@dresmerelda

ID/Micro Academic Doctor & Smiley-faced lover of purple

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Full disclosure during Mental Health Week: it’s been hard. 😢 • Last week was tough enough: as the number of cases of Covid decreases, we’ve all had to face the uncertainty of what happens next. Lots of doctors have had to change career plans to step up to help and uncertainty breeds anxiety: what changes have to be made to our yearly reviews? And if we all moved back to our ‘normal’ jobs again, what happens when the second wave hits?! 😕 • And then I’ve had my night shifts. I’ve had sick Covid patients, and that’s hard. But I also had a REALLY sick non-Covid patient: one who was unexpectedly, suddenly sick 😰 • Not all deaths affect us the same way as doctors. Most are expected and if we ‘felt’ each death, we’d be useless to those who were alive. The ones that are harder, we try to learn from. Aside from specifics I can’t discuss, I learnt: 1️⃣ That I have good instincts. I asked for blood tests that, when I tried to teach my junior colleagues why I made those decisions, I could only explain as my “spider sense was tingling..!” 🦹🏻‍♀️ 2️⃣ That presented with the choice of letting a family member see my sick patient or stopping them so that I could try to save the patient’s life, I would choose again to stop them, even if it meant they couldn’t say goodbye in the end. My patient had a truly lovely family, so I hope they forgive me for that. 😢 • Tomorrow is Eid and one family member will be missing for them. I hope they find comfort in their memories and strength in each other 💕 • At the end of this week, my mental health take-home is to always live in the moment. This pandemic has shocked the world. But we have to take and enjoy every precious day that we have. Eid Mubarak to those celebrating and love to everyone who’s suffered even more for this situation. Remember to #bekind to yourselves and each other ❤️ • #mentalhealth #anxietyawareness #instascience #instamedicine #research #medicine #medic #oncalllife #scrubs #scrubslife #family #infection #infectiousdisease #microbiology #doctorslife #lifeanddeath #womeninmedicine #eidmubarak

Covid-19 UK trials: the Recovery-Respiratory Support trial 🗣 • When people are sick enough to require help with their breathing and oxygen levels, there are 4 main options we generally use in medicine: 👩🏻‍⚕️ • 1️⃣ Patient awake. A variety of ‘simple’ face masks and nasal prongs 👃 • 2️⃣ Patient awake. Tight-fitting, high-flow oxygen via nasal prongs called High Flow Nasal Oxygen (HFNO) 🩺 • 3️⃣ Patient awake. Tight-fitting, pressurised oxygen masks called Continuous Positive Airway Pressure (CPAP). It’s a form of Non Invasive Ventilation (NIV) 😷 • 4️⃣ Patient asleep. A tube is put in the throat and a machine supports their breathing. It is called Invasive Mechanical Ventilation 😴 • Covid-19 can cause a disease similar to Acute Respiratory Distress Syndrome (ARDS). The management for this is ‘traditionally’ invasive ventilation but this doesn’t come without risks and we try to avoid it if we can, using simple masks, HFNO or CPAP first if possible. 👏 • The question then becomes: which is better- simple masks, HFNO, CPAP? This is why the Recovery-RS was set up 🙌 • In this trial, patients that are eligible for invasive mechanical ventilation are randomised to ‘standard of care’, ‘HFNO’ and ‘CPAP.’ The primary outcome is intubation or mortality within 30 days. 🩺 • Now this is a TRICKY study to set up in real-time, rather than just looking back at former patients. The reason is that in reality, doctors will switch between the different treatment options if it will save their patient. The study therefore allows for this, and I don’t much envy the statistician that will have to pick it apart!!! 📊 • But it IS an important question. Early in this pandemic, neighbouring countries were favouring ‘early’ intubation. As time has gone on, we’ve all had experience of patients that we managed to avoid intubating by using HFNO or CPAP, and patients that couldn’t be intubated that did brilliantly with HFNO or CPAP. Questions below 👇 • #medicine #intensivecare #researcher #scicomm #instascience #medic #doctors #doctorslife #ventilator #scrubs #womeninscience #womeninmedicine #infectiousdiseases #infection #intubation #medstudent #odp #pa #nurse #purplehair #scrubstyle

Clinical Covid: clotting and bleeding risks 🩸 • When patients have clinical signs of large blood clots in their legs or their lungs (Deep Vein Thromboses and Pulmonary Emboli), we risk assess them and if they seem low risk we do a blood test for a D-dimer. It is a break-down product of blood clots and having a high D-dimer with a low-risk score means that we will scan patients to look for large blood clots. Lots of conditions can cause high D-dimers though, including sepsis and inflammation, because small (micro) clots can happen in these conditions. Severely ill patients with sepsis sometimes develop a clotting and bleeding disorder called Disseminated Intravascular Coagulation. Characterised by high D-dimers, dropping platelets (the sticky clotting blood cells) and longer clotting times, I was taught at medschool that DIC also meant “Death Is Coming.” 💀 • A recent paper in Dublin by Fogarty et al has added to the data from Chinese studies (eg, Tang et al) that shows that patients with Covid often have hugely raised D-dimers that keep rising as they get sicker BUT that they don’t usually develop DIC. They (and a group in Imperial- about a month ago) suggest that the high D-dimers are due to local microvascular clotting disorders in the lung that they term ‘Pulmonary Intravascular Coagulation.’ 😷 • Why is this important? 🤔 1️⃣ Coupled with the severe inflammation, it may help explain why we can’t get enough oxygen into the blood of severely unwell Covid patients- there’s a ventilation/perfusion mismatch 🩺 2️⃣ Studies are needed to see if higher doses of anti-clotting drugs (like the heparin we give patients to prevent clots in hospital in the UK already) might help patients with Covid 💉 3️⃣ Monitoring D-dimers may predict patients at higher risk of severe illness- more studies needed! 🩺 4️⃣ It ties in with us also noticing that patients with Covid are at higher risk of large blood clots, strokes and heart attacks too ❣️ 5️⃣ Different ethnicities are at higher risk of blood clots- could this explain the possible higher risk of death in different ethnicities? 🤔 • Questions below 👇 • #doctors #research #instascience #nhs #scrublife #virology #haematology

Covid-19 UK trials: the incredible ISARIC study with some good and bad news... 👩🏻‍⚕️ • After the Swine Flu pandemic, and with MERS an increasing threat, the UK developed a “‘sleeping’ pre-pandemic suite of documents, agreements and protocols in preparation for future outbreaks.” When another pandemic hit, they wanted to start real-time (observational) research ASAP, with ethics, forms and protocols ready that could help form public health policy and save lives. 🙌 Of particular importance was the Clinical Characterisation Protocol for Severe Emerging Infection, developed by the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC). This was adopted by the WHO following their own ethics review to be implemented on a global scale during outbreaks 📈 • So when Covid-19 hit, we could rapidly recruit patients who consented. What for? Essentially, to just follow their clinical course and review their samples as needed. From the patient’s point of view, nothing changes. 👍 But from our point of view, we can monitor the outbreak MUCH better. 😷 • And so it is that the ISARIC team have just published data summarising the clinical characteristics of nearly 17000 patients admitted to 166 hospitals across the UK so far… Key findings are: 🧐 • 🦠 60% were men, 40% women 👫 🦠 47% of patients were not known to have any other illnesses 🩺 🦠 Overall 49% of patients were discharged alive, 33% have died and 17% were still inpatients 😕 🦠 3 symptom clusters are noted (and fits with what we’re seeing clinically): a respiratory cluster (cough, fever, breathless), a musculoskeletal cluster (muscle and joint pain, fatigue) and an enteric cluster (tummy pain, vomiting and diarrhoea) 🤔 🦠 Pregnancy wasn’t associated with deaths (unlike flu) 🙌 🦠 The median age was 72 but risk of death started climbing from age 50. Only 2% of patients were under 18 🩺 • You will hear a lot about this on the news over coming days I expect. There is good and bad news to digest here. Makes me feel glad for the lockdown though... Questions below 👇 • #research #instascience #scrubslife #scicomm #doctorslife #womeninmedicine #publichealth #globalhealth #virology #nhsheroes

Clinical Covid 👩🏻‍⚕️ • Most sick patients come in to hospital at about day 5-7 of symptoms. It’s usually when they feel the sickest but from a medical POV are often still holding their own. We’ve known since January that Covid patients can get sicker between days 6 and 12 (Huang et al 2020). In my experience (though it is well documented), people then have what I call the “day 10 wobble.” 😷 • The “day 10 wobble” is like the “hump” that folks go through- either starting to get better or worse. Getting worse doesn’t mean they can’t still get better overall though. 💪 But it means that clinically we watch people according to day of symptoms in a way I’ve previously only done for Dengue 🤒 • Why does this happen? We think it’s when the adaptive (and memory) immunity kicks in. In the early illness, your innate immune system (the real front-line fighters) do their thing. Ordinarily viruses tend to kick off a Type I Interferon response but there’s evidence that in severe cases, SARS-CoV-2 probs interfered with this so that it could keep replicating early on. As the immune big guns come in we get this “cytokine storm” picture where the immune system goes into a dysregulated overdrive. Those of us that have a better Th1 response (a type of T immune cell) are less likely to have severe disease (Prompetchara et al 2020). How smoothly this signalling occurs is also important in severity- and older ages are more likely to have a dysfunctional immune response (Nikolich-Zugich et al 2020). 😕 • It probably means that when it comes to drugs, we need a drug/combination that focuses on the virus early in the illness and the addition of something that balances the immune system later on 🤷🏻‍♀️ • In Covid, it’s about doing the clinical basics well. We closely monitor oxygen levels and breathing rates. But I’ll chat more about this and ICU another time 👍 • Like my goggles? ☺️😷 • #clinician #research #scicomm #doctor #scrubslife #medicine #medical #infection #infectiousdiseases #microbiology #womeninmedicine #womeninscience #researcher #virology #fashion

So yeah, I’ve almost certainly had Covid-19. After a friend became classically unwell but had an early negative test, I had to self-quarantine in case I developed symptoms. Thankfully, my friend is now better. 🙌 • I kept quiet because I didn’t want to freak close family/friends out and had to see how I got on first! And then tell them later (sorry Mum!). I strongly suspect, with the benefit of hindsight and working out timing, that I got it in the community just before I started clinical- I never had cough or fever, but maybe had some mild, intermittent breathlessness that I thought was reflux/hay-fever but has now settled?? I felt fine. I even went for a (naff) run and thought I was just being tired and lame 😅🤦🏻‍♀️ And if I didn’t have it then (I mean, this is retrospect), I WILL have had it asymptomatically now. So 🤷🏻‍♀️ • It highlights again the importance of keeping up with our lockdown procedures. I’ve now done the staying at home thing and it’s wholly 💩 but SO much better than the alternative. I’m lucky. The spectrum of illness with this is massive- I’ve seen people with no symptoms, people with mild to severe symptoms... and I’ve seen people die. 😔 It’s the weirdest Russian Roulette I’ve ever witnessed because I’ve seen “healthy” people do well and poorly, and “unhealthy” people do the same thing. 😐 • I kind of feel better for knowing that I can stop second-guessing my “symptoms” so much now. But ultimately until there’s a reliable serology test, I won’t know for sure if I’ve had it, and even then it won’t change what I do next 🙌 • And that’s NOTHING DIFFERENTLY. We still don’t know how long our immunity lasts. We still need to be sure it doesn’t alter our risk of severe disease. I still need to use my PPE correctly and I still need to protect others by keeping at home when I’m there and maintaining distance if possible at work. 💪 • #staysafe #stayhome #savelives 🙌 • #scrubslife #virology #scicomm #scicommunity #doctors #healthcareworkers #healthcareheroes #healthcareprofessional #dresmerelda #research #instascience #instamed #medic #infected #infectiousdiseases #microbiology #microbiologia #livelife #womeninmedicine #clinical #nhs #nhsstaff

Covid-19 UK trials 2: Remdesivir Trial 🙌 • Some trials are being run internationally by drug companies- this is one of them. 💊 Remdesivir is a direct-acting antiviral agent that works much like some of the HIV treatments- it’s a “fake base”, a fake building-block of RNA (namely adenosine), that inserts itself into the virus and mucks up its attempt to replicate (make more of itself) by affecting the enzyme making it 🤯 Originally created for Ebola, it’s been shown in the lab to affect MERS, SARS, and more recently, the Covid virus. Remdesivir is new and only comes in drip (intravenous) form at the moment 🤔 • The study primarily aims to compare how well different course-lengths of Remdesivir work in patients with moderate or severe Covid infections by assessing their responses. They also want to look at how long they stay in hospital, their oxygen use, causes of any deaths, how long it took them to clear the virus and, in some places, the blood levels of the drug. All this is important to understand a new drug working clinically on a new virus 💪🦠 • The things I’ll want to know from this study as a doctor? 🩺 1️⃣ Did it stop my patients getting sicker/make them better/improve their chance of survival with Covid? 💪 2️⃣ Was there a “best time” to start this drug? Often antivirals (eg oseltamivir (tamiflu) for flu) need to start early to work well but that’s not necessarily the case (eg, HIV drugs still work even when started later, though people do better for starting sooner for general health reasons) 🦠 3️⃣ Do my patients tolerate the drug? And do they need to work out an oral version...? 🩺 • This trial is happening in a number of countries but recently stalled in China as they don’t have enough active cases 🙌 Only some hospitals will be doing it though and patients have to meet certain criteria to take part. We STILL don’t know of any drug treatments that work for Covid. Nothing is a guarantee but we’re all trying to learn 💪 • Questions below 👇 • #infection #scicommer #doctorslife #trials #instascience #nhsrainbow #happythoughts #colorful #virus #research #studygram #community #health #scrubs #medical #staypositive #dresmerelda #microbiology #virology

Covid-19 UK trials 1: The RECOVERY Trial 🙌 • Set up by Oxford, this NIHR/UKRI-backed #study recruits patients from hospitals all over the UK with confirmed/probable Covid-19. A computer randomises them to 5 different treatment options. It’s voluntary and it’s happening because at the moment we just don’t know what drug works! 🤷🏻‍♀️ If you’re asked to take part, it may not help you but it might help others in the future 👍 So, what’s being tested? 👇 • 1️⃣ Standard care- more patients recruited will be randomised to this arm so that the investigators have good baseline data for comparison 💪 2️⃣ Lopinavir/ritonavir 💊 this is the HIV drug also known as Kaletra. They are Protease Inhibitors shown to have laboratory (in vitro) activity against SARS and MERS. A recent NEJM study by Cao et al in 199 patients with Covid did not show statistically significant benefit but the RECOVERY team argue that a modified analysis does and the trial was small. 📊 3️⃣ Dexamethasone 💊 Steroids in infection? 🤔 We know that they help in some cases (certain TB presentations) and there’s also some evidence of benefit in ARDS- the type of lung inflammation seen in Covid. It’s a bit conflicting though. A low dose is used here to reduce side effects. 💪 4️⃣ Hydroxychloroquine 💊 An antimalarial and anti-inflammatory drug. The doses used are higher than for those conditions, based on pharmacology data and concurrent WHO international studies. There’s some promising data from other countries BUT we still just don’t know. 🤷🏻‍♀️ 5️⃣ Azithromycin 💊 This is a macrolide antibiotic (like clarithromycin) that has some anti-inflammatory and anti-viral activity. There was a lot of noise about its use with HCQ after a French study but on its own it may also give benefit. 👀 • Whilst we have a lot of experience with them and they’re pretty safe, ALL of these drugs have side effects or can interact with other meds. So ONLY have them under medical supervision and no, if we don’t have evidence for them as treatment, we don’t have evidence of them for prevention either!!!! 🦠 • More on other studies coming soon. Ask questions below 👇 • #research #instascience #infection #doctors #healthcare #nhs

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