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Nick Mark MD

@nickmmark

Jun 5, 2022 • 11 tweets • 7 min read • Read on X

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Once again there is a wave of #misinformation about #ExcessMortality & #vaccines in the US.

A mysterious insurance report says “excess mortality is rising” could it be the vaccines?
No. Virtually all the excess mortality is associated with COVID infections!

A debunking 🧵.
1/

Every few months, a myth of “unexplained deaths not from COVID” resurfaces.
Last time they claimed “young people” were inexplicably dying. Looking at the actual data it was pretty clear that virtually all the excess deaths under 45 were due to COVID.

https://twitter.com/nickmmark/status/1452487179364564996?s=20&t=Ub8btz0TcqDi3OYx3UKtiw

In a later incarnation, this conspiracy theory revolved around a mysterious (and nameless) "insurance industry expert” & "former Wall Street analyst” who did his own analysis and “found an 84% increase in excess mortality."

This too has been debunked.
reuters.com/article/factch…
3/

Let’s look at the actual data:
If we look at weekly deaths of all cause, we can see five spikes above baseline in weekly deaths, each corresponding to a wave of the pandemic.
Source: CDC
cdc.gov/nchs/nvss/vsrr…
4/

How much of the increase in mortality is due to COVID?
If we look at # of deaths/week, comparing weekly COVID deaths to total deaths. we can see the answer is almost all of it!
Example: Of the ~27k excess deaths in early 2021, ~26k were due to COVID!
cdc.gov/nchs/nvss/vsrr…
5/

But we don’t have to look just at correlations, because Doctors put the cause of death on death certificates.

Looking at COVID associated deaths🟦vs non COVID deaths 🟩, we can see that virtually all of the excess mortality can been attributed to COVID infection!
Source: CDC
6/

This isn’t really surprising since COVID was the THIRD leading cause of death in the US in 2021.
cdc.gov/mmwr/volumes/7…
7/

Not only do mortality spikes correlate with surges in COVID infections, they do NOT correlate with vaccinations.
Compare 3 lines: weekly excess Mortality ⬛, COVID cases 🟥, & vaccinations🟦
The correlation (R²) is higher for mortality⬛ & cases🟥.
github.com/hmatejx/COVID_…
8/

If we look at that insurance report that Kory shared (and clearly didn’t read), we can see more evidence that vaccination *reduces* excess mortality.
Specifically excess mortality is HIGHEST in the places with the LOWEST vaccinations!
Source: soa.org/48ff80/globala…
9/

This too isn't surprising, we know that at this point in the pandemic the vast majority of COVID mortality occurs among unvaccinated people.
Source: Our World in Data
ourworldindata.org/grapher/united…
10/

Summary:
-there IS a significant increase in excess mortality...due to COVID infection
-there IS NOT a temporal association between vaccines & excess mortality. In fact, quite the opposite: states with the highest vaccination rates had the lowest mortality #VaccinesWork
11/

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More from @nickmmark

Nick Mark MD

@nickmmark

Oct 13

#HurricaneHelene damaged the factory responsible for manufacturing over 60% of all IV fluids used in the US, leading to a major national shortage.

As clinicians what can we do to about the #IVFluidShortage and how can we prevent this crisis from happening again?

A thread 🧵
1/

There are many things we can do as clinicians to improve ICU care & reduce IVF use.

1️⃣Don't order Maintenance IV Fluid!
Almost no patient actually needs continuous IV fluids.
Most either need resuscitation (e.g. boluses) or can take fluid other ways (PO, feeding tube, TPN).
2/

Frequently if someone is NPO overnight for a procedure, MIVF are ordered.
This is wrong for two reasons.
We are all NPO while asleep & don't need salt water infusions!
We should be letting people drink clears up to TWO HOURS before surgery, per ASA.

3/ pubs.asahq.org/anesthesiology…

Read 16 tweets

Nick Mark MD

@nickmmark

Oct 1

New favorite physiology paper: Central Venous Pressure in Space.

So much space & cardio physiology to unpack here including:
- effects of posture, 3g shuttle launch, & microgravity on CVP
- change in the relationship between filling pressure (CVP) & LV size
- Guyton curves!
1/

To measure CVP in space they needed two things:
📼 an instrument/recorder that could accurately measure pressure despite g-force, vibration, & changes in pressure. They built & tested one!
🧑‍🚀👩‍🚀👨‍🚀 an astronaut willing to fly into space with a central line! 3 volunteered!
2/

The night before launch they placed a 4Fr central line in the median cubital vein & advanced under fluoro.

🚀The astronauts wore the data recorder under their flight suit during launch.

🌍The collected data from launch up to 48 hrs in orbit.
3/

Read 16 tweets

Nick Mark MD

@nickmmark

Jul 16

https://twitter.com/matt4va/status/1813202802337779731

The media silence on this is deafening.

Did he have a head CT? What did it show?
Did he have stitches? Tetanus shot?

The NYT ran nonstop stories about Biden’s health after the debate but can’t be bothered to report on the health of someone who was literally shot in the head?

https://twitter.com/matt4va/status/1813202802337779731

To the people in the replies who say it’s impossible because of “HIPPA”
1. I assume you mean HIPAA
2. A normal presidential candidate would allow his doctors to release the info. This is exactly what happened when Reagan survived an assassination attempt.
washingtonpost.com/obituaries/202…

My advice to journalists is to lookup tangential gunshot wounds (TGSW).

Ask questions like:
- what imaging has he had?
- what cognitive assessments?
- has he seen a neurosurgeon or neurologist?
- he’s previously had symptoms like slurred speech, abnormal gait - are these worse?

Read 4 tweets

Nick Mark MD

@nickmmark

Jun 30

You've probably heard "don't give lactated ringers because it raises lactate"

This statement is ~98% false, but there's one crucial practice-changing fact that you need to know.

A 🧵 all about lactic acid and lactated ringers!
1/

First off, we should ackowledge the obvious: Lactated ringers does in fact contain lactate... 28 mEq/L in fact

BUT there's one little detail to remember:
Lactate ≠ Lactic acid

When we measure "lactate" we care about the ACID (H+) which lowers pH & causes organ dysfunction
2/

But the correlation between pH & lactate is really bad!

Look at this analysis of lactate vs pH in 171 ICU patients.

There is a *weak* correlation in people with arterial lactate > 5, but even w/ lactate =10, pH ranged from 7.5 to 7.05. Quite a spread!

3/ ncbi.nlm.nih.gov/pmc/articles/P…

Read 10 tweets

Nick Mark MD

@nickmmark

Jun 13

If you intubate you need to read the #PREOXI trial!
-n=1301 people requiring intubation in ED/ ICU were randomized to preoxygenation with oxygen mask vs non-invasive ventilation (NIV)
-NIV HALVED the risk of hypoxemia: 9 vs 18%
-NIV reduced mortality: 0.2% vs 1.1%

#CCR24
🧵
1/

Hypoxemia (SpO2 <85%) occurs in 10-20% of ED & ICU intubations.

1-2% of intubations performed in ED/ICU result in cardiac arrest!

This is an exceptionally dangerous procedure and preoxygenation is essential to keep patients safe.

But what’s the *BEST* way to preoxygenate?
2/

Most people use a non-rebreather oxygen mask, but because of its loose fit it often delivers much less than 100% FiO2.

NIV (“BiPAP”) delivers a higher FiO2 because of its tight fit. It also delivers PEEP & achieves a higher mean airway pressure which is theoretically helpful!
3/

Read 15 tweets

Nick Mark MD

@nickmmark

Jun 12

Results from #PROTECTION presented #CCR24 & published @NEJM.
- DB RCT of amino acid infusion vs placebo in n=3511 people undergoing cardiac surgery w/ bypass.
- Reduced incidence of AKI (26.9% vs 31.7% NNT=20) & need for RRT (1.4% vs 1.9% NNT=200)

Potential game changer!

🧵
1/

I work in a busy CVICU & I often see AKI following cardiac surgery.

Despite risk stratification & hemodynamic optimization, AKI remains one of the most common complications after cardiac surgery with bypass.

Even a modest reduction in AKI/CRRT would be great for my patients.
2/

During cardiac surgery w/ bypass, renal blood flow (RBF) is reduced dramatically. This causes injury, especially in susceptible individuals.

But what if we could use physiology to protect the kidneys?

Renal blood vessels dilate after a high protein meal increasing RBF & GFR!
3/

Read 11 tweets

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