quarantines, excepting for high risk people. We need to learn how to live with a pandemic simmering in the background of our lives. How that shakes out will be fascinating to observe.

For example, we actually had guests over the weekend: Elana, Ben and our grandchildren Isaac and Aviva. We had not seen them in the flesh since early March, though we have seen them every day through the miracle of FaceTime. We shared some pizzas — they were on our patio, and we were in the family room, with the French doors swung open to the patio — socially distanced and wearing masks when not eating. We had to settle for air hugs, but the relative immediacy was a breath of fresh (droplet-free) air for us. After eating, we took a walk to the grounds of the National Cathedral and hung out in the Bishops Garden and the adjacent, wonderful little outdoor amphitheater. It felt kinda normal. I hope it was safe.

Meanwhile, someone forgot to tell cancer that we are in the midst of a viral pandemic. One of my patients, a 43-year-old man, died on hospice on Monday from complications of a rapidly progressive metastatic neurendocrine tumor. His wife, a nurse, was a fabulous support throughout his illness. He leaves behind three kids, aged 19, 15 and 8. Another patient, a 37-year-old man, is now on hospice following numerous failed attempts to control his pancreatic neurendocrine tumor. Although he has lived with his disease for almost five years, he is cachectic and suffers from significant pain. When I visited him in the hospital to discuss hospice, speaking behind my mask and wearing PPE, I was struck, as so many are, that the relationships between care providers and their patients, which so often deal with emotional life and death issues, are severely hindered by PPE barriers. However, in this time of coronavirus, we have no other choice. He will not live to see his beloved Redskins play this season. In his honor I may root for them, just a little bit, and only for this season. But not when they play the Eagles!

Finally, there is the 93-year-old man with end stage myelofibrosis, falling apart, immobile and no longer able to even move without significant assistance. On Thursday, I need to have “the talk” to convince him that the time has come for home hospice. He won’t listen to anyone else when it comes to his health. It is a truly horrible privilege and burden to be compelled to have that conversation with my own father, but it is time. Don’t expect a blog from me on Friday. I will be traveling all day Thursday, and probably won’t be feeling much like sharing my thoughts at that moment.

Three patients, three stories. Each different, yet so similar. They remind us that cancer indeed is the Emperor of All Maladies. I cannot wait for all of us to get back to work and answer our calling to prevent and cure cancer, with local focus and global impact. There is so much to do.

Stay safe and be well.

Lou

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May 26 2020

Life in the Time of Corona(virus) – Day 72

by at 9:35 am

Greetings on a Memorial Day weekend like no other — for some. For others, the starting pistol seems to have fired for a complete return to normalcy, defined here as a disregard for social distancing measures. Some believe the coronavirus pandemic is a hoax, while others have decided that their own risks are low, and thus worth taking. Still others just want to party. Whatever the cause, the outcome cannot be good for those of us who choose to exercise care and wear masks when social distancing cannot be avoided. In fact, it’s not good for any of us.

Over the weekend I read reports of incidents around the country where angry unmasked people accosted those who chose to wear masks in public spaces, in some cases going so far as to spit or deliberately cough in their faces. Why? The simple answer is that some people are mean-spirited morons, and certainly acts such as those easily clear the bar for such a description. But I think there is more to it.

Historically, attacks on this country or on fundamental American principles have unified our nation. Here, I think especially of World War II, which ended 75 years ago, and 9/11. While there were dissenters, to be sure, the country pulled together in remarkable ways, especially during World War II. The development and first use of the polio vaccine was a cause for national celebration. We have faced illnesses before, but a pandemic of the type posed by SARS-CoV-2 has not torn through the United States since the advent of what we consider to be the era of modern medicine, which is based at its core on scientific principles. In a very real way we have been invaded. Why then, has this invasion failed to unify us? In many ways the pandemic has illustrated, and perhaps widened, the political divide that separates so many of us.

While many deaths from COVID-19 were inevitable, the fact that we are closing in on 100,000 deaths is an indictment of our country’s preparedness and uncoordinated response coupled with toxic, selfish individualism that some seem so happy to celebrate these days. When I hear someone on a crowded beach, wrapped in an American flag, bellow out when asked about social distancing, “This is a free country, and I have the right to do whatever I want!” it makes me sick with fear. What about driver’s licenses, stop signs and laws to prevent theft or assault? Are they not attacks on individual freedom too? Where does this end? Are we not accountable to others in our community? And, to me, this is the problem. Searches for consensus and compromise focus almost exclusively within silos. After all, our political process is at its core one huge marketing exercise.

The objective of any marketer is to win market share. If the product is good, that is OK, but it does not matter as long as the product sells. Pick your side, pick your slogans. When I was a kid, market segments pretty much did not exist. Most everybody watched the same TV shows. Political differences did not prevent the emergence of consensus. Leaders led, and were expected to get results. Extremists were generally not trusted. Expertise was valued, even admired. This also was a time of conformity, blatant racism, misogyny and homophobia, so it was by no means an idyllic era.

We have an opportunity to capture some of the finer characteristics of that time, and to reject its unpleasant and hateful elements. I hope we can remember who we are, and are able to embrace our many shared beliefs. Our response to COVID-19 can be liberating, ushering in an era of inclusion, respect, searches for consensus and truth. Alternatively, it can accelerate the toxic spiral and imperil the foundations of this country, which despite its shortcomings remains perhaps the most noble political and social experiment in human history. On this day, when we remember those who sacrificed their lives so that we can reap the bounties of freedom, this would be an unspeakable tragedy.

Don’t spit. Do vote.

Stay safe and be well.

Lou

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May 22 2020

Life in the Time of Corona(virus) – Day 68

by at 7:30 am

Happy Memorial Day weekend: the kickoff to a summer unlike any we have experienced. Those of you who read my blog yesterday should know that it was inspired by a note Stan Fricke sent my way in response to one of my earlier posts. His musings about the future stirred my imagination, so I looked at a possible reminiscence from a future perspective as well.

Enjoy Stan’s blog and have a great long holiday weekend. Stay safe, be well, and I’ll see you on the other side of the holiday this coming Tuesday.


 

Perspectives From the Future: Remembering the “Coronavirus Period”

 

Newsreels have it that everyone is beginning to feel cabin fever.

The caricatures of flat-screen talking heads would like us to buy into their message.

Looking up from my living room window I see clear blue sky.

My wife started a deck garden and insisted that I set up bird feeders. We now have daily guests in the form of Red-winged Blackbirds, Blue Jays, Cardinals and Mourning Doves. Also, fox and rabbits have made their way up two flights of stairs just to visit our free-roaming voluntary menagerie

The hole in the ozone over the Pacific Ocean is closed not due to anything but a big storm from the north.

I spend copious amounts of time with my family. We eat, cook and even camp inside the house, TOGETHER.

City noise levels are lower than ever.

This will not last forever. I suspect that in the future, when we all go back “to the way it was,” many of us will be asking ourselves why we didn’t take advantage of our “forced stay-at-home turn-of-the-century coronavirus period”?

I would predict that the arts that are now being created, especially the material that reflects today’s mood, will be enshrined in history as the “Coronavirus Period” or something similar.

Will ecologists, when speaking of this period, say “they learned important lessons,” or will they say “they had a chance to make a change but did not”?

By the way… The internet works. It did not come to a screaming halt! Technology finally is able to provide paperless, work-from-home situations that will have, and already are having, a positive impact on our ecology.

Perhaps we should look at how our situation, albeit forced, is actually better than it was in 2019. Perhaps we should capitalize on what is now amazingly better than last year. Perhaps instead of calling this “the new norm” we should call it “something we should have done 10 years ago.”

The debate about home-schooling has had a happy compromise: now we are all home-schooled, but with professional educators supervising what we are doing.

I wave as the mail carrier drives by, instead of wondering whether or not the mail carrier has delivered the mail until I get home to discover the truth.

I am writing this as a challenge to you: Take this post and add one unique sentence or more about the good in our current situation, pass the message to one other person to do the same… and by the end of the week, maybe we will have an amazing positive side of the “Coronavirus Period.”

Perhaps we should start thinking about what we are doing that we were not doing before, and what, when the situation gets back to “normal,” we should keep from all of this.

— Stanley Fricke, PhD

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May 21 2020

Life in the Time of Corona(virus) – Day 67

by at 7:54 am

Fewer people are hospitalized in our area every day. That is such great news. It got me to thinking…

We sat on the deck, overlooking the beach and the pounding surf on this sunny, warm day in May. Clara, a self-assured and thoughtful young woman, placed her right hand over her eyes to blot out the sun, turned and looked my way. “PopPop, my senior project is due in a few weeks, and I want to interview you to learn about life in the time of coronavirus.”

I was a bit startled. Surely she knew, for it was not that long ago; then I remembered, she is only 17. When the pandemic struck, she was only about a year old. By the time the last embers had been extinguished she was only five. Who remembers the details of their early lives?

“What was it like?”

“It was frightening, and a bit normal. Perhaps that’s why it was so scary — surreal, eerie. We all worked from home, except for medical workers and so-called essential workers, many of them poor. The coronavirus swept through our city in three waves. The first wave was terrible; around the country more than 100,000 Americans died — all innocent, many long before their time. We sheltered in place, got tired of it, prematurely resumed “normal” life, and then the second wave hit. It was an apocalypse. We were totally unprepared, without effective medicines or vaccines. Our hospitals were overwhelmed, and many more people died. I lost relatives and neighbors. We all did.”

“What happened then?”

“Well, we hunkered down at home, all of us, and this time, we took it seriously. After the second wave, and that election, foolish talk of hardy individualism being more important than community safety evaporated. This time, the lockdown lasted for six months, and we learned how to operate a necessarily crippled but functioning economy through the great recession. The last wave was not nearly as bad, as the virus had mutated and lost some of its infectivity. Finally, someone developed a partially effective vaccine. I hope we’ve learned our lesson. But so many died, stupidly, and so many lives could have been saved.”

“How is life different now?” “Well, for one, I am a lot older. I miss work. I wish I could still exercise and take long walks with your grandmother like we used to.”

She rolled her eyes. “PopPop, of course you are older. I know it was a long time ago. But you still get around pretty well. So, how is life different because of that coronavirus pandemic?”

“Well, in some ways life is better, and in other ways it is not so great. The air is a bit cleaner. People seem to respect each other’s commonalities and differences more than they did back in 2020. We all hold on to our loved ones a little tighter and a bit longer than we did back then. We are a kinder and gentler society, and all of that is good.  But, we have lost some of our edge; life is not as exciting as it used to be. I miss the crowds, the packed restaurants, shopping malls and crowded beaches. I tired long ago of the impersonality of food delivery services. I miss handshakes and hugs; they fell out of fashion during that prolonged pandemic, and faded away.” I hate virtual society.

Clara began to squirm. She saw the pain in my eyes. She was clearly uncomfortable, vicariously reliving this dark part of our shared history. She stood up, walked over, reached down and gave me a big hug. “It’s OK, PopPop. You’re part of our inner circle.”

It doesn’t have to be this way. May this story turn out to be fiction. Stay safe, wear your mask, observe social distancing, and wash your hands.

Lou

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May 20 2020

Life in the Time of Corona(virus) – Day 66

by at 7:30 am

I hope you are doing well. The infection rate seems to continue to decline, and Delaware beaches are opening up on Friday. No, we are not heading out there this weekend, but just knowing that it is a tangible future option breathes a bit of fresh air into our thoughts, if not our lungs.

Meanwhile, let me tell you a bit about my day. I woke up fairly early, checked emails quickly, worked out for about 30 minutes and sat down at the desk in my home office at about 8:30. I got through some correspondence, and the parade of Zoom calls began at 9 a.m. It started with a call from a referring physician who needed help getting a visitor to our city, who has advanced lung cancer, seen urgently. A quick flurry of calls ended with one of our dedicated physicians squeezing in the patient. Mission accomplished. I then had a 45-minute call with a faculty member who is dealing with challenging clinical responsibilities while trying to sustain a research career. After a five-minute break, it was time for our weekly call for Ed Healton and his senior leaders group. These meetings, which previously happened far too rarely during my time at Georgetown, have been highly impactful. I am certain that our group has coalesced, and I expect this meeting will be a welcome staple moving forward.

After another brief break, I had a Zoom meeting with Rachael Maynard, an MD/PhD student doing a rotation in my lab. As she can’t do any actual laboratory work, she has been writing a review article with me that focuses on NK cell biology and the roles of NK cells in the tumor microenvironment. We meet once every 10 days or so to review her progress, and she gets to participate in laboratory meetings as well. It is a most peculiar rotation for a student, but she will come away with a nice paper. I then turned my attention to editing a review being written by David Zahavi, a TBio PhD student doing his thesis work in my lab. He and Allison Fitzgerald, an MD/PhD student in my lab, have used this experimental break to write the first two chapters of their respective future theses; David’s review is Chapter 1 of his thesis. Allison is in the middle of three papers: one is a review of Fibroblast Activation Protein (FAP) biology based on Chapter 1 of her future thesis, and she has two computationally-rich papers related to her twin interests in FAP and NK cell biology. I then broke for a quick bite to eat. It’s easier to get to my kitchen from my home office than it is to walk from my Georgetown office to Epicurean or the Leavey Center! Harriet and I chatted briefly, and then she was off to the dining room for the Zoom funeral of an elderly, distant relative from Harriet’s home town of Lima, Ohio. Lima, once a thriving community, has fallen on hard times, though it proudly boasts one of the last, if not the only remaining Kewpee Hamburgers restaurant in the United States. I want to go there to better understand the forces that shaped Harriet, but she will have none of that. She shudders whenever I suggest a road trip to her home town. Actually, I just want to try a Kewpee’s burger. I hear they are quite good.

As for me, it was back to Zoom to interview a superb clinical investigator candidate for the Breast Cancer Program. I then met with Marc Schwartz to discuss a range of CPC-related issues, and had a two-hour research-focused conference call. All of a sudden, it was 5:30 p.m. Harriet and I made a couple of FaceTime calls — one to our son David and his family, the other to my father, who continues to gradually recover from his broken hip. Then it was Boomer Zombie Apocalypse time, as Harriet and I took a surprisingly chilly and windy walk in the neighborhood (we ran into two masked people we knew!). I finished my workout after that, and then it was time for dinner and the remainder of our family check-in calls. After that, it was time to dig into the 50 new emails that had arrived in my inbox in the two hours since I had pushed back from my desk. We watched another episode of “Foyle’s War,” had a bit of coffee, and then it was time for me to write this blog.

I still have a bit of work to do, but will be back at it early tomorrow. Wash, rinse, repeat. Never has this phrase been more resonant or pandemic-relevant.

Stay safe and be well.

Lou

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May 19 2020

Life in the Time of Corona(virus) – Day 65

by at 8:01 am

I need a vacation. This working at home stuff is not easy — it is real work! The days simply blur into each other. Weekends lack meetings but not work. I cannot wait until we can get to the beach for some R&R. The various curves in DC, Maryland and Virginia are stable or dropping. Is the end in sight, or is there another hill to climb just beyond the horizon? We obviously cannot plan for the pandemic to evaporate, so we are in the process of making painful decisions regarding Georgetown Lombardi fundraising events. For example, the Lombardi Women event, originally scheduled for April, was canceled for this year. The Men’s Event, originally scheduled for June, was originally postponed until September, and on Monday the event’s leadership came to the sad conclusion that even that delay was not sufficient, so the event will not be held this year. Nobody feels comfortable inviting crowds to celebrate, even for a great cause like cancer research, when such events carry any risk. We’ll get ’em next year. Meanwhile, we are looking for other ways to recoup the lost revenues that support our work.

Speaking of that sports analogy, it seems that spectator-less sports are on the near horizon. I actually watched a bit of the first German Bundesliga match over the weekend, which was held without spectators. It was like watching a scrimmage — mildly interesting, but lacking the excitement that comes with a crowd. Then I watched a few minutes of a live charity golf match on TV, again without spectators. I like golf, but a TV broadcast of the match on a quiet golf course was like watching paint dry. Should we see a return of baseball, basketball and hockey in the next few years, it will be very weird — and maybe not so wonderful. It’s also hard to imagine watching an NFL football game held in an empty stadium. I actually think the reruns of old games will be more interesting, but hope I am wrong.

I need a vacation. A trip. A beach. Anything. It doesn’t have to be for too long, but variety is truly the spice of life. But for now, I will simply stick with the routine, write more papers, work to improve the cancer center any way I can, knowing that when I take a break I will have truly earned it.

Be safe, stay well, wear your mask and wash your hands.

Lou

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May 18 2020

Life in the Time of Corona(virus) – Day 64

by at 8:30 am

I interrupt this pandemic-focused blog series to stop and give thanks. Many of you have seen my announcement that Bob Clarke and Leena Hilakivi-Clarke will be leaving Georgetown at the end of August, after 30 years of service. Bob will be Executive Director of the Hormel Institute, affiliated with the University of Minnesota, and Leena will join the same institute as a professor and section leader. Our friend Doug Yee and the University of Minnesota got themselves a great haul. Of course, since Doug is a Lombardi alumnus, we are certainly keeping it in the family. I am happy for both Bob and Leena, as Bob gets a chance to exercise his leadership chops and Leena goes to an institution that focuses on nutritional science. Good for them!

Bob and Leena have been marvelous colleagues, but more importantly they are great friends. We have done collaborative research, written many grants together (some of them funded!) and have commiserated over the challenges of leadership. We have also had our share of road trips. One of my favorite memories was a fundraising and research collaboration trip to Ireland and Northern Ireland years ago with Bob, Howard Federoff and Andy Deubler. You really get to know a guy when he is in a bar where he grew up. Dublin was wonderful, but the trip up to Belfast was fascinating. After driving through the essentially invisible border between Ireland and Northern Ireland (a testimony to the power of liberal democracy and tolerance to overcome nativism and anarchy), we had meetings and then took a Clarke tour of Northern Ireland, replete with tours of windswept castle ruins, picturesque bays dotted with sailboats (one of Bob’s passions) and wickedly cruel drive-bys of iconic golf courses, none of which I was able to play. Oh, there was a distillery tour — of Old Bushmills Distillery, with a rather thorough tasting of their excellent products. Although the collaborations we initiated did not achieve all we had hoped, the whiskey and the memories were enduring. I keep a bottle of Bushmills in our kitchen pantry to this day.

As for Leena, I remember a long-ago Breast Cancer Think Tank in Costa Rica. We all took a tour of the jungle and watched an endlessly fascinating game of crocodile vs. bird (fighting over a nearby chicken carcass). The bird won. Walking with Leena, whose idea of a casual amble is a 20-mile jog, was both tiring and inspiring. Over the years, she discovered the joys of immunology research, and I have enjoyed the opportunities to comment on or contribute to her relevant grant submissions.

We have been so fortunate to have benefited from Bob and Leena’s 30 years at Georgetown and at this cancer center. Their science speaks for itself, their leadership helped make Lombardi what it is today and what we’ll look like in the future. But most of all, I will miss the opportunity to interact closely with two of the finest, kindest and most genuinely benevolent colleagues I have had the chance to work with in my career. This is not goodbye, but it certainly is a moment for me to say thank you. I am sure I speak for countless colleagues.

Stay safe and be well.

Lou

(P.S. In the announcement this morning, I said Rebecca Riggins was mentored by Leena. She and Ayesha Shajahan-Haq were both mentored by Bob, and Sonia de Assis by Leena).

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May 15 2020

Life in the Time of Corona(virus) – Day 61

by at 7:25 am

Not much new to report today. I did enjoy Amrita Cheema’s excellent Cancer Data Meeting presentation, and spent the rest of the day primarily focused on seeing patients in person and through the MedStar TeleHealth platform. I have been thinking about yesterday’s blog, where I described the things I have missed in the first two months of the DC stay-at-home order. Hence, it is only fair that I finish the week by noting those moments that have newly emerged over the past two months.

Moments That I Have Liked                                     Not So Great Memories
Daily FaceTime calls with loved ones—————————–No hugs or kisses

Quiet, springtime neighborhood walks————————–Cornhole tournament on ESPN

Spending time with Harriet—————————————–Harriet has to spend time with me

Cheering for health care workers———————————Policy that ignores science

Andrew Cuomo————————————————————Him

Zoom communities—————————————————–Endless meetings

Deep data dives———————————————————No new data

New grant and paper ideas—————————————-Empty labs

Virtual hugs with my grandkids———————————-Missing Clara’s first steps

Empathetic, purposeful senior leadership meetings—–Painful decisions

Repurposed research for COVID-19—————————Cancer still kills

The power of human decency————————————The Divided States of America

It has been another very busy week, and with any luck we’ll have a chance to stretch our legs for a long walk or two over the weekend, eat some smoked brisket from a great vendor in Austin, Texas (courtesy of Goldbelly.com), watch Foyle’s War on Acorn TV (we love it), and kick back just a bit. Perhaps, just perhaps, we’ll make a drive by to see some kids/grandchildren. A guy can dream, can’t he?

Have a great weekend. Stay safe and be well.

Lou

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