New paper on ICU-acquired infections in COVID from my group and colleagues from the @ESICM UNITE-COVID investigators published in @crit_care
Key finding, a strong association between use of cortico-steroids and development of ICU-acquired infection. A 🧵
ccforum.biomedcentral.com/articles/10.11… We’ve known for some time that critically ill patients with COVID are highly susceptible to developing secondary infections whilst in ICU – infections they didn’t have when they came in. Here’s a previous paper of ours on this
ccforum.biomedcentral.com/articles/10.11…

🚨Brexit damage story🚨How Britain is losing £Mns in investment and left unable to exploit technologies developed in the UK.
Speaking to a friend, serial entrepreneur who has spun successful companies out of several top UK universities. Recently relocated his latest venture to 🇫🇮 Why? It’s based off UK tech, developed in an elite UK university with a global reputation- surely this should be a UK company? The problem is, investment and research funding. Inside a market the size of the EU this is easy to access, outside not so much.

Exciting new paper, TARGET trial of therapeutic drug monitoring (TDM) in beta-lactams (piperacillin/tazobactam) has been published in @yourICM. Its an interesting paper which deserves close reading. A 🧵

link.springer.com/article/10.100… TARGET randomised patients with sepsis and septic shock receiving Pip/Taz to TDM or standard dosing. Target was 4x MIC of the bug, or the upper limit for Pseudomonas (nasty, resistant bug) if empiric. Primary outcome was organ failure (SOFA score).

Levelling up – German style (and why the Tories are lying again).
In 1989 the Berlin wall came down, in 1990 the DDR rejoined the BRD.
Years of corrupt, incompetent, ideologically driven government of the DDR had left it in a mess The (West) German government realised a major programme of ‘levelling up’ would be required – infrastructure was a mess, industry was backward and underinvested, the economy stagnant, environment poor. $2Trillion was transferred from West to East Germany.

New data from South Africa in @JAMA_current shows omicron is mild, case proven, game over, stop worrying? Before we declare this we need to look at what the paper actually shows ja.ma/3zePICi The data comes from @Netcare_Limited the largest private provider of acute care hospitals in South Africa. Patients from the early omicron wave are compared with those from previous ancestral, beta and delta variant waves.

🚨🚨New Years Day Quiz🚨🚨 (*massive prize available)
What links these two items?
‘Snatch landrover’ ‘FFP3 mask’ They both represent a failure of the British state to protect public servants who place themselves in harms way. To explain;

This is clear good, if increasingly expected, news. Omicron (at least in highly immune populations) is associated with less episodes of severe disease than delta. Great, should we relax and all go out and party? No, a quick thread to explain why.

https://twitter.com/kallmemeg/status/1476932349694775303

Omicron is clearly more infectious, and as a result cases are at a massive high, we’ve never seen so many cases. And because of the well attested testing problems, cases are considerably higher than daily reports suggest.

Some encouraging data on longer term outcomes of survivors of COVID needing mechanical ventilation- good functional recovery, low rates of psychological and psychiatric morbidity and radiographic resolution of fibrotic changes in the majority at 1 year.

https://twitter.com/sranesthesiaicu/status/1476836327530418188

This is consistent with previous studies of ARDS (most of which will have been caused by bacterial or viral pneumonia). Fibrosis tends to resolve in most patients, functional recovery often lags radiographic or spirometric measures of lung function.

As of yesterday around 1 in 8 acute care beds in England was occupied by a patient with COVID. 12.5% of all beds, when winter bed occupancy routinely runs at 95% in a ‘normal year’. In fact the proportion is higher as COVID cases amongst NHS staff lead to bed closures. This number of occupied beds represents a major strain on other services, it will limit the ability to undertake surgery, to provide routine care for other conditions. Even if no one dies of Omicron (sadly this will not be the case) it will have massive impact.

Excellent article on the new Muscular Unionism and how this strains the UK- possibly to breaking point. journals.sagepub.com/doi/full/10.11… However, Muscular Unionism is not so much a coherent political philosophy as a good old-fashioned power grab. The current govt have marked authoritarian tendencies, cannot abide the idea of any power beyond their own.

A number of prominent journalists, none of whom specialise in science, medicine or epidemiology, have started mumping around about epidemiological modelling. This has spilled over into politicians as well, claiming ‘we need more data before we decide’. This is poor policy, a 🧵 As with all epidemics, infection precedes illness. If the lag between infection and illness is short (like in covid) and the doubling time is also short (like in covid), by the time you have data on how many people become ill the disease has already massively expanded.

Press release from our HEPA filter project now published in Clinical Infectious Diseases. Air filter significantly reduces presence of airborne SARS-CoV-2 in COVID-19 wards | cam.ac.uk/research/news/… Paper here academic.oup.com/cid/advance-ar…

This week in ICU, we’ve got a lot of COVID- currently around half our level 3 (ventilator) beds are filled with patients with COVID. A lot of the patients are double vaccinated, and pressures are rising from other conditions. This is in significant part because we have high levels of community transmission - under conditions of high transmission even small percentage of vaccine-breakthrough infections will be severe, a small percentage of a very large number is still a large number

Perhaps if we think of the economy as an organism it would help understanding. Organisms keep themselves in balance by the process of homeostasis- compensating for increases in demand (e.g. having to flee a sabre-toothed tiger)

https://twitter.com/GoodwinMJ/status/1441514187495067650

They do this by having ‘reserve capacity’, allow them to cope with short term demand fluctuations. If part of the organism is damaged or depleted it may function ok, until strain is placed on it. The smaller the reserve the less strain it can cope with.

By popular request @a20Stephen A thread on our recent pre-print “The removal of airborne SARS-CoV-2 and other microbial bioaerosols by air filtration on COVID-19 surge units” (**Pre-print -not peer reviewed**)
TL:DR Hospital air is dirty, we can clean it
medrxiv.org/content/10.110… If you don’t want to read any further -these are the key figures. Filter off SARS-Cov-2 present in air, lots of other bugs too, filter on – SARS-CoV-2 disappears, bugs go right down, filter off SARS-CoV-2 back again.

On the day we remember a truly horrific death toll, can we also recall those who spent the last year denying the severity of Covid? I have some close to me who are COVID deniers, but I don’t hold them responsible- they arguably didn’t know better

It’s noticeable the difference in framing of media responses to US and EU Covid vaccine vs the UK Whilst the US has so far not licensed the Oxford-AZ vaccine, waiting for trials involving US patients to report (normal for the FDA) I’ve not heard U.K. media commentators declaring this to be ‘snubbing the U.K.’ (EMA approved it 1 month after MHRA)

Is this the end of liberal blood transfusion? The last bastion was in patients with acute coronary syndromes, where observational data has long told us that anaemia was associated with worse outcomes
jamanetwork.com/journals/jama/… Of course just because anaemia is associated with worse outcomes does not automatically mean correcting anaemia with a blood transfusion will improve outcomes -and now Ducroq and colleagues have done the study to examine this.

We’ve known for some time about the apparent ‘obesity paradox’ where obese patients in ICU have better outcomes than the non-obese.

https://twitter.com/youricm/status/1365711562204450821

This apparent paradox illustrates some of the problems of inferring causative relationships from observational data. Firstly ‘non-obese’ includes patients who are low weight, and as a marker of poor nutrition and severe pre-existing illness, such patients tend to do badly

I suspect that many healthcare staff are anxious about the coming months, I know I am. Please remember it’s ok to not be ok, we are not superhuman, a medical or nursing degree does not mean you can’t suffer. Never be afraid to talk to someone A colleague, a senior, your hospital’s psychology or mental health service, or national helplines
For East of England details for staff mental health are here
ohwellbeing.com/improving-work…

“ICUs aren’t full” shout the denialists, shall we unpack that a little? Firstly, ICUs in many hospitals are full to bursting, despite having increased their capacity this year (we have 20% more ICU beds than December 2019, but notably not 20% more staff) But running at 100% capacity is a sub-optimal way to run an ICU. When someone needs an ICU bed, they need it ‘now’ not in 6-12 hours time- delays in admissions to ICU cost lives, and it’s something we routinely audit as a measure of care quality.