Dr. David Lyness Profile picture
Dec 8, 2021 27 tweets 19 min read Read on X
What were the most impactful non-COVID papers over the past 2 years? Let's delve in and take a look. #SOA21
Finally an opportunity to not talk about COVID! #SOA21
TOMAHAWK - immediate vs delayed/selective angio. 3 years to conduct the trial in 31 ICUs. 554 patients. 'Worse' survival in immediate angiograph? Not SS, but close... #SOA21
TOMAHAWK - subgroup analysis .... no SS. Generally in favour of delayed angio though? WRT 30 day mortality. #SOA21 This is in OOHCA.... which brings us to...
Vasopressin + methylpred vs placebo on ROSC in IHCA. #SOA21 An important trial to challenge current practice. 501 patients randomised after 1st dose of adrenaline... Primary outcome ROSC for at least 20mins... Clear benefit in vaso+methylpred. #SOA21
Care post ROSC was not protocolised. Primary outcome was clearly SS. Secondary outcomes... well... for benefit/harm for longer term survival (30 days, or neuro recovery etc... is uncertain. #SOA21
Another trial that highlights the difficulties in these sorts of studies. If you don't control the 'rest' of care... post-resus etc - then how can we know? #SOA21
Now with fluids... #SOA21 BaSICS was published 2m ago. Saline v Balanced C.... first of all, remember 2018 SMART trial = >15000 patients. Composite outcome of MAKE30. Combined (I think) 3 outcomes to find a positive trial.... but in a subsequent analysis...
(2019) - looking at mortality... beneficial with balanced soln.
So this informed the SSG/SSC - and based on the 2019 analysis (and others) - statements were changed. BALANCED crystalloid instead of saline... #SOA21 So - back to BaSICS in 2021
Patients randomised (not ICU's), >11,000 patients. Randomised to either fluid (plasmalyte vs saline0.9). Key Q looked at mortality. #SOA21 - no significant difference... in fact...
No SS, but also trends to harm in TBI! So... back to the beginning... again. #SOA21
So... why so different? Median of 2.9L of study fluid (<1L of fluid per day).... also fluids prior to enrolment in trial... #SOA21 ?? Also different continents/environments.
Not all balanced solutions are equal? What about pH? #SOA21 Are any of them really 'physiological'? BaSICS were almost 50% post surgery.... So we still don't know.
Dare we move on to VICTAS? Patients with sepsis, randomised to VitC/Thia/Hydrocortisone v Control. Vent/Vaso-free days as outcome. No SS difference. #SOA21 No difference in mortality. No difference in anything really. 🤷
THIS IS CONSISTENT WITH THE OTHER MAJOR LITERATURE CONTRIBUTIONS. #SOA21 But... it didn't fully recruit the number of necessary patients, steroids allowed in both arms, heterogeneity in practice, no significant adverse events. 🤷
Still SSC/SSG suggest against using Vit C. #SOA21
Moving on. Too many sepsis pts lumped together... no phenotypes/microbes/molecular status looked at in detail... A massive heterogenous group bundled together in trials. #SOA21
AdrenOSS-2 trial. Adrecizumab. Binds to adrenomedullin (ADM). Protective role in the endothelial barrier. Regulates vascular tone. In sepsis, ADM can leak out of vasculature --> vasodilates and impairs endothelial barrier, incr perm. So the MAB stops this happening. #SOA21
4 Euro countries. Adults. Sepsis. Raised ADM level in vasculature. 2 different doses allocated. Feasibility and safety study. Lower SOFA score seen. No SS for mortality seen... Different approach seen in this trial! #SOA21 No signs of harm. More studies planned.
ETT cuff pressure control - continuous control v intermittent. To prevent VAP. 3 sites in Vietnam. 1500 patients screened - 600 randomised. No sig difference up to 13 weeks. Subgroups didn't reveal much either. #SOA21
How do we time RRT? >30 studies on early v late. >10 metanalysis... sometimes opposing conclusions! 4 RCTs - and now this trial #SOA21 only 278 randomised from 5336!! V.small group - niche. Thus, no SS in RRT-free days. Mort diff - no SS diff - hint towards higher mort in delayed
And so AKIKI-2 concluded.... but remember this was only a very small subgroup of patients. #SOA21
Final trial - ARDS-related: #SOA21 - vent-free days and mortality outcomes. Stopped early due to low recruitment. 5 years to 277 patients.... each site only randomised very infreq. Still - important results.
This would have probably gained more traction had it not been for COVID. #SOA21 Comments below:
Palliative Care: #SOA21
Personal views have tremendous impact... #SOA21

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More from @Gas_Craic

Dec 8, 2021
We've looked at bats for a long time.... #SOA21 They have strong interferon responses, but not strong inflammation....
So what happens instead? #SOA21 They will tolerate high levels of viraemia with little symptoms. Bats are old... 65million years ago - they appeared at the end of the dinosaurs! They are far longer lived that other mammals. Senescence is late - more towards end of life.
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Dec 7, 2021
Organophosphate poisoning, toxicology, dengue, snake bites and malaria.... sure what could go wrong? #SOA21 @ICS_updates Drs. Chacko, Yacoub, Bhaumik and Dondorp tell us more.... 🧵👇😘
Let's go to India - Tamil Nadu.
I'd advise anyone not overly family with Organophosphates to start here: ncbi.nlm.nih.gov/books/NBK49986… #SOA21
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Dec 7, 2021
Biomarker guided abx treatments in sepsis. We catch up with Drs/Profs: Paul Dark, Stacy Todd, Enitan Carrol, Jonathan Sandoe and Matthew Stevenson on this large area of research @ICS_updates #SOA21
So, do biomarkers have any utility in guiding abx use in sepsis? We can measure, usually, these ones fairly easily: #SOA21
In around 2014, commissioned review in PCT. Seemed to suggest a shorter duration in abx use when PCT used.... tenuous data though. #SOA21 Low quality. Little evidence from UK... how does this fit into NHS practice in the realms of stewardship?
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Dec 7, 2021
@iceman_ex, myself and @dr_mattmorgan talk about how to keep yourself intellectually safe on Social Media at #SOA21 (full talk at soa.ics.ac.uk)

A thread 🧵👇
There's been a lot that's gone on over the past few years that's exposed the well known 'darker' side of social media. Traditional paradigms of knowledge dissemination have changed (if not disappeared). Much higher tech-savy population. #SOA21
This has democratised the discussion space to an extent. It allows for *anybody* (lit. anybody) to get involved. #SOA21
Read 17 tweets
Dec 6, 2021
Is COVID-19 hyperinflammation, or a cytokine storm in a teacup? @DrPujaMehta1 's fab talk from #SOA21 today! Image
Main Q = "Hyperinflation contributing to worse outcomes for some patients with COVID-19" - clinical similarities to sHLH seen. Viruses are the most common trigger of sHLH. Early reports from China suggested cytokine profile was similar to sHLH in terms of COVID severity. #SOA21 Image
We now know some things work and some things don't.... in certain populations. #SOA21 Image
Read 28 tweets
Dec 6, 2021
What have we learned during COVID? Prof Tony Gordon takes us through a whirlwind tour of COVID-19 research.... #SOA21 Image
Scientists AND politicians in the spotlight during COVID. Very different approaches between the two groups.#SOA21 Image
First reports and articles with hundreds of patients.... moving on to thousands of patients. #SOA21 ImageImage
Read 21 tweets

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