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With reopening gearing up, common sense Covid interventions are still our best bet. What's the underlying evidence?
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How do you answer tough questions with incomplete data? A large WHO-funded systemic review and meta analysis combined published and pre-print Covid data with studies on linked coronaviruses SARS and MERS. The results for proximity and infection do not surprise: keeping a physical distance of 1m in both healthcare and community settings was associated with an 82% decreased risk of infection, with some evidence of benefit for 2m or more, across 11,000 participants in 29 studies. Enclosed spaces are especially dangerous – those who shared a bedroom, bathroom, or kitchen with an infected person had a relative risk of 10x or greater in a large MERS study.
Lancet
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Evidence for mask and face coverings was deemed low quality, but the authors estimated that the equipment reduced infection risk by 85%. A sub-analysis found that N95s were more effective than other masks, which may explain why masks performed better in healthcare settings than in the community. Eye protection also helped. While we wait for more robust data, we now have a helpful baseline from which to judge new info.
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Retractions are popping up all over the place in light of the rush to print everything Covid-related possible. We apologize for including Mehra et. al's registry analysis linking hydroxychloroquine (HCQ) to possible harm when used to treat Covid-19 in our May 29th newsletter – it has subsequently been retracted. Instead note that an observational study for HCQ as Covid-19 treatment and an RCT for prophylaxis found no drug-related benefits.
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When you ask the attending what else is for breakfast
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Right idea, wrong question. The same goes for use of the aldosterone-renin ratio (ARR) to screen for primary aldosteronism: a cross-sectional study of patients across the hypertensive spectrum found that elevated aldosterone production as measured by the oral sodium suppression test exceeded prevalence expectations (22% vs. an estimated 12% in resistant / severe hypertension) and correlated with hypertension severity. The guideline-recommend ARR suffers from poor sensitivity and negative predictive value.
Annals
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When telemedicine means you don't have to put on pants
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Anything to save time. Patients with uncomplicated Gram-negative bacteremia typically receive 14 days of antibiotics, and a RCT comparing CRP-guided antibiotic therapy (stopping antibiotics when CRP decreased by 75%) to 7 or 14 days of therapy found no difference between treatments and a low rate of treatment failure. Some CRP-guided patients stopped antibiotics at day 5.
JAMA
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We stand in solidarity with nationwide protests against police brutality, systemic racism and economic injustice. Black Lives Matter. In healthcare we must do better for our patients, our communities, and ourselves.
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Race correction in spirometry
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Modern spirometry has a flagrantly racist past. Beginning with Thomas Jefferson, 'deficiencies in the pulmonary apparatus' of enslaved blacks were used to justify slavery and later push baseless theories that freedom was unhealthy. Today, race correction is standard practice in spirometry, but lung function in non-white populations remains poorly characterized. For more, see our tweetorial (crafted by @nsrosenberg) on the groundbreaking work of Lujan and DiCarlo, @LundyBraun and many others.
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For race correction in spirometry? Way too flimsy: standard lung volumes are based almost entirely on European and North American populations, and while there may be a genomic basis for lower FEV1 in some patients of African descent, current corrections (based on self-reported race) fail to account for key factors like employment, air pollution, and socioeconomic status. Important care decisions – disability benefits, preoperative clearance, diagnosis and management – hinge on accurate PFTs. To improve, we must acknowledge a racist past and work towards better representation for all populations.
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Send your interns something to look forward to
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Graduating? Make sure to sign up with with your long-term email address
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