Nick Mark MD Profile picture
Jan 20 7 tweets 3 min read
Just 3️⃣simple acts of compassion can go a long way

Important RCT just published in @TheLancet shows that a family support strategy consisting of 3 extra family meetings can substantially reduce family grief 6mo after the death of a loved one in the ICU
thelancet.com/journals/lance…
1/
Pre-pandemic, ICU mortality was often ~20%

In the US, 30-60% of ICU deaths were preceded by a decision to withdraw life support

We are experts at providing comfort focused care for patients but in many cases, families feel grief months afterwards

What can we do about this?
2/ ImageImage
The COSMIC RCT studied this.

The intervention was 3 family meetings held following a decision to withdraw life support:

1️⃣family conference to prepare relatives for the imminent death
2️⃣ICU-room visit to provide support
3️⃣meeting after death to offer condolences & closure

3/ ImageImage
COSMIC was done at 34 🇫🇷ICUs

Between 2017-2019, they enrolled n=484 relatives of ICU patients to the intervention group & n=391 to the control group. ICUs were cluster randomized to the 3 part intervention case SOC.

Most (78-79%) completed the 6-month telephone interview.
4/
The effect was pretty impressive:

The median PG-13 score (an instrument used to measure grief, not movie ratings) was lower in the intervention group: 19 vs 21

More importantly, it reduced the number of relatives with prolonged grief symptoms: 57 (15%) vs 66 (21%)

5/ Image
So why tweet this? Because it will change my practice!

Pre-pandemic, I always meet with families *before* transitioning to comfort. I often informally talked to relatives afterwards. I didn’t always meet at the bedside (thinking I was giving them “space”)
COSMIC changes that.
6/
The combination of a large effect size (NNT 4 to prevent one person from having severe persistent grief) & being fairly easy to implement (hold two more family meetings), makes this the ideal trial to change my practice in the ICU.

7/

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More from @nickmmark

Jan 21
The ivermectin crazies are now recommending hydroxychloroquine too.

Their “protocol” includes a dangerously high dose of diuretics & recommends high dose steroids in people not on supplemental O2.

This has crossed the line from (mostly) harmless nonsense to actual harm. Image
Supporting Evidence:

A 2021 Cochrane meta-analysis (the 🥇standard) concluded that HCQ “has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo…”

cochranelibrary.com/content?templa… Image
A more recent meta-analysis in @NatureComms that included unpublished studies went further, concluding “that treatment with hydroxychloroquine is associated with increased mortality in COVID-19 patients”

nature.com/articles/s4146… Image
Read 9 tweets
Jan 17
To those who are unvaccinated because of worries about “unproven mRNA technology” you know you can get:
- the J&J vaccine (🇺🇸)
- the Oxford-AZ vaccine (🇬🇧&🇪🇺)

Both can prevent hospitalization or death from COVID. Neither are mRNA vaccines. So why not get vaxxed today?
To those worried about blood clots after J&J, as of April 2021:
-there were 15 cases of TTS
-out of 8 million J&J doses

That’s a risk of less than 1 in 500,000. cdc.gov/mmwr/volumes/7…

The risk of getting struck by lightning is higher than that! cdc.gov/disasters/ligh…
The vaccine efficacy (VE) of the J&J vaccine *is* slightly less than the mRNA alternatives: 68-71% VE to prevent hospitalization (compared to ~90% for mRNA vaccines). That’s still much much better than being Unvaxxed.

(N.B. this is pre-omicron data)
cdc.gov/mmwr/volumes/7…
Read 5 tweets
Jan 16
Updated WHO severe COVID treatment guidelines bit.ly/3rhGgKW

Recommended
🟢Steroid (#Dexamethasone)
🟢IL6 blocker (#Toci) or 🟢JAKi (#Baricitinib)
🟠±mAb in seronegative people

NOT recommended
🔴#Hydroxychloroquine
🔴#ivermectin
🔴#remdesivir

Lots to discuss, a🧵
1/
Remdesivir (RDV) is in the “We suggest no remdesivir” category.
At some level, this isn’t too surprising & is old news.
Despite initial hype, RDV never moved the needle much on patient centered outcomes (risk of mortality or requiring IMV) & many of us had stopped using it.
2/
In #ACTT1 RDV did improve outcomes on an ordinal scale, but the effect was modest. It shortened time to clinical improvement but not hospital LOS (patients stayed in the hospital longer to receive it).
RDV did NOT improve mortality or risk of IMV.
ncbi.nlm.nih.gov/pubmed/32445440
3/
Read 19 tweets
Jan 15
I was alone on an elevator today when I began hearing a voice.

It asked me if I “still support President Donald Trump’s ambitious agenda?”

I look around. No one here.

Hmm that’s weird
1/
Then the voice asked me if I’d like to “make a donation to support President Trump and the America first agenda he enacted?”

Pause

Umm no. This is an elevator.

Pause

The voice said “Aha.”

Then it continued “I’m sorry. Thank you bye bye.”

2/
So either:
A. I’m having a pro-Trump command auditory verbal hallucination or
B. His campaign robocalled the elevator’s emergency phone

3/
Read 7 tweets
Jan 7
As someone who has dedicated a lot of time to studying and making #dataviz, let me explain why I dislike this NYT COVID graphic so much.

1/
It’s not that it’s a spiral - one of my favorite types of graphs is the Condegram spiral. (Named after Mark Conde)

It’s used in astronomy/meteorology to show changes the Earths magnetic fields (Kp index) & is used to visualize space weather.

2/
Another awesome spiral graph - and one of the best examples of #dataviz ever IMO - is the Rose plots by Florence Nightingale.

These 1858 plots show the causes of mortality in Crimean war & make a compelling case that for improving conditions (particularly shelter in winter).
3/
Read 11 tweets
Jan 5
The risk of myocarditis in kids after mRNA vaccines is MUCH lower than was initially feared.

12-15 yo: 265 cases/18.7m doses = 1.4 cases/100k kids vaxxed
5-11 yo: 12 cases/8m doses = 0.12 cases/100k kids vaxxed

For context, the risk of getting struck by⚡️ is ~0.2/100k per year.
People asking about 16-17 yo males:

Yes we know that group has slightly higher (but still objectively low 7/100k) rates of myocarditis

The point is that rates of myocarditis are *even* lower in younger kids (5-15 yo) Hence ACIP’s recommendation that kids *should* get boosted.
As for the VSD data. In this dataset, among people aged 12-17yo, they reported 39 cases out of 1.1m vaccinations. Most were mild.

This is higher but still objectively very rare: 3.2/100k

Again, this safety data was used by ACIP to justify a stronger “SHOULD” recommendation
Read 5 tweets

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