"Six Feet"

Six feet.

I’ve said it. You’ve said it. Fauci has said it. But why are we saying it?

Doesn’t that seem a bit… I don’t know, arbitrary? Random? Other synonyms?

Did you know that the World Health Organization actually recommends one meter?

Can’t germs travel seven feet? Or ten? What about the butterfly effect – if a butterfly sneezes in Taiwan, can’t it infect someone in Madagascar? (Something like that.)

Where did this number come from… (ominous ellipses)

Back in 1942, someone took a “high-speed camera” and photographed respiratory droplets to see if they could travel six feet. They found that most of the droplets fell within 3 feet, which became the party line for social distancing for decades. That’s right – we based social distancing on images from a 1940s camera that photographed spittle drops. 3 feet.

To try and further suss it out, a few bold (?crazy) scientists in the UK opened up the Common Cold Research Unit in 1946. They offered volunteers a 10-day getaway in Salisbury, UK, under one condition… volunteers agreed to be inoculated with the common cold. They suggested in 1947 that the safest distance was 30 feet, though the podcast referenced later here suggests 3ft for large droplets (again). Check out this original publication:

https://journals.sagepub.com/doi/pdf/10.1177/003591574704001104

And a video of their unit from the 50s: https://www.youtube.com/watch?v=SJfBU_MUpI0&feature=emb_logo

In the 1980s through the 2000s, more data (from studies and other outbreaks) came out to suggest not one, but two meters would likely be more effective. So that's where we've stayed...

Fast forward to this year, a systematic review that respiratory droplets often went farther than two meters – like, much farther. Like, 8 meters.

Not only that, but some suggest COVID stays in the air for 16hours! (Though the prevalence and infectivity of these particles is debatable.)

Lots of factors can increase the distance of droplet/particle transmission and it seems that 6 feet may be a bit of an outdated blanket statement. Consider maintaining as much distance as reasonably attainable in your various social situations. Wash your hands, wear a mask, and wear eye protection.

For all you auditory learners, check out this 20min podcast by Radiolab: https://www.wnycstudios.org/podcasts/radiolab/articles/dispatch-4-six-feet

For all you visual learners, below are some fascinating shots of simulated “violent respiratory events” with and without masks, from AIP Physics of Fluids.

(For all you kinesthetic learners, just wear a mask.) 

References:

WHO: who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-publi

CEBM: https://www.cebm.net/covid-19/what-is-the-evidence-to-support-the-2-metre-social-distancing-rule-to-reduce-covid-19-transmission/

Visualizing the Effectiveness of Face Masks in Obstructing Respiratoory Jets: https://aip.scitation.org/doi/10.1063/5.0016018

Radiolab: https://www.wnycstudios.org/podcasts/radiolab/articles/dispatch-4-six-feet

Other references embedded in the the above email

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COPD and antibiotics.

Welcome back to POTD. 

The weekend has come and the weekend has gone. I know you've all been holding your breath to hear about----

A message from our sponsors:

Take a deep inhale. feel some wellness. feel the firmness of your feet on the floor. hold onto your seat.   

Exhale nice and slowly......like someone with a COPD exacerbation.

Because today we're discussing antibiotic coverage in acute COPD Exacerbations. I know you've been waiting a lung time for this one. 

Background

  • Acute COPD exacerbations (AECOPD) account for ~1.5 million ED visits annually in the ED.

  • Many physicians routinely prescribe antibiotic coverage for AECOPD

  • a 2018 review demonstrated antibiotic prescriptions given on 39% of ED visits for AECOPD between 2009-2014.

  • Due to the structural changes in the bronchi of COPD patients they are more prone to bacterial colonization (as opposed to asthmatics - which have no structural change but a reactive process)

Do guidelines exist?

  • Sure do. 

  • if the patient appears infectious (think fever) administer antibiotics. This is understandable given their risk factors and bronchial structural changes.

  • Several guidelines exist for more subtle cases, they exist as follows: (see chart below)

    • Global initiative for Chronic Obstructive Lung Disease:

      • Antibiotics should be given to

        • patients with all 3 of the following cardinal symptom

          1. increased dyspnea

          2. increased sputum volume

          3. increased sputum purulence

        • patients with 2 cardinal symptoms, if there is increased purulence

        • patients requiring noninvasive or invasive ventilation

    • American Thoracic Society/European Respiratory Society

      • hospitalized patients with chanegs in sputum characteristics

      • all patients admitted to an ICU

    • Canadian Thoracic Society

      • patients with severe purulent AECOPD

    • National Institute for Health and Clinical Excellence

      • patients with more purulent sputum

  • Basically, pay attention to that sputum. take a thorough history and discuss changes in sputum production. 

-Elly

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POTD. Pediatric Grand Round. Pediatric Fevers

Today’s Pediatric grand rounds was given by Dr. Prashant Mahajan, MH, MPH, MBA. 

  • Professor and Vice-chair of the department of Emergency Medicine; Professor of Pediatric Medicine, Division Chief of Pediatric Emergency Medicine, Professor of Pediatrics at the University of Michigan

  • For those that don’t know him- He’s really smart and has done a ton of research on febrile infants

  • and he's proposing a new model to rule out serious bacterial infections in infants <60 days old. 

TL:DR

  • Serious Bacterial Infection (SBI) can be ruled out febrile infants from 29-60 days old with a-

    • Negative UA

    • Absolute Neutrophil Count (ANC) < 4090/μg

    • Procalcitonin < 1.72 ng/m

  • This prediction rule has a

    • Sensitivity of 97.7% (95% CI, 91.3-99.6)

    • Negative predictive value of 99.6% (95% CI, 98.4-99.9)

    • Negative likelihood ratio of 0.04 (95% CI, 0.01-0.15)

    • Specificity of 60.0% (95% CI, 56.6-63.3)

  • This rule requires further validation, but has promise to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.

The longer and more detailed approach:

- 8-13% of infants <60 days with  fever have a SBI

  • ~5-8% have a UTI

  • ~1-2% have bacteremia

  • ~0.5% have meningitis

- ~500,000 febrile infants are evaluated by healthcare professionals annually

  • Missed SBIs may lead to serious complications

  • Febrile infants frequently receive invasive management including lumbar punctures, broad spectrum antibiotics, and hospitalization

  • Variation exists in the management of febrile infants <60 days

  • 90% of those 28 days or less receive lumbar puncture and admission

  • The incidence of SBIs has decreased over time

  • We need to balance hospital related complications, costs, and increases in antimicrobial resistance with the consequences of missed SBIs

- Our screening tests to assess for SBIs have holes in them

  • Physical Exam

    • Yale Observation Scores (YOS) in infants with SBI’s have similar median scores to those without SBI’s

    • I didn't know the YOS was a thing either. It's a clinical score developed on 6 behavioral domains to predict SBI’s, 

  • CBC’s are not sensitive in ruling out bacteremia or meningitis

    • WBC< 5,000 has a sensitivity of 10%, specificity of 91%

    • WBC> 15,000 has a sensitivity of 18%, specificity of 87%

  • Several of the commonly used rules for febrile infants (Philadelphia, Rochester, Boston, and Pittsburgh) were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). Additionally, several included data from LP’s an invasive procedure not required in the newly proposed rule (Boston, Phladelphia, Pittsburgh, Milwaukee.

- In this study

  • Negative UA alone ruled out an SBI in 97.6% of cases

    • Anyone hear of diapedesis? Consult Hector Vazquez for more info

  • Negative UA + ANC <4090 ruled out SBI in 99.2% of cases

  • Negative UA + ANC <4090 + PCT <1.71 ruled out SBI in 99.8% of cases

- Further validation in a cohort with more SBI’s is needed before implementation of this new rule.

The conclusion

  • Dr. Mahajan recommends using this rule in infants 29-60 days old. He currently recommends pursing your institutions’s standard of care (Full Sepsis Workup) in infants 28 days old or less  

The Article:

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725042

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