Wednesday, April 8, 2020

SARS-CoV-2 is an Airborne Virus?




I thought I would say something more about airborne viruses. They have been a hobby of mine for some time.  The first time I heard about how easily the current coronavirus was spreading I thought “this is an airborne virus”. But then there were the usual protests. Some scientists came out and said that coronavirus requires “droplet” precautions rather than “airborne” precautions. The common definition is that droplets are large enough settle out quickly. They may touch you directly if you are close enough but a lot of what droplets do is settle on surfaces. That leads to surface contamination and spread of the virus.  Airborne viruses can travel longer distances within smaller droplets. An even more unique characteristic is that airborne viruses are released with normal expiration. No coughing, sneezing, or shouting is necessary. Just normal breathing can release airborne respiratory viruses into the air in the smallest droplet fraction.

An easy way to conceptualize airborne viral spread is to look at the distribution of particles occurring with every breath. They can range in size from 200 µm on the large end to less than 5 µm on the lower end. Experiments can be done to show how aerosols of these particle sizes spread through a room. Naturalistic experiments can also look at how these are all spread through hospitals, airplanes, and other natural settings. By looking at those patterns and the distance involved as well as any other paths that could lead to transmission – a determination can be made about whether or not a viruses “airborne” or not.

The second issue is whether or not live infectious virus is spread by these droplets. In many cases that has been limitation in the experiments. Direct evidence of viral spread at a distance requires culture of the virus or a bioassay that shows the samples have a cytopathic (killing) effect on live cells. Indirect evidence is typically by PCR where the available nucleic acid is amplified and assayed.  In researching this topic, I found early literature that documented numerous respiratory viruses in ventilation systems of buildings. That research was possible because nobody knew how to capture and culture the virus samples until that time. The other technical issue is air sampling. Certain air sampling devices do not allow for adequate virus detection. There is a technical report recently that showed of a total of four commonly used air sampling devices only one allowed virus to be identified or cultured. These technical constraints have led to a lot of confusion about whether a particular virus is airborne or not.

A practical definition of an airborne virus is one that is exhaled during normal breathing can travel a distance in small droplets (less than 5 µm) and create infection by landing on mucosal surfaces, facial services, or the lining of the nasopharynx, oropharynx, or lungs.  In that case you don’t have to be in the presence of anyone coughing or sneezing. You don’t have to touch any contaminated surfaces. You don’t have to touch your face. You just have to breathe contaminated air. It is entirely possible that you can walk through a cloud of airborne virus and not be aware of how it got there. A common example is walking down the hallway after a crowd of people have walked through some of them carrying the virus. Once you know about airborne viruses it gives you an entirely different perspective on social distancing.  Airborne particles can easily transverse the longest dimension of typical rooms. The distance of 6 feet suggested in typical social distancing guidelines is not nearly far enough.

In a previous post I highlighted an experiment by Donald K. Milton where he designed a machine to sample flu viruses in a natural setting. Research subjects breathed normally and their expired air was sampled for influenza virus. Influenza virus was recovered from 89% of the nasopharyngeal swabs and 39% of the fine aerosol sample defined as droplets less than or equal to 5 µm and greater than 0.05 µm. There was no coughing or sneezing during the collection.. That is proof that influenza virus is airborne.

A recent experiment carried out at the University of Nebraska Medical Center (3) in their bio containment and quarantine units showed that in addition to abundant surface contamination by SARS-CoV-2 the virus was also present in hallway air samples, in areas where only aerosol deposits could reach, and personal air samplers carried by staff.  The virus was detected by PCR analysis as well as culture in some cases. The authors concluded that this was definite evidence of an airborne virus and that facilities treating patients with SARS-CoV-2 should use airborne precautions. This paper is currently undergoing peer review and is on a preprint server.

The technical aspects of aerosol fractionation and dispersion is a subject best addressed in the engineering literature. The best paper I could find on the subject (4) had a goal of studying the dispersion characteristics of exhaled droplets in a ventilated room. The engineering goals are to find out what physical parameters affect the dispersion rate and hopefully lead to better indoor environments. The experimental paradigm looked at a room that was 5 x 4 x 3 m (L x W x H) and ventilated by a downward airflow from the ceiling. Aerosols were injected into this room and the following distance and trajectory along with trajectory time was calculated for the fractional droplets. As expected droplets with larger diameters (110-115 µm) fell at a faster rate and traveled a much shorter distance than the smaller diameter fraction. Droplet dispersion was studied under a number of physical conditions including different airflow, different temperatures, different relative humidity, and the original exhaled initial velocity.

The 0.1, 1.0, and 10 µm droplets covered horizontal distance of 5 m or the entire length of the room. Droplets in the range of 50 to 200 µm cover distances ranging from 0.5 to 4 m.  This study has numerous excellent graphs about varying conditions and how droplets in different fractions are dispersed. The reader is referred to the original reference to review all those conditions. The bottom line for me was it is clear that airborne droplets in the 0.1 to 10 µm range are commonly seen in exhaled air and easily covered distance in this experiment of 5 m or (for Americans) 16.4 feet. That is well beyond social distancing recommendations it explains why this virus continues to spread. Within the past week I have seen clips of New Yorkers in congested subway cars.  Any asymptomatic SARS-CoV-2 carriers in those cars are expelling virus into the air just by tidal volume breathing.  Coughing and sneezing is not required. It would be very good if you covered your cough or sneeze but when your mouth is not covered and you are a symptomatic or asymptomatic carrier you are exhaling viral particles.


The relevance of this virus being airborne cannot be underestimated. It is the real reason behind social distancing and stay-at-home orders. It is the reason for the new recommendation to wear masks in public and the various explanations being given for those masks. The absolute best approach is to not have any close social contact until this pandemic is over. I am very concerned about my colleagues and fellow healthcare workers who have inadequate personal protective equipment (PPE). The expectation is that they will continue to take care of the very ill patients with COVID-19. Every effort must be made to make sure they have adequate protection. 

In my particular specialty, all psychiatrists should have access to electronic interviewing at this point. As I pointed out in my earlier posts, I am used to talking people for 30 to 60 minutes at time. Some of those evaluations are 90 minutes in duration. During that time the patient may be coughing or sneezing but for the most part they are breathing and engaged in normal interview conversation. My office is smaller than the room described in the droplet dispersion experiment. By the end of one interview, the smallest fraction of exhaled droplets is dispersed throughout the room. Any viral particles in that fraction can lead to infection.

All health care workers in these environments need immediate protection by the implementation of airborne precautions. I am hopeful that as more people become aware of the airborne route of transmission that it will lead to more caution on the part of the public and the social distancing and staying at home and away from this kind of transmission will make more sense. In the future we need to design indoor environments that can minimize this type of transmission. There is too little innovation in the role of the physical environment in airborne transmission of infectious illness.

I hope the added cost will be looked at in terms of the total cost of illnesses caused by respiratory viruses every year with the recognition that they can still cause devastating pandemics.

George Dawson, MD, DFAPA


References:


1: Lei H, Li Y, Xiao S, Lin CH, Norris SL, Wei D, Hu Z, Ji S. Routes of transmission of influenza A H1N1, SARS CoV, and norovirus in air cabin: Comparative analyses. Indoor Air. 2018 May;28(3):394-403. doi: 10.1111/ina.12445. Epub 2018 Jan 6. PubMed PMID: 29244221. 

2: Yu IT, Li Y, Wong TW, Tam W, Chan AT, Lee JH, Leung DY, Ho T. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med. 2004 Apr 22;350(17):1731-9. PubMed PMID: 15102999.

3: Santarpia et al. (2020) Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. Retrieved from https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2.

4: Chen C, Zhao B. Some questions on dispersion of human exhaled droplets in ventilation room: answers from numerical investigation. Indoor Air. 2010 Apr;20(2):95-111. doi: 10.1111/j.1600-0668.2009.00626.x. Epub 2009 Sep 24. PubMed PMID: 20002792.

5: Li, Y., Huang, X., Yu, I.T.S., Wong, T.W. and Qian, H. (2005), Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong. Indoor Air, 15: 83-95. doi:10.1111/j.1600-0668.2004.00317.x

6: Carl Heneghan, Jon Brassey, Tom Jefferson. SARS-CoV-2 viral load and the severity of COVID-19.  March 26, 2020.  Link

7:  National Research Council 2020. Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020). Washington, DC: The National Academies Press. https://doi.org/10.17226/25769.

8: Pan M, Bonny TS, Loeb J, Jiang X, Lednicky JA, Eiguren-Fernandez A, Hering S, Fan ZH, Wu CY. Collection of Viable Aerosolized Influenza Virus and Other Respiratory Viruses in a Student Health Care Center through Water-Based Condensation Growth. mSphere. 2017 Oct 11;2(5). pii: e00251-17. doi: 10.1128/mSphere.00251-17. eCollection 2017 Sep-Oct. PubMed PMID: 29034325.





Graphics Credit:

Graphic is from Shutterstock per their standard agreement.
























Sunday, April 5, 2020

Acute-Care Psychiatry During the Pandemic




in the early days of this century, I spent a lot of time in Avian Influenza Task Force meetings. I was on two separate task forces and at the same time working on an acute care inpatient psychiatric unit. One of the meetings took up four hours in the afternoon and I would have to go back to my unit and make up those four hours. I made the mistake of that not saving all the documentation from those meetings. There were hundreds of pages. The main focus of one task force was on “surge suppression” or helping with crowd control to prevent emergency departments from being overwhelmed by people who did not really have the viral infection. The other meeting was more about the actual response to the viral infection. I was always skeptical of what I heard. We kept hearing that if there was an epicenter of infection, large pallets of Tamiflu would be on the way. We saw presentations with pictures of those pallets under plastic wrap. At the same time there was discussion about morgues and refrigerated trucks that have become part of the current crisis.

I was more concerned about what would happen to inpatient psychiatry units. I kept hearing that the medical and surgical beds would be overwhelmed. When I suggested that we increase the capacity of negative airflow rooms and rooms vented directly to outside air, I was told that was impossible. One expert gave the opinion that if there is an airborne virus in the hospital: “The minute you walk into the hospital you should be wearing an N95 mask”.

That was about 2005 and I had never heard of an N95 mask before that. I had certainly worn masks for painting, dust protection, and various chemical and biological experiments that I did in the course of education and research. I went out and bought a small package of N95 masks. I fitted them per the instructions and noticed a couple of things. The fit was extremely snug due to upper and lower elastic bands (that have a much smaller circumference than a human head or neck), the circular contour of the mask providing a suction fit to some extent, and a flexible metal band that bends over the bridge of the nose to effectively seal that area. When you are wearing an N95 mask your voice is muted and you are breathing against resistance. If you wear it long enough, it becomes soaked with exhaled droplets. I rapidly concluded that it would be nearly impossible to conduct a psychiatric interview wearing this mask.

I never really learned at the time whether there was a plan to shut down inpatient psychiatry and use all the beds for avian influenza patients. Thankfully it never got to that point. Flashing forward 15 years a real pandemic is upon us and the problems remain unsolved. Inpatient psychiatric units and residential drug and alcohol treatment units are considered necessary services in most states and they remain open. Very recent information from the authorities now suggest that SARS-CoV-2, the virus causing COVID-19 is airborne and that there are a significant number of asymptomatic carriers.

I have been using telepsychiatry at this point for two weeks and it seems to be going well. There are definite constraints compared with face-to-face interviews. I have noticed more constraints since my original post on this topic. I put a couple of questions out there on social media today to see how my colleagues who are still actively engaged in acute care are adapting to the changing parameters of this pandemic. Before putting those questions out, I had the thought that telepsychiatry could be used over the short distances in inpatient settings. As a resident I had the experience of observing psychotherapy firsthand and being observed from adjacent rooms that also had microphones for communication between those rooms. I was interested in seeing whether or not anyone had implemented those solutions.  I was pleased with the feedback that I have so far.

One of the first responses was that psychiatric staff were using surgical facemasks and face shields in some settings. In other settings, adjacent rooms and telepsychiatry both on-site and off-site were being used for acute-care units. The most unique solution I heard of was a consultation liaison team using iPads to interview medical and surgical patients remotely where possible. That reminded me that some people have joined my telepsychiatry sessions using smart phone apps. It was generally very suboptimal if the phone was not completely stabilized.  I also had the experience this week of getting a link sent to me from a colleague who worked for a large healthcare system. It was an invitation to open up a video session with him even though I am not registered in his clinic.  It was very similar to a Zoom session that I did for a podcast. All this information shows that there are technologies available right now that are effective and actively being used. They have also been very rapidly deployed or are in the process of being deployed. There is some potential that this sudden change in the delivery of psychiatric services may be a more permanent one.

I asked the question about whether or not the services were saving personal protective equipment (PPE). The response to that question was somewhat mixed. I am not clear on what it means but speculate that some of the staff still need to have direct patient contact at some point during the day. Most acute-care staff at this point have been assigned PPE. The PPE specifics seem to vary from place to place but it is clearly rationed. If I was designing a survey of acute-care psychiatric facilities I would like to see the specifics of how many people had N95 masks and other kinds of protective gear.

Preadmission screening remains a question mark.  There is general agreement that there is an asymptomatic carrier state for SARS-CoV-2 (1,2).  Carriers may have a lower viral load and be partially symptomatic. Most people admitted to inpatient psychiatric units these days require intensive nursing care for their own safety. If there were environments where patients with COVID-19 could be safely segregated and treated that would be ideal, but I doubt those kinds of environments exist on inpatient psychiatric units. Even then the asymptomatic carriers would require the same psychosocial interventions as non-carriers.  The general screening done is to ask about contact with known cases and daily temperatures. I am not aware of any screening procedures that involve trying to identify the virus and carrier state.

My overriding concern is that medical and psychiatric staff everywhere have adequate protection. We have known since my days on the avian influenza task forces that airborne viruses are difficult to contain. They can infect through surface contamination, droplet contamination, and traveling on air currents. Working to cancel all those routes of infection is a tall order especially on an inpatient psychiatric unit.

The only practical way to maintain the level of communication necessary and minimize risk of infection is through some type of electronic communication. Some of the early methods have been listed in this post. Having worked in these settings for a large part of my adult life I am very concerned about the staff with daily direct patient contact including nursing, nursing assistants, and occupational therapy.  Housekeeping staff also have a vital role and are directly exposed to most contaminated surfaces. I have seen large numbers of inpatient staff come down with seasonal respiratory viruses and I know that vulnerability is there. They all need PPE. We need additional innovation in these settings to protect all staff and patients.  

And we have needed that innovation for a long time.


George Dawson, MD, DFAPA




References:


1: Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, Ko WC, Hsueh PR. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012. [Epub ahead of print] Review. PubMed PMID: 32173241.

2: 1: Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H, Chen W, Lin Y, Zheng Y, Wang J,Hu Z, Yi Y, Shen H. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 Mar 4. doi: 10.1007/s11427-020-1661-4. [Epub ahead of print] PubMed PMID: 32146694.

Supplementary 1:

I am very interested in what you are doing at your facility to contain this virus while continuing to go to work every day and treat patients.  I am also very interested in whether you have enough PPE.  I am interested in hearing from everybody staff psychiatrists, residents, social workers, occupational therapists, nurses, nursing assistants, and housekeeping staff.  Please post in the comments section below and feel free to remain anonymous. 


Graphic Credit:

Shutterstock per their standard agreement.






Monday, March 23, 2020

Telepsychiatry - Day One





These are strange times.

For the past several years I have attended seminars on telepsychiatry. In Minnesota, we have an expert who has been doing it for a long time. He talks about the advantages of being an independent practitioner and using your own equipment rather than being a subcontractor. He has a definite method that includes seeing all of his patients in person at least once a year. His practice covers a large area that would otherwise probably not have a lot of psychiatric services. Over the years that I have been going to the seminars, I have thought about private practice and Telepsychiatry. I even looked at a storefront building at a shopping mall and fantasized about starting it up. But I am too close to retirement and there is a thing called tail coverage. That means if you carry malpractice insurance and retire you need to still pay the premium for two or three years into retirement in the event that you are sued.  That was a major deterrent and it seemed like I would just carry on in my current position until I decided to quit. And then the coronavirus and social isolation hit.

The transition to Telepsychiatry rapidly happened last Thursday. I was going about my day when my younger colleague told me that she was switching to Telepsychiatry this week. She encouraged me to get on board. Several people were critical to the effort and I was up to speed on the system by this weekend. I had to confirm that I had the computer power, bandwidth, and dropped frame rate consistent with software. I pulled up my schedule this morning and the main difference I was sitting at home looking at it on my big Mac Pro. I tested the camera and microphone. It produced a good image of me sitting in my home office and I was ready to go. What followed was a big glitch and some realizations about the visual aspects of psychiatry.

An initial series of emails let me know that the visual feed was not working. That essentially took out the software and as a replacement I was supposed to do telephone interviews. Hoping that they could get it up and running I moved the first patient new evaluation to the last slot in the daytime. There was some suggestion that only follow-ups should be seen as telephone interviews. I was concerned that patients would have to hold the telephone receiver for 45 to 60 minutes but was reassured that it would all happen over speakerphone. The locations were all secure and managed by our clinical administrator. When it became apparent that the visual feed would not occur I started doing new assessments and follow-ups strictly on the telephone.

In retrospect I found myself myself in an ironic position. For years I studied telephone switching both as a high-tech investor and as electronics hobbyist. I eventually got involved in communications theory. The engineering version of communications theory is highly technical and interesting but I have never been able to apply it to the clinical interview. The clinical interview is an exchange of information. There is always a certain noise level that varies significantly from person to person. That noise can occur strictly on the information being exchanged or various emotional levels that can add or subtract from the overall noise level. A good example would be a person who brings a lot of biases into the interview. As an example, I have had people slow the interview down or bring it to a halt just based on my physical appearance and how it was interpreted. Some of those people would be very explicit in telling me they could only work with a psychiatrist who had a certain religion, philosophical bent, or political affiliation. There was often speculation, that I did not meet the preferred categories. Interviews done without the visual channel, removed those factors.

I dictate all my valuations and follow-ups and have done that most of my career. Critical parts of what has become known as the Mental Status Exam are dependent visual assessment. A few examples of common bullet points include:

Appearance: I comment on whether the person appears to be alert, interactive, their overall grooming and hygiene, their eye contact and social demeanor. Where it applies I also comment on whether they appear to be intoxicated, distracted, potentially delirious, and in some situations whether they realize I am in the room with them.

Psychomotor: Hyperkinetic and hypokinetic movements and possible movement disorders need to be described. Psychomotor agitation and retardation as well as motor restlessness also need to be commented on. It is about a 40 foot walk to my office and the person’s gait also needs to be described.  Gait analysis is useful because of the association with dementias, neurological disorders, and medication side effects. It is also useful in assessing chronic pain patients. The commonest acute pain disorder I notice is gout due to its high prevalence in men of all ages. Specific movements require additional examination in some cases rating scales. For example if tardive dyskinesia is noted and AIMS (Abnormal Involuntary Movement Scale) can be done to determine a baseline score. There are additional rating scales for Parkinson’s, akathisia, tics, and dystonia.

Affect: Psychopathologists like Sims have pointed out the subtle differences between affect and mood. In his text for example he describes affect as “differentiated specific feelings directed toward objects”. Mood is described as “a more prolonged prevailing state or disposition”. He comments that both terms are used “more or less interchangeably”. Modern use is much more basic and it has to do with direct observation of the patient’s emotional expression, the specific context, and whether or not it may be consistent with an underlying phasic mood disturbance.  A common error I notice in many descriptions is that the time domain is omitted - people never seem to comment on the affective state over the course of the interview or the fact that the patient's affect appears to be completely normal - despite the assessment being done for a mood or anxiety disorder.

If you are interviewing people by telephone rather than Telepsychiatry, you don’t have access to any of those three critical domains as well as other parameters that might be important. For example, vital signs, focal physical examination, and the overall determination about whether or not a patient may be physically ill or critically ill just based on their appearance.  There is also a pattern matching aspect to psychiatric diagnosis. After psychiatrist has evaluated hundreds or thousands of patients, certain patterns are evident that can facilitate diagnosis. The most obvious one is delirium. It has always been a mystery to me why that diagnosis is so difficult for a lot of people to make. Once you have seen a few delirious people, the pattern seems obvious. Other findings are much more subtle. An example might be a patient appears to be in pain but also does not want to disclose the source of that pain. It could be a self-inflicted injury or injury from intimate partner violence. Those findings would be very difficult to pick up over a telephone interview.

A couple of examples come to mind when I think of critically ill patients who did not come to see me because they were critically ill. The first was a patient who looked the whitest I had ever seen a person. I asked him if he was physically ill and he denied it. I asked him about possible causes of blood loss and that was also denied. He did eventually allow me to order a complete blood count. I got the results back his hemoglobin was extremely low and when I called him - he did acknowledged some symptoms of G.I. blood loss and agreed to go to the emergency department. He was subsequently found to have a gastric ulcer. In another case I was talking with the patient appeared to be physically ill. He seemed to have some abdominal distress. He allowed for a limited exam of his abdomen and appeared to have right upper quadrant pain and tenderness. He was also referred to the emergency department and had acute cholecystitis and required surgery. Both of these scenarios depend on how the patient actually looks to the psychiatrist and that is why the visual presentation is so important.

Many people think that psychiatry is an exchange of words. A common myth these days is that these words allow people to be grouped into diagnoses based on other sentences and phrases. A discussion between two people is always much more than that. When a psychiatrist is in the room the discussion is between two people one of whom has memories of tens of thousands of important patterns and findings that mean something. A significant number of those patterns are visual rather than strictly verbal.

I have lost count about how many times a rapid visual diagnosis played a critical part in the diagnostic process. When I see a patient with serotonin syndrome or neuroleptic malignant syndrome or malignant catatonia - I am not running down the diagnostic criteria in my head. I am thinking that they are critically ill probably have a specific diagnosis - but I have to get them somewhere fast where they can receive the necessary supportive care while that diagnosis is clarified and treated. Most of that is a visual process based on what I have seen in the past. In most cases, the diagnosis occurs in seconds to minutes.

I thought the telephone interviews went well. My notetaking was as intense as ever. I am looking at an average of about six pages of handwritten notes that I base my dictations on. But I know the process can be much better. Telepsychiatry is superior to telephone psychiatry, and I hope to find out how close it is to a face-to-face interview.

Hopefully that visual feed will be there tomorrow.


George Dawson, MD, DFAPA







Sunday, March 22, 2020

How To Survive Social Distancing If You Are An Exercise Fanatic





This is an interesting topic from a personal, practical, and consciousness level. I came by some of this knowledge the hard way and hope to pass that along to people who can benefit from it. I also hope to reach the people that are thinking right now “I can make the best of staying at home by only eating between 2 PM and 9 PM, increasing my resistance workouts, and doing more intervals or HIIT (high-intensity interval training)”.  You might be able to but there are some precautions along the way.

A couple of high points from my experience. About 10 years ago, I was out on the local speedskating track. I had just started warming up and noticed my heart rate monitor was at 160 bpm. I did not see that is being out of the ordinary and after another couple of laps my monitor started chirping away. The display read 240 bpm. There was also a warning light. I checked my carotid pulse and sure enough I was in atrial fibrillation. That began a 10-year saga of cardiac ultrasounds, stress tests, episodes of anticoagulation, cardioversion, and antiarrhythmic therapy. The ultimate diagnosis was lone atrial fibrillation. In other words, atrial fibrillation from no known structural cause. The likely cause was long periods of time of running my heart rate way beyond the maximum recommended heart rate for a guy my age.

Even before that I was out speedskating on the roads when I went down and ended up with a large abrasion over my left lateral thigh. My first thought was whether I should cover it with something. It was a clean abrasion that I had washed thoroughly and immediately and it looked good.  Over the next several days it no longer looked good and was clearly infected. In the emergency department was given an intramuscular injection of cephalexin with a number of capsules to take home.

Both of these scenarios highlight the fact that exercise related injury can lead to treatment in the ED (emergency department). During the time of a pandemic you do not want to end up in an emergency department. So the first lesson here is to avoid extremes and also high risk scenarios where you could end up with an abrasion, a cut, head trauma, fracture, a sprain, or any other sports injury that needs acute medical attention. I think there are practical ways around that but it also takes addressing the exercise fanatic mindset.

1.  Avoid the gym:

I can only speak for what happens in the men’s locker room but hygiene at the gyms I have been in is atrocious. It is the primary reason I stopped going to gyms even though my wife encourages me to go to her gym on a regular basis. There is also the problem of risky behavior. I got tired of seeing personal trainers trying to kill novices with some absurd exercise routine, the roid rage folks threatening one another, and having to intervene in order to prevent serious injury. You can only advise that teenager with a loaded barbell resting on his cervical spine that it is not a good idea so many times, before you get known as the old white guy who is a know-it-all.  Luckily many governors and mayors have shut these facilities down as a transmission risk.

2.  Maintenance not maxing out:

Most exercise fanatics collect a lot of data on their favorite exercise routines. You can certainly do it with smart phones and activity monitors these days but a lot of us also automatically keep track of reps, times, and maximums. For example on a day-to-day basis I can predict my maximum number of push-ups, pull-ups, back extensions, bicep curls, max power output on my ergometer, and max road speed on a bike. When you think like an exercise fanatic, you are always thinking about how to maximize those numbers. That also happens to be the periods of likely injury. I naturally hit a wall at about age 55. Up to that point I thought it was indestructible in terms of exercise tolerance. After that point, I questioned why I had been so foolish and not adhered to some basic rules like maximum heart rate.  First and foremost don’t push it like you are 20 when you are 40 or 50. Secondly, don’t push it to high age-appropriate levels when there emergency services are limited by a pandemic and you don't want to be an additional burden on that resource.

3. Avoid the typical Internet suggestions:

During this period of social isolation there are any number of exercise sites advising you on how to stay fit outside of the gym. They range from exercises that focus on specific body regions to replacing exercise equipment with everyday household items. Keep in mind that doing reps with a gallon of milk or a can of paint is not like using that Cybex machine at the gym. The biomechanics are completely different and even the grip can result in injury. Don’t take innovation too far when it comes to exercises that you are used to doing in a specific range of motion on well-designed equipment. Even mimicking that young aerobics instructor video and she does various leg extensions can be a problem. Start out with very few repetitions to make sure it is safe before you try the whole workout.  Even then there are exercise that are not appropriate for certain ages or injury patterns. Many athletes have learned this over a number of years from their physical therapist. Don't ever ignore the advice of a physical therapist. 

4. Stop immediately if you are hurt; don’t exercise until the pain is long gone.  If it doesn’t go you need an assessment.

Repetitive stress and overuse injuries are common with aging and you have to overcome the propaganda that you heard in high school or your early 20s that all you have to do is “shake it off” or that pain is somehow therapeutic. I first noticed significant knee pain when I had to carry a floor sander up three flights of stairs. It weighed about 250 pounds. I remember thinking as I went up that stairway: “It feels like my knees are going to blow out at any time”. I was about forty years old. By paying close attention to that feeling I have been able to preserve my knees for another 25 years. During that time they have served me well with thousands of miles of cycling and speedskating. I pay close attention to that joint stress perception when I am weightlifting or even doing push-ups or pull-ups. I plan to avoid any of those situations during the pandemic social isolation.

These are a few tips to avoid injury and needing medical care during a pandemic. To most people they are obvious. To exercise fanatics they may not be.  Being an exercise fanatic is an interesting conscious state. Reality testing is intact to a large extent. As an example I would never think that I could skate in the Olympics or cycle in the Tour de France. At the same time my personal goals were probably unrealistic for men my age and yet I reached many of them. The part of my reality testing that was not intact involved the basic denial of the aging human organism. For example, I recognized in a nick of time that my spine could probably not tolerate lifting large amounts of weight anymore. As we age, intervertebral discs degenerate and in many cases disappear. Osteophytes form. The old human spine is a lot less stable then the young human spine. That has implications for maximum load whether that load is a stack of weights or running.

I used to think that men were particularly prone to the exercise fanatic mindset but since then I have encountered many women with the same biases. A significant number of them continued to exercise when they were injured and ended up with permanent disabilities. Women may be more likely to be told that their exercise is “an addiction” because of the over exercising associated with an eating disorder diagnoses. They have that bias to live with that men generally do not.

Stay fit during this time by staying with what you know, taking it easy, and avoiding injury. If you are an exercise fanatic this is the wrong time to be pushing your limits - and you might ask yourself if there is ever a right time.  Even as a novice it is the wrong time to jump into a rigorous program because there is somebody selling it on the Internet and it looks good.


George Dawson, MD, DFAPA





Monday, March 16, 2020

The First Case Report - Implications For Coronavirus Conspiracy Theories



At the time of this writing I have encountered at least three coronavirus conspiracy theories.  The American version goes something like this. The current pandemic resulted from a leak from a Chinese bioweapons laboratory. The supplementary information generally talks about how these particular bioweapons labs are not very secure and leaks are common. The Chinese version has a human twist and it involves a visit to China by 300 US military athletes. The suggestion is that these athletes intentionally introduced the virus or inadvertently passed the virus to the Chinese population. There is an Iranian version - suggesting that the virus is basically an American bioweapon.  There are various embellishments. Prominent politicians are involved in restating these conspiracy theories. I have been reading about bioterrorism for the past 20 years and would dismiss these theories as being implausible from a technical perspective. From a political perspective, it makes perfect sense to me that politicians will always try to look for a way to deflect any responsibility. One of the most common ways to do that is to blame an adversary - especially one that might be unpopular with the majority of citizens.

The report of the first case of coronavirus in the US is a rare opportunity to end all the conspiracy theories with real evidence. I do realize that conspiracy theories are not generally refutable by facts.  This post is directed at those who can incorporate factual information into their worldview. There has been a lot written lately about distinguishing opinion from fact, including the results of a standardized international test suggesting that American students may have some deficits in this area.

Detailed case report in the New England Journal of Medicine is interesting from a number of perspectives.  The patient is a 35-year-old man walked into an urgent care in Snohomish County, Washington on January 19, 2020 the four-day history of cough and “objective fever”. He had returned from visiting relatives in Wuhan, China. His health history was basically unremarkable. Initial vital signs showed a temp of 37.2°C, BP of 134/87, and pulse was 110 bpm. Restaurant rate was 16 breaths per minute and O2 sat was 96% on room air.  Initial viral screen for influenza a and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and for common coronaviruses was negative. The CDC was contacted and samples were collected for 2019-nCoV. The virus was confirmed one day later.

The patient had been discharged home but after 2019-nCoV was confirmed he was admitted to an airborne isolation unit for observation. The clinical course is described in the figure below that is taken from the original paper (with permission). The symptom course before the admission date of January 20 is estimated on the diagram. I think it is instructive to note that cough preceded the development of a low-grade fever on day five of 37.9°C or 100.2°F. The patient also had fatigue nausea and vomiting before the development of fever.



Laboratory findings over the course of the illness are presented in the original article and six blood samples did not show any marked abnormalities. He had mild elevations of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase. Blood tests were done due to fevers and they showed no growth.  Chest x-ray on day 9 of the illness showed left lower lobe pneumonia that correlated with decreased O2 sat down to 90%. At that time he was put on supplemental oxygen. It is also treated with vancomycin and cefepime for presumed hospital acquired pneumonia. On day 10, based on his chest x-ray, the need for supplemental oxygen, and reports of the development of severe pneumonia is physicians decided to treat him with an investigational drug - remdesivir. By day 12 he was clinically improved and no longer needed supplemental oxygen. His oxygen saturations were normal on room air. As seen in the diagram, is always symptoms at the time were a cough and rhinorrhea.

Contrary to the conspiracy theories, this paper points out that the Chinese researchers shared the full genetic sequence of the 2019-nCoV in the National Institutes of Health GenBank Database and the Global Initiative on Sharing All Influenza Data (GISAID) database. 

The authors emphasize at the time of this writing that the full spectrum of clinical disease is undetermined. Transmission dynamics are also undetermined because the patient had not visited the seafood market in Wuhan or had any contacts with known cases in China. They list several complications noted in the Chinese population including acute respiratory distress syndrome, severe pneumonia, respiratory failure, and cardiac injury. There are several radiographs on Twitter suggestive of significant lung injury and at least one report of myocarditis in a significant subset of patients. The authors also point out that the patient is nonspecific symptoms prior to the onset of pneumonia were consistent with the number of common respiratory viruses. In differentiating this illness travel history, the decision by the patient to seek treatment, and a coordinated effort among public health officials led to the timely identification of the virus. I would add that this case report also shows the clear need for clinical expertise as the illness transforms from what appears to be a typical respiratory virus to pneumonia. The question that needs to be asked is whether that level of expertise is available everywhere in the country.

Addressing the threat of emerging infectious diseases requires a public health infrastructure and cooperation across many countries with their own political interests. Many those countries may have public health officials that are cooperating with one another, but politicians who may decide to use a pandemic for their own interests. With most countries engaged in significant quarantine efforts at this time, clear cooperation among world leaders in stopping this pandemic is urgently needed.

George Dawson, MD, DFAPA



References:

1: Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, Spitters C, Ericson K, Wilkerson S, Tural A, Diaz G, Cohn A, Fox L, Patel A, Gerber SI, Kim L, Tong S, Lu X, Lindstrom S, Pallansch MA, Weldon WC, Biggs HM, Uyeki TM, Pillai SK; Washington State 2019-nCoV Case Investigation Team. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020 Mar 5;382(10):929-936. doi: 10.1056/NEJMoa2001191. Epub 2020 Jan 31. PubMed PMID: 32004427.



Permission:

Figure 2 above is from the original article in reference 1 - with permission from the Massachusetts Medical Society.  License date is March 16, 2020 - license number is 4791120888948 for 12 months from the date of the license. 


Saturday, March 14, 2020

The Pandemic Report From Beam Avenue





It was my day off yesterday but I have been looking at a “need maintenance” light for the past four days. I had to leave the house for car maintenance. Given the pandemic status this would be a whole new trip. Even though Minnesota does not have a lot of cases at this time, they are increasing and there is an identified COVID-19 case in a town 5 miles away and a neighbor four houses away with direct exposure to coronavirus in the workplace. My secondary goal during this trip was to take a look at social distancing and the other practical suggestions to contain the spread of this virus.

Beam Avenue is a busy thoroughfare that connects Highway 61 on the west and White Bear Avenue on the east. My Toyota dealer is on the west end of Beam Avenue and 1.5 miles away a popular shopping mall sits on the corner of Beam Avenue and White Bear Avenue. St. Johns Hospital is about half way down and the photo was shot from the sidewalk. Average vehicle traffic in this area is about 17 to 18,000 vehicles per day.

I don’t generally set up appointments for vehicle maintenance. I wait until the light goes off and then I typically drive in and wait. Even though the wait takes 1 to 2 hours, the accommodations for customers at this dealership are excellent. A comfortable waiting area, free cookies, and free coffee. This waiting area is generally very congested due to the high levels of work done at this dealership. It was going to be a challenge to see if social distancing was possible or not.

I pulled into the service area and was greeted by one of the service managers. He took me over to his desk and we started going through all the details. I told him I needed a new battery in my starter fob. He took it from me, pried open, installed the new battery, blew the dust out of both halves of the fob with his own breath, snapped it together, and handed it back to me. We talked about the purpose of this visit specifically oil change and tire rotation. He offered to sell me a new service plan but I told him I was thinking of trading in my current RAV4 for a new one. He asked me what my timeframe was and I told him:

“I want to see this coronavirus thing pans out.”  He smiled at that.

After deciding the course of action he told me it might take one to two hours and I headed into the customer waiting area. I have probably seen more customers there at other times but it was packed, everyone was eating cookies and drinking coffee, and there were few open seats. There are study carrels along one wall. That is where I typically sit and do computer work while I wait. I decided it was a bad idea because there is no expectation that these surfaces would be sanitized. The same would be true of the padded and more comfortable seating in the middle of the waiting area. Appropriate social distancing was not evident and in fact I counted 16 people in the service area that were probably within a 10 foot radius of me. I decided it was a good time for a walk.

Beam Avenue is not the ultimate walking course. There are numerous pedestrian crossings just to get to the main sidewalk on the north side. Several large businesses have entrances across that sidewalk. It was an opportunity to see how many motorists never stop or even slow down when making a right-hand turn at a red light or stop sign. Costco motorists seemed more prone to that maneuver. The problem with the walkway is the intensity of traffic and the associated noise and exhaust fumes. That might explain why during the entire 3 mile walk I did not encounter a single fellow pedestrian. The traffic at 3 o’clock on Friday afternoon was as intense as I have ever seen it.

I got to the mall and walked through the main entrance. All the entrances and exits to the mall had pneumatic sliding doors and that is clearly a plus in terms of virus transmission. As I walked further into the mall those benefits seem to diminish. I came across children who were swarming all over free plastic playground equipment. I also saw kids jammed into moving seats wearing some kind of virtual reality goggles that appeared to be simulating a Star Wars battle. I did not inspect all of this equipment but hand sanitizers were not apparent. The kids all looked like they were having fun - it is probably hard to think about social distancing when you are a parent of young children.

When I got to the food court I was surprised that the tables had been thinned out. It looked like there was about a 60% reduction in the total number. As a result there was roughly 10 to 12 feet between most of the tables-the suggested social distancing interval. The other notable change was that even with fewer tables, there was hardly anybody eating at the food court. There was one long line of what appeared to be high school students who had not been seated. There is also visible housekeeping staff with sanitation equipment and they appear to be interested primarily in the food court area.

The men’s room was disappointing. With all the emphasis on handwashing there should be an expectation that any facility will be adequate for that task. In the men’s room, 40% of the soap dispensers and 60% of the faucets were not working. One of the faucets was totally gone. There was a paper towel dispenser that was empty and two air hand dryers. I had time to discover that I needed to go from sink to sink but if there was any crowding - I am sure it would affect the number of people adequately washing their hands. I headed out the door and back to the Toyota dealer.

When I got back - social distancing remained a problem. The service manager met me in the cashier line and reviewed all of the billing. There are two cashiers with six people in two lines and we were all about 1 foot apart. Nobody was coughing or sneezing. I was able to pay and leave in about five minutes.

On the way home I had to pick up some milk and bread and stopped at one of the major grocery store chains in the Twin Cities. The parking lot was packed. I decided to shop without a cart and avoid any cart contamination. There were hundreds of people in the store many of them very old. The store was well-stocked and the only thing that was missing was the toilet paper and paper toweling. A woman in front of me laughed very loudly when she turned the corner and saw that there was about a 50-foot section of shelving completely empty where these paper items had been. I grabbed the milk and bread and headed to the self-checkout line. Six people in line again to get to the touchscreen checkout computer. I checked out got in my car and used a liberal amount of hand sanitizer. I had also used outdoor gloves to negotiate doorways at the car dealership.

On the final drive home, I was thinking about how social distancing was absent in most of the scenarios I encountered. Vehicle and foot traffic were heavy and there was plenty of congestion.  What will it take to get people to stay home and out of public spaces? Some commentators have said that inconsistent messaging is a big part of it. Declaring a pandemic a political hoax one day an actual public health emergency the next day doesn’t work. Today I read three different conspiracy theories on COVID-19 as a bio weapon that was either deliberately used by the United States or China or inadvertently escaped the Chinese bioweapons lab. None of those theories appears to be consistent with what really happened. I was watching a celebrity news program and saw a caller say that the only time he took the pandemic seriously was when he learned that Tom Hanks and Rita Wilson had contracted the virus.

I started to think about why I take it seriously. I worked on two different Avian Influenza Task Forces about 15 years ago. It was a significant effort. One of the main concerns was surge suppression or preventing emergency departments and other resources from being overwhelmed by people who thought they had the disease. There is actually a program called Psychological First Aid where mental health professionals train volunteers to counsel these people and direct them away from emergency departments. I was a trainer for this course. In our meetings there was always a vague discussion of what would actually happen in hospitals if they were overwhelmed by patients with avian influenza.  In some of those discussions we would see a PowerPoint slide of a pallet loaded with Tamiflu at some Air Force Base. We were reassured that in the event of a local epidemic- that medication would be made available. The specifics about negative pressure rooms, ventilators, workflow, and manpower requirements were never really discussed. The current strategy for coronavirus of slowing the infection rate by social distancing and quarantine was also not discussed. At some point it was apparent to me that if avian influenza pandemic occurred, we would be making it up as we went along. I had studied several of these epidemics and had concerns about surge suppression especially in a highly infectious situation.

There appear to be some common errors that are made along the way when considering that pandemics are not only possible but likely. The first one is analyzing the situation according to a particular political bias. This is a very common mistake these days even though it clearly doesn’t work. Contradictory information in addition to those political biases amplifies the problem. Independent of political bias, it takes the ability to imagine that a pandemic is possible. That approach can be historical, biological, medical or mathematical. Any one of those disciplines can provide the necessary knowledge base. There are concerns today that in the era of social media dynamics – every one is an expert at the rhetorical level. The signal of real expertise is lost in the noise of grabbing for celebrity and the associated benefits. Self-selection leads to all of the adherents of a common belief isolating themselves in one little area on the Internet. That leads to the expected cognitive biases but also the illusion that life can go on as a member of an isolated group with no role in greater society.  Pandemics directly confront that denial.

I did see some bright spots on Beam Avenue today, but not many.  Vehicle and foot traffic is heavy and social isolation is a problem in high congestion areas. If people are expected to wash their hands frequently – washrooms need frequent attention and repair. The focus on cancellation of mass sporting and entertainment events is useful, but day to day sources of possible contamination need attention – especially when there are clearly identified cases and exposures in the area.

People need to stay home unless travelling to congested areas is absolutely necessary.  It is the best way to prevent the severe measures being taken in some countries right now and get through this.


George Dawson, MD, DFAPA




Saturday, February 22, 2020

The Best Advice I Got In Medical School







It has been a long time but when you get to be an old man you can obsess about what you currently know, what you used to know, and how you got here.  I got some life-changing advice as an undergrad but not much good advice in medical school or residency. I can say without a doubt, the best advice I got was:

“If you are sure you are going into psychiatry, take as many medical electives as you can. Don’t take any psychiatry electives because you will be doing that for the rest of your life.”

I did not have to think too much about it because I enjoyed most aspects of medical education and training. The only two negative rotations I had in my training were based primarily on the staffing patterns at the time and they were not major medical or surgical rotations. They also did not seem to be very interesting. Practically all of the medical and surgical residents I worked with were outstanding in many ways. I felt like an integral part of the team and I was happy to do the necessary work.

As a result of the advice I took endocrinology, cardiology, renal medicine, allergy and immunology, neurology, infectious disease, and neurosurgery in addition to the required general medicine rotations. I took a little flak from the Dean. There was some concern that there were not that many spaces available in medical electives. At one point it was suggested that I should limit myself to two or three medical electives. I prevailed and got what I wanted largely because the specific rotations were at a public hospital and the local VA hospital. 

One of the aspects of medical training that is not discussed enough is camaraderie. When you are a medical student, your role is often ill-defined. The role generally depends on the staff you are working with, the institution, and the general culture within the medical school. At the hospitals where I spent most of my time medical students were an integral part of the team. On day one – you are assigned patients and admissions. You were expected to report on patient progress and write progress notes. You learn communicate with everybody in the hierarchy ranging from the intern to the resident to the attending physician. You are supposed to learn how to research and study the specific problems that your patients had and in some cases do a special report. Examples would include a chart review I did on gram-negative meningitis at the VA medical center and presentation on anaphylaxis on my allergy rotation at Milwaukee County Hospital. Both of those studies went extremely well.

But camaraderie is more than knowing the chain of command, hospital systems, and how to get the work done. A key component is the educational quest that everyone is on. Doing rounds with five or six different people at all levels of training ranging from novice to world expert is experience that you don’t get in many places. Some of the results can be stunning. I did a consult on a patient with possible spontaneous bacterial peritonitis (SBP). I wrote up the consult form and prepared to present to the attending physician that afternoon. When he walked in the room from about 10 feet away, he asked everyone else on the team what the problem was with the patient’s leg. I had been focused on abdominal, systemic, and laboratory findings. Nobody could answer the question. The attending physician who happened to be an expert in streptococcal infections, pointed to a rosy rash on the patient’s left shin and suggested that it was a form of streptococcal cellulitis. He did the necessary tests to confirm that diagnosis at his lab.  One of the many processes that must be attended to in these rounds is the pattern matching aspects of diagnosis. It was vaguely implicit in my training and I realized only later when teaching a course in avoiding diagnostic errors - that these rounds are the place to ask experts: “What are you seeing that nobody else is?” All experts including psychiatrists recognize certain patterns and can make more rapid and more accurate diagnoses than people outside their specialty.

A lot of people reading this may have a hard time believing that what you learned in medical school is relevant to a specialty that you practice your entire life. After all - aren’t these specialties updated at some point and doesn’t your knowledge base become dated? It is surprising how the basic approach to the patient that is unique to each specialty does not change much. There is still relevant review of systems, specialty specific diagnoses, and laboratory testing. Working with specialists for even a month gives medical students and residents a clear idea of how to approach patient problems in a systematic manner. Even though there have been radical changes in some specialties like cardiology, most medical specialties change slowly at the mechanistic level typically with some pharmacological innovation. A clear example relevant to psychiatrists is the endocrinology of metabolic syndrome and diabetes mellitus. Over the course of my career that has resulted in increasingly complex pharmacotherapy ranging from insulin, metformin, and sulfonylureas to an additional five classes of drugs and more complicated insulin preparations.

A unifying concept that I learned on all those medicine specialty rotations is that it is important to still know about these mechanisms and medications even if your specialty involves another bodily system and you are prescribing an additional treatment. No matter what specialty service I was on there was never the idea that we could focus only on a specific bodily system and ignore the rest. On all of those rotations including neurosurgery, I was often the person focused on what was going on with the patient’s brain.

Learning medicine and neurosurgery on all of these rotations was quite exciting. I am much more likely to retain information if I am excited about it. I was excited right up until 11 PM on the last day of medical school.  I was doing renal medicine at the time and the senior resident was going to be a rheumatology fellow. We finished rounding about 6 PM and he noticed we had 4 or 5 additional consults. He was the kind of guy that you really like working with. He had a great sense of humor and was always engaging. He could even engage an introvert like me. I remember him saying: “Look I know - this is your last day but you could really help us out by doing some of these these consults. The new team is coming in tomorrow and I don’t want to leave all of these consults behind.” He threw in a couple of politically incorrect jokes for good measure and I headed off to do two consults. We came back and met with the attending physician who was considerably older than I am right now and finished them all by 11 PM. I really did not want to say goodbye to that team. But I headed off by foot across the golf course sized county hospital grounds to my apartment on 89th St.

The knowledge gained in that fourth year of medical school was a springboard for the next 30 years. I continue to read about all those medical specialties and remember what happened in 1982. I continue to research all the medical problems and medicines that my patients are taking. I continue to wish at times that I was still on that renal medicine team back at Milwaukee County Hospital.

I didn’t get a lot of good advice in medical school but for all those reasons the advice about what to do in my fourth year was the best.


George Dawson, MD, DFAPA





Supplementary 1:

Second best piece of advice in med school was from the head of our Biochemistry class in the first year.  Our biochemistry class consisted of lectures and research seminars where we read and critiqued biochemistry research. At one of the first lectures, the department head stated:

"Subscribe to the New England Journal of Medicine and read it."

I have been reading it ever since and that was definitely a good idea.


Supplementary 2:

I did take one psychiatry elective in the last two years of med school - Infant Development and Psychotherapy.  It was taught by two psychiatrists who were very excited about the field Frank Johnson, MD and Jerry Dowling, MD - both Medical College of Wisconsin psychiatrists. We screened infants and very young children at risk especially if they had one or both parents with severe mental illness. We instructed parents on how to interact with their children in order to overcome behavioral difficulties associated with disruption of the infant or child and parental bond.  Every week we had a research seminar where we read relevant papers on the subject.  We had a very large clinic where we did evaluations and saw large groups of parents. It was a very positive experience and has implications to this day.  As far as I know there are no clinics in the US like the one we had in 1982.  It provided a valuable service to infants, young children, and their families.

1: Wesner D, Dowling J, Johnson F. What is maternal-infant intervention? The role of infant psychotherapy. Psychiatry. 1982 Nov;45(4):307-15. PubMed PMID: 7146225.