The PicPod

From the 8th to the 14th May 2021 the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) organised a very impressive, continent by continent programme of events to celebrate, discuss, and share PIC around the world.

To mark this we invited four really special guests to the PicPod: Satoshi Nakagawa from Japan, the current WFPICCS president, Brenda Morrow from South Africa, the WFPICCS president-elect, and Ann-Marie Brown from the USA and Luca Tortorolo from Italy, who both helped to organise the week.

What is PIC, and how does this differ amongst countries and cultures? How important is the role of family, and how is visiting different around the world? What is the role of WFPICCS in trying to combine a very disparate sub-specialty, and how can WFPICCS advocate for everyone? How does PIC work in different geographical areas, including the South African getting-to-PIC paradox.

We are a global specialty, and in this podcast we address PIC for everyone.

The news has been full of pictures of the Covid situation in Brazil. In a huge and diverse country, control seemed to have been lost.

We have interviewed Fatima Marinho and Ana Bierrenbach from Sao Paulo who work for a non governmental organisation (Vital Strategies) which is keeping track of the medical situation in Brazil. These are the real numbers.

But how has this affected children? In the UK there have been 29 paediatric deaths within 28 days of a positive COVID test. How does this compare to Brazil? (Partial spoiler: please listen to this sat down, it’s shocking).

What are the causes for these huge admission rates and mortality? Is it medical equipment and facilities, is it identification and treatment of cases, is it underlying population health inequalities, or is it the Brazilian variant?

And why has Bravil been so badly hit? How much of an interplay do we have between politics, society, and medicine? How does leadership from the top affect the population? And have you heard the one about ventilator piracy…?

Extraordinary times need extraordinary solutions. The SARS-CoV2 pandemic has caused global health and economic devastation. But humanity is fighting back. It is an incredible effort of humankind to create vaccines in less than a year.

But not only have we been able to create vaccines, we have created them in ways never before seen. The Pfizer/BioNTech vaccine is the first ever mRNA vaccine, where your own ribosomes do the hard work of creating the antigen. But how does it work?

Software developer, physicist, and entrepreneur Bert Hubert from the Netherlands (@PowerDNS-Bert) wrote a superb article where he reverse engineered the Pfizer BioNTech vaccine (available in a variety of languages here. Each of the six critical parts of the vaccine is discussed: the starting cap, the ribosome “landing strip”, the signal section which gives the final protein a destination, the code for the spike protein, the finish section, and the number of repeats code.

The vaccine is a lipid encapsulated string of mRNA. But the human body is often exposed to foreign DNA and RNA, which is rapidly broken down. How did the vaccine developers trick us to be able to accept their mRNA? How did they make it the protein fold the correct way? How many mRNA strands are there, and how many time is each one used? What are the positive, and negative implications for the future?

Thanks also to @disasteradio for the unique music to play us out.

Bronchiolitis (remember that condition) will come back, and it will again be the staple of the PICU winter. It’s our bread and butter: but are we doing the right thing?

Becky Mitting from St Mary’s in London has just published experience from three centres in London, all very close together, but with some surprising differences in management. Her paper, published in PCCM, entitled !Invasive Mechanical Ventilation for Acute Viral Bronchiolitis: Retrospective Multicenter Cohort Study!, is available for free to download here.

One centre had ventilation times of 40 hours less than another. How did sedation strategies change ventilation times? What happened to the patients who were nasal ET tubes? What other factors influence intubation time? What about non invasive ventilation? Are the patients equivalent: and what is the difference between OSI, OI, SF, and PF ratios?

If you think you are doing bronchiolitis correctly, listen to this. If you don’t think you are doing it correctly, listen to this.

The PicPod project has hit 50 episodes, a milestone we never imagined we would reach. We hope you have found these podcasts informative and useful. Here’s to the next 50!

For this special anniversary episode we have three very special guests: Deanna Behrens from Chicago, Sapna Kudchakar from Baltimore, and Robert Tasker from Cambridge and Harvard.

Deanna and Sapna are highly active on twitter in the #PedsICU domain, and Sapna is also a senior associate editor at PCCM. Robert Tasker is the editor in chief of PCCM. Between @DeannaMarie208, @SapnaKmd, @RobertCTasker, and @PicPod_Podcast we share over 20,000 followers on Twitter (methodological and statistical note: these are not all unique followers).

Is medical twitter useful? How should we use the huge amounts of information there? What is the difference between information and knowledge, and how do we (should we) ensure that we use the second, not the first?

The rigour applied to traditional publishing is important, but how much is this being undermined by the headline grabbing tweets, and by the extensive use of preprints which then lead to media stories?

What is the future for hard copy journals, and how do they compete with open access journals? How do predatory journals fit in to the picture? What do researchers do who cannot afford the open access fees?

Finally, we discuss how to encourage diversity and equality in medical publishing and information dissemination.

Thank you to our guests both on this podcast and on the previous 49, to everyone who has been so encouraging, and to the thousands of listeners around the world.

One of the extraordinary aspects of the pathophysiology of COVID-19 is the so-called “Cytokine Storm”. This is implicated both in the adult type condition, and as part of the PIMTS-TS / MIS-C condition.

We were lucky to spend time talking with Prof Ram from Bristol, a paediatric rheumatologist with an interest in cytokines. What is the difference between biologics and small molecules? What is the future of cytokine blockade?

Specifically, which cytokines are involved in PIMS-TS / MIS-C? Should we blockade them? What is the difference between all the inflammatory conditions, eg PIMS-TS/ MIS-C, toxic shock syndrome, HLH, and even sepsis? When should we use IVIG, steroids, or a targeted biologic?

And, as an aside, why is the COVID mortality so high in certain high income countries, and so low in many low income countries?

Enjoy and learn!

COVID-19 has devastated the world, with millions of deaths and socio-economic disasters. Medicine has been fighting back hard, with some incredible examples of research answering the important questions at breakneck speed.

The RECOVERY trial is the one which has answered questions on Dexamethasone, Hydroxychloroquine, Azithromicin, Lopinavir-Ritonavir, and now convalescent plasma (works, harms, no effect, no effect, no effect).

To get high quality, properly randomised, trustworthy data so incredibly quickly is an amazing feat. RECOVERY has a paediatric arm, which was agile enough to have included a PIMS-TS / MIS-C arm as early as June.

Answers on the therapies on these important conditions are urgent, and at the time of recording 118 paediatric patient have been randomised. There are two arms: for respiratory COVID, and for PIMS-TS / MIS-C. IVIG, steroids, and Tociluzimab are all being randomised: soon Baricitinib will be joining the party.

Saul Faust leads the paediatric arm of RECOVERY. He talks about the history of the trial, how we got here, and what is next. What has been found so far? What are the implications for future studies?

Our only weapon in this situation is knowledge.

Kathy Wilkinson is the lead author and project co-lead for the The National Confidential Enquiry into Patient Outcomes for Long Term Ventilation

Hilary Cass leads the CoLab project: Partnership throughpaediatric complexity, and is the former President of the Royal College of Paediatrics and Child Health.

They both gave excellent talks at the 2020 E-PCCS conference in the Complexity in Paediatric Critical Care section.

They both have interests in the long term care of complex children. The landscape around long term ventilation patients is changing. Numbers are increasing and the type of patients is changing. What does the future hold? Are there any limits? Where should the limits be? Does society drive management, or are ethics absolute?

We have no answers, we only have questions.

Most people retire and take up a suitable hobby. Pat Weir however moved from the PICU in Bristol, a large cardiac surgical unit, to Malawi to continue her work there.

She spoke eloquently at the 2020 E-PCCS conference about her experiences, and agreed to an interview on the topic. The medical, technical, and societal culture shock was huge: but she was able to help many children who would otherwise have had no care available.

We discuss her experiences, the challenges she faced and the wider issues of whether a low income country should spend resources on a small number of high demand patients, or spread resources more widely.

Is there a children’s intensive care system which is ideal? How is the case selection different between high and low income countries? What is the “right” way to do it?

Nutrition is important: but as we discussed way back in PicPod 13, nutrition should be at the right time, at the right amount.

Luise Marino is the senior dietician at the PIC in Southampton. She gave an excellent talk at the 2020 E-PCCS conference on refeeding syndrome. Children admitted to PIC have varying levels of malnutrition. How do we react to this? How should we feed these patients?

Should we give trophic feeds? Should we give micronutrients? Pre or post pyloric feeding? What amount?

Discussion about and around these topics.

More to come from the E-PCCS conference soon.