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Southwest Pulmonary and Critical Care Fellowships

 Editorials

Last 50 Editorials

(Most recent listed first. Click on title to be directed to the manuscript.)

A Call for Change in Healthcare Governance (Editorial & Comments)
The Decline in Professional Organization Growth Has Accompanied the
   Decline of Physician Influence on Healthcare
Hospitals, Aviation and Business
Healthcare Labor Unions-Has the Time Come?
Who Should Control Healthcare? 
Book Review: One Hundred Prayers: God's answer to prayer in a COVID
   ICU
One Example of Healthcare Misinformation
Doctor and Nurse Replacement
Combating Physician Moral Injury Requires a Change in Healthcare
   Governance
How Much Should Healthcare CEO’s, Physicians and Nurses Be Paid?
Improving Quality in Healthcare 
Not All Dying Patients Are the Same
Medical School Faculty Have Been Propping Up Academic Medical
Centers, But Now Its Squeezing Their Education and Research
   Bottom Lines
Deciding the Future of Healthcare Leadership: A Call for Undergraduate
   and Graduate Healthcare Administration Education
Time for a Change in Hospital Governance
Refunds If a Drug Doesn’t Work
Arizona Thoracic Society Supports Mandatory Vaccination of Healthcare
   Workers
Combating Morale Injury Caused by the COVID-19 Pandemic
The Best Laid Plans of Mice and Men
Clinical Care of COVID-19 Patients in a Front-line ICU
Why My Experience as a Patient Led Me to Join Osler’s Alliance
Correct Scoring of Hypopneas in Obstructive Sleep Apnea Reduces
   Cardiovascular Morbidity
Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System
Lack of Natural Scientific Ability
What the COVID-19 Pandemic Should Teach Us
Improving Testing for COVID-19 for the Rural Southwestern American Indian
   Tribes
Does the BCG Vaccine Offer Any Protection Against Coronavirus Disease
   2019?
2020 International Year of the Nurse and Midwife and International Nurses’
   Day
Who Should be Leading Healthcare for the COVID-19 Pandemic?
Why Complexity Persists in Medicine
Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del
   paciente y del publico: Unir dos idiomas (Also in English)
CMS Rule Would Kick “Problematic” Doctors Out of Medicare/Medicaid
Not-For-Profit Price Gouging
Some Clinics Are More Equal than Others
Blue Shield of California Announces Help for Independent Doctors-A
   Warning
Medicare for All-Good Idea or Political Death?
What Will Happen with the Generic Drug Companies’ Lawsuit: Lessons from
   the Tobacco Settlement
The Implications of Increasing Physician Hospital Employment
More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine. Authors are urged to contact the editor before submission.

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Thursday
Jun182020

What the COVID-19 Pandemic Should Teach Us

As I write this between telemedicine patients on June 16th, I am reflecting back on the pandemic and what we have learned so far, not in how to diagnose or care for the COVID-19 patients, but in government and healthcare administration’s response to the pandemic.

Politicians have made both good and poor decisions regarding the COVID-19 pandemic. In the summer of 2005, President George W. Bush was on vacation at his ranch in Crawford, Texas, when he began flipping through an advance reading copy of a new book about the 1918 influenza pandemic (1). He couldn't put it down. What was born was the nation's most comprehensive pandemic plan -- a playbook that included diagrams for a global early warning system, funding to develop new, rapid vaccine technology, and a robust national stockpile of critical supplies, such as face masks and ventilators. Bush’s remarks from 15 years ago still resonate. "If we wait for a pandemic to appear," he warned, "it will be too late to prepare. And one day many lives could be needlessly lost because we failed to act today."

In what will probably go down as some of the worse timing in history, the Trump administration eliminated or severely cut funding to these Bush-era programs (2). In March of 2018, Timothy Ziemer, whose job it was to lead the United States response in the event of a pandemic, abruptly left the administration and his global health security team was disbanded. In February 2020 the administration released its proposed federal budget proposal for fiscal year 2021, calling for a cut of more than $693 million at the Centers for Disease Control and Prevention, as well as a $742 million cut to programs at the Health Resources and Services Administration. Overall, the president’s budget proposed a 9% funding cut at the U.S. Department of Health and Human Services. More recently the US has pulled out of the World Health Organization with the dubious timing of being in the middle of this pandemic. In addition, Trump downplayed the pandemic from the beginning and has ignored the advice of virtually every epidemiologist encouraging “opening up” the country ignoring accelerating COVID-19 cases and death tolls (2,3).

In Arizona early in the pandemic we were doing OK with most businesses shut down and people by and large staying at home. Our clinic was closed although we continued to see telemedicine patients. However, Governor Ducey, under the apparent urging of Trump, “opened up” the state beginning May 15 resulting in an apparent resurgence of COVID-19 cases. No word from Ducey, the Arizona State Department of Health Services or Maricopa Health and Human Services on how we should respond to the resurgence. I cannot find any admission by any of the governors, and certainly not Trump, that states that prematurely “opened up” was a mistake.

Misinformation is everywhere. Everyone with a computer and no or inadequate medical education has suddenly become an expert in COVID-19. My inbox is flooded with multiple emails from people I do not know espousing their latest theories, guidelines, unproven treatments, or passing along the latest internet COVID-19 chatter.

This disinformation is potentially dangerous but the scientific community has also made mistakes. For example, a controversial study led by Didier Raoult from Marseilles on the combination of hydroxychloroquine and azithromycin for patients with COVID-19 was published March 20 (4). It showed a reduction in viral load and “clinical improvement compared to the natural progression.” This was picked by several including Trump who claimed to be taking hydroxychloroquine as a preventative. Papers purporting to show that hydroxychloroquine was ineffective were published in the New England Journal of Medicine and the Lancet. These have been retracted since the database from which they were derived was found to be unreliable (5). These studies have only added to the confusion of hydroxychloroquine’s effectiveness in COVID-19.

Government and hospitals were unprepared. In 2009, a smaller pandemic due to H1N1 swept through the United States (6). Ventilators, ICU beds, and adequate numbers of healthcare providers were in short supply despite the Bush administration’s attempt at preparedness (7). When the pandemic resolved no additional preparations were made for another and larger pandemic. Disturbingly, when the current COVID-19 pandemic occurred there were inadequate numbers of ventilators for patients and inadequate protection for healthcare workers. In some instances, personal protective equipment was not allowed to be used (8). There was no response from the federal government or hospitals. What could they do? They needed the physicians and nurses to care for the tidal wave of patients exposing the healthcare workers to COVID-19. To date about 600 healthcare workers have died during the COVID-19 pandemic and it will likely go much higher.

Healthcare hyperfinancializaton was the source for the unpreparedness. The source of this unpreparedness at both the national and local level was a desire to save money since a pandemic was viewed by decision makers as unlikely in the near future. Cutting taxes and maximizing profits were the real goals and preparation for a pandemic was not viewed as a priority especially since it interfered with the real goal of making money. We are now paying the price for these short-sighted decisions. Since the federal government has markedly increased the federal debt with a COVID-19 bailout, we will likely continue to pay the price with higher taxes and/or by cutting other government programs viewed as low priorities. Some of these programs may prove to be as potentially valuable as the trashed pandemic plan.

As a country we need to start thinking about how to approach these decisions in the future. In my view, the present system of politicians and businessmen serving as healthcare decision makers has been an abysmal failure. The COVID-19 pandemic is but one example of this failure. Clearer heads both in government and healthcare regulation such as the Joint Commission need to become more concerned that the voices of knowledgeable people such as Tony Fauci are heard. Until we develop such a system, we can anticipate healthcare to be unprepared for calamities such as the COVID-19 pandemic they occur in the future.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Mosk M. George W. Bush in 2005: 'If we wait for a pandemic to appear, it will be too late to prepare'. A book about the 1918 flu pandemic spurred the government to action. ABC News. April 5, 2020. Available at: https://abcnews.go.com/Politics/george-bush-2005-wait-pandemic-late-prepare/story?id=69979013 (accessed 6/16/20).
  2. Morris C. Trump administration budget cuts could become a major problem as coronavirus spreads. Fortune. February 26, 2020. Available at: https://fortune.com/2020/02/26/coronavirus-covid-19-cdc-budget-cuts-us-trump/ (accessed 6/16/20).
  3. Fadel L. Public health experts say many states are opening too soon to do so safely. NPR. Weekend Edition. May 9, 2020. Available at: https://www.npr.org/2020/05/09/853052174/public-health-experts-say-many-states-are-opening-too-soon-to-do-so-safely (accessed 6/16/20).
  4. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial [published online ahead of print, 2020 Mar 20]. Int J Antimicrob Agents. 2020;105949. [CrossRef] [PubMed]
  5. Gumbrecht J, Fox M. Two coronavirus studies retracted after questions emerge about data. CNN. June 4, 2020. Available at: https://www.cnn.com/2020/06/04/health/retraction-coronavirus-studies-lancet-nejm/index.html (accessed 6/16/20).
  6. CDC. 2009 H1N1 pandemic (H1N1pdm09 virus). Available at: https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html (accessed 6/16/20).
  7. WHO. Shortage of personal protective equipment endangering health workers worldwide. Available at: https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide (accessed 6/16/20).
  8. Sathya C. Why would hospitals forbid physicians and nurses from wearing masks? Sci Am. March 26, 2020. Available at: https://blogs.scientificamerican.com/observations/why-would-hospitals-forbid-physicians-and-nurses-from-wearing-masks/ (accessed 6/17/20).

Cite as: Robbins RA. What the COVID-19 pandemic should teach us. Southwest J Pulm Crit Care. 2020;20(6):192-4. doi: https://doi.org/10.13175/swjpcc042-20 PDF 

Saturday
May162020

Improving Testing for COVID-19 for the Rural Southwestern American Indian Tribes

Arshia Chhabra1

Varinn Sood2

Vanita Sood, MD3

Akshay Sood, MD, MPH4,5

 

1La Cueva High School, 7801 Wilshire Ave NE, Albuquerque, NM USA

2Albuquerque Academy, 6400 Wyoming Blvd. NE, Albuquerque, NM USA

3Andrew Weil Center for Integrative Medicine, University of Arizona, 655 N Alvernon Way, Tucson, AZ USA;

4Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM USA; 5Black Lung Program, Miners’ Colfax Medical Center, Raton, NM, USA.

 

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome-related coronavirus-2 (SARS–CoV-2) infection. The United States (US) currently has more officially reported cases and deaths from COVID-19 than any other country in the world. The rural Southwestern American Indian (SAI) tribes are disproportionately affected, due to genetics, immunological naivety, social determinants of health, and high prevalence of concomitant comorbidities and co-exposures (1). On March 30, 2020, the New Mexico Governor, Michelle Lujan Grisham, informed the US President Donald Trump of the “incredible spikes” in cases of COVID-19 within the Navajo Nation in the rural Four Corners region of the American Southwest (2). The Governor warned that the disease “... could wipe out those tribal nations.”

Use of COVID-19 testing as an approach to combating the pandemic is supported by an Iceland-based epidemiological study, and endorsed by the World Health Organization (3). Rural states in the US rank higher in prevalence of COVID-19 risk factors (hypertension, obesity, and diabetes), but rank lower in overall testing rates (4). Notably, several Southwestern states such as Arizona, Texas and Oklahoma have among the lowest testing rates in the country (5). Taken together, these results suggest that the current COVID-19 surveillance does not effectively capture medically vulnerable rural populations in the Southwest (4). Testing in the SAI tribal communities is further limited by the following reasons: 1) misinformation on tests due to the lack of broadband Internet access; 2) inadequate access to test sites due to lack of transportation and long travel distances; 3) traditional mistrust of the healthcare system; 4) concern about mishandling of biological samples; 5) misunderstanding that molecular assays interpret the genetic structure of the virus and not their people; 6) difficulty paying for the tests; and 7) nationwide shortage of test kits. Buy-in from community leaders and traditional healers, utilizing culturally sensitive communications, and access to broadband Internet are crucial to improving effective testing-based surveillance in these communities.

A large number of molecular and serological tests for COVID-19 are currently available, many of which lack evaluation data. Molecular tests, useful for establishing a diagnosis, utilize respiratory tract specimens to assess for the presence of nucleic acid targets specific to SARS–CoV-2 using the reverse transcriptase-polymerase chain reaction (RT-PCR) or nucleic acid amplification assays. RT-PCR–based assays performed in the laboratory on nasopharyngeal swabs collected by trained professionals are currently the cornerstone of COVID-19 diagnostic testing. Most RT-PCR assays take a few hours to complete, but the Cepheid assay has shortened the test duration to 45 minutes (6). Recent molecular tests such as CRISPR-Case12-based lateral flow assay and Abbott ID Now™, utilizing isothermal nucleic acid amplification technology for the qualitative detection of viral RNA have shortened the turnaround time further (7). Unlike molecular tests, serological tests may be useful in public health surveillance and vaccine evaluation, but not as the sole test for diagnosing the acute stage of the disease (8). Performed on blood specimens, serological tests use formats such as enzyme-linked immunosorbent assay and rapid lateral flow immunoassay, to detect immunoglobulin M (IgM) and/or immunoglobulin G (IgG) antibodies, which are produced by the body at approximately 10 days and 20 days respectively following COVID-19 infection. Current molecular and serological tests are laboratory-based and not easily available in the SAI tribal settings.

Living far away from hospitals, rural SAI residents need easy access to sample collection venues.  Across the world, many different sample collection venues can serve as useful prototypes, which includes drive-through-, booth-, mobile laboratory-, and home-based approaches. The latter approach involves the use of self-test kits, which are ideal. The approach involves kits containing instructions for testees to self-collect nasal swabs (or possibly early morning salivary specimens (9)) for molecular tests, or finger-stick blood samples for serologic tests. The FDA recently granted emergency clearance to the first at-home molecular test, a nasal self-swab kit (Pixel, LabCorp, USA), with a mail-back to the company laboratory for conducting the PCR assay, with online access to the results (10).

Although not currently available, the ideal test for the SAI tribal settings is low cost, less complex, point of care, rapid (i.e., test turn-around time preferably within an hour), and able to be performed by non-laboratory professionals in low-infrastructure settings, such as homes. The test results could be potentially uploaded to a mobile app or be viewed over a telemedicine consultation to interpret the results and provide immediate counseling on the next step. Smartphone-based devices containing a cartridge-housed microfluidic chip, which carries out isothermal amplification of viral nucleic acids from nasal swab samples in 30 minutes, which are detected using the smartphone camera, may soon be available for home testing (11). Rapid point of care serologic tests, similar to finger-stick blood glucose tests, and home pregnancy tests with colorimetric reading, mal also soon become available for home testing (12).To take advantage of rapid point-of-care testing that will soon become available, improving access to smartphones and broadband Internet in SAI tribal communities is crucial.

The primary goal of the pandemic containment in the rural SAI tribal communities is to reduce the basic reproductive number (R0, the expected number of cases directly generated by one case) of the SARS–CoV-2 virus, thereby reducing disease transmission. Given the lack of effective vaccines or treatments, the only currently available levers to reduce SARS–CoV-2 transmission are to practice social isolation, universal masking, and hand hygiene, identify asymptomatic and symptomatic infected cases through ideal testing strategies, and isolate contagious persons (8). Although not currently available, the ideal test for SAI communities is point of care, rapid, and home-based and requires efforts to improve access to smartphones and broadband Internet. Testing can be popularized using community leaders and traditional indigenous care providers. Finally, policy solutions are needed to eliminate financial barriers for uninsured or underinsured patients, to help meet the goal of improving testing-based COVID-19 surveillance in the rural SAI tribal communities.

References

  1. Kakol M, Upson D, Sood A. Susceptibility of southwestern american Indian tribes to coronavirus disease 2019 (COVID-19). J Rural Health. 2020. [CrossRef] [PubMed]
  2. Faulders K, Rubin O. New Mexico's governor warns tribal nations could be 'wiped out' by coronavirus, https://abcnews.go.com/Politics/mexicos-governor-warns-tribal-nations-wiped-coronavirus, published March 30, 2020,  accessed on April 3, 2020: ABC news (online); 2020.
  3. Gudbjartsson DF, Helgason A, Jonsson H, Magnusson OT, Melsted P, Norddahl GL, et al. Spread of SARS-CoV-2 in the Icelandic population. N Engl J Med. 2020 Apr 14.  [Epub ahead of print] [CrossRef] [PubMed]
  4. Souch JM, Cossman JS. A commentary on rural-urban disparities in covid-19 testing rates per 100,000 and risk factors. J Rural Health. 2020 Apr 13. [Epub ahead of print] [CrossRef] [PubMed]
  5. Monnat SM. Why coronavirus could hit rural areas harder. Available at https://lernercenter.syr.edu/2020/03/24/why-coronavirus-could-hit-rural-areas-harder/.  Printed March 24, 2020. Accessed March 26, 2020. Learner Center for Health Promotion.
  6. Xpert®Xpress SARS-CoV-2. Available online: https://www.cepheid.com/coronavirus. March 21,2020. (accessed on 2 April 2020).
  7. Abbott Launches Molecular Point-of-Care Test to Detect Novel Coronavirus in as Little as Five Minutes. Available online: https://abbott.mediaroom.com/2020-03-27-Abbott-Launches-Molecular-Point-of-Care-Test-to-Detect-Novel-Coronavirus-in-as-Little-as-Five-Minutes.  March 27, 2020. (accessed on 2 April 2020)
  8. Cheng MP, Papenburg J, Desjardins M, Kanjilal S, Quach C, Libman M, et al. Diagnostic testing for severe acute respiratory syndrome-related coronavirus-2: a narrative review. Ann Intern Med. 2020 Apr 13. [Epub ahead of print] [CrossRef] [PubMed]
  9. To KK, Tsang OT, Leung WS, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. 2020 May;20(5):565-74. [CrossRef] [PubMed]
  10. LabCorp. Pixel by LabCorp, COVID-19 At-Home Kits. Available at https://www.pixel.labcorp.com/covid-19. Accessed April 23, 2020.
  11. Sun F, Ganguli A, Nguyen J, Brisbin R, Shanmugam K, Hirschberg DL, et al. Smartphone-based multiplex 30-minute nucleic acid test of live virus from nasal swab extract. Lab Chip. 2020 May 5;20(9):1621-7. [CrossRef] [PubMed]
  12. Vashist SK. In vitro diagnostic assays for covid-19: recent advances and emerging trends. Diagnostics (Basel). 2020 Apr 5;10(4). pii: E202. [CrossRef] [PubMed]

Cite as: Chhabra A, Sood V, Sood V, Sood A. Improving testing for COVID-19 for the rural Southwestern American Indian tribes. Southwest J Pulm Crit Care. 2020;20(5):175-8. doi: https://doi.org/10.13175/swjpcc037-20 PDF

Wednesday
May132020

Does the BCG Vaccine Offer Any Protection Against Coronavirus Disease 2019?

Mueez Rehman1

Akshay Sood MD, MPH2,3

 

1University of New Mexico Main Campus, Albuquerque, NM, USA

2Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM USA

3Black Lung Program, Miners’ Colfax Medical Center, Raton, NM, USA

 

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-COV2), shares features with diseases caused by other coronaviruses such as influenza, the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003, and the Middle East Respiratory syndrome (MERS) outbreak of 2012. COVID-19 has been a challenging and devastating pandemic, resulting in death rates of more than 1%, testing nations both rich and poor, and outlining the importance of strong public health programs. Social distancing, masking and hand washing have become the new norm. Healthcare professionals are on the front lines, risking their lives. Those with pre-existing health conditions or older individuals face a significant risk for complications.

As scientists race to understand this deadly virus and find a cure to protect millions, an unlikely ally may come in a vaccine created over 100 years ago. The Bacillus Calmette-Guérin or BCG vaccine was created in 1921 to protect against tuberculosis (TB). At the time, tuberculosis was widespread, and the BCG vaccine was quickly implemented globally. However, as tuberculosis rates declined, developed countries such as the United States and many European countries discontinued widespread BCG administration. This change in vaccination policy was due to the supply of the vaccine and concerns for its efficacy. On the other hand, countries such as India, Pakistan, Indonesia, Vietnam, Russia, Ethiopia, and many others have continued widespread administration of the BCG vaccine. Many of these countries still have high rates of tuberculosis infections, as well as a large percentage of their population live in poverty (1). When COVID-19 started to emerge as a pandemic, global leaders and public health officials feared this pandemic would have catastrophic effects on these countries, overwhelming their healthcare systems, and killing millions. Interestingly, the opposite outcome was observed as these countries reported low rates of COVID-19. Instead, Europe became the world’s first epicenter outside of mainland China, followed by the United States, both of which reported large infection rates and death tolls due to COVID-19. The hardest hit countries had a similarity in that, they did not require widespread neonatal BCG vaccination. Ultimately, it is possible that the key difference between rates of COVID-19 infections in nations lies in neonatal BCG immunization rates amongst the populations. However, these conclusions are subject to confounding variables, such as the strength of the public health programs, and testing and reporting rates for COVID-19. An interesting outlier is Iran, which implemented a nationwide BCG vaccination program late in 1984, for children less than 6 years of age, using the Pasteur strain (2). With the high rates of COVID-19 cases in Iran, further research needs to examine this outlier, to see if there is any association with the type of vaccine used, administration at a later age, or the fact that currently middle-aged and elderly Iranians are not universally vaccinated.

Another interesting observation comes from the COVID-19 racial/ethnic distribution in the United States. The Centers for Disease Control and Prevention (CDC) released the race/ethnicity data for 580 lab-confirmed COVID-19, hospitalized patients on April 8, 2020 (3). In this data, African Americans constituted 33% of patients (when compared to 18% in the catchment populations) while Asians constituted 5.5% of the patients (proportion of Asians in the catchment population was not described). In certain states, Asian American populations showed higher disease and death rates for COVID-19, when compared to the general population (4). Interpretation of this data is, however, subject to confounding variables. The racial category for the Asian population is reported differently throughout the nation. Many states have differing definitions for the Asian race, certain states fail to divide the Asian population into different subgroups, and others combine Asian populations with ‘other’ racial groups (5). Furthermore, because the US does not have a widespread COVID-19 testing program, certain communities lack access to tests, and disparities for groups may be hidden. Once comprehensive data is available, it would be interesting to examine if the Asian subgroups consisting of individuals who received the BCG vaccine from a BCG administering country, before immigrating to the US show better outcomes against COVID-19, when compared to other Asian American subgroups.

The BCG vaccine was created by Albert Calmette and Camille Guérin against a live attenuated strain of Mycobacterium bovis, a mycobacterium that is similar to the one that causes tuberculosis. The vaccine creates both specific immunity to that mycobacterium, as well as nonspecific immunity against other pathogens that cause respiratory tract infections. In a study conducted on mice, researchers found that when subjecting mice to infectious viruses such as the A0 and A2 influenza viruses, herpes simplex virus, as well as other highly infectious viruses, mice inoculated with BCG were found to exhibit a significantly higher resistance to these infections compared to control mice (6). An explanation for this finding may lie in the fact that the BCG vaccine results in innate immune memory in the host. This trained immunity works by reprogramming a host’s bone marrow hematopoietic stem cells and multipotent progenitors through epigenetic/metabolic changes, resulting in greater variability of the differentiated innate immune cells response following a pathogen (7). Ultimately, this may result in the host’s immune system being able to successfully fight off large numbers of respiratory tract infections, including possibly SARS-CoV-2.

The World Health Organization (WHO) stands firm on the stance that there is no scientific evidence as to whether the BCG vaccine actually protects against COVID-19. Furthermore, WHO mentions that BCG vaccination is particularly important for children in countries with high prevalence of tuberculosis, and if local supplies are diverted, these children will face an increase in disease and death from tuberculosis (8).

As more scientific research is being conducted, the preliminary findings may indicate BCG as a potential safeguard against COVID-19. This may be explained through the lower rates of infection in countries with widespread neonatal BCG vaccination policies. Furthermore, immigrants who come from BCG administering countries may also have this advantage against COVID-19. Currently, the US Government is working to release a racial/ethnic breakdown of COVID-19 cases. As more data is published on race and ethnicities, it will be useful to examine if fewer COVID-19 cases and deaths occur amongst immigrant populations from BCG-administering parent countries, after adjusting for confounders.

References

  1. Zwerling A, Behr MA, Verma A, et al. The BCG World Atlas: A Database of Global BCG Vaccination Policies and Practices. PLoS Med. 2011 Mar;8(3):e1001012. [CrossRef] [PubMed]
  2. Fallah F, Nasiri MJ, Pormohammad A. Bacillus Calmette-Guerin (BCG) vaccine in Iran. J Clin Tuberc Other Mycobact Dis. 2018;11:22. [CrossRef] [PubMed]
  3. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69.458-64. [CrossRef] [PubMed]
  4. NYC Health. Age-adjusted rates of lab confirmed COVID-19 non-hospitalized cases, estimated non-fatal hospitalized cases, and patients known to have died 100,000 by race/ethnicity group as of April 16, 2020. Available at https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04162020-1.pdf; Printed April 16, 2020. Accessed May 1, 2020.
  5. Growing Data Underscore that Communities of Color are Being Harder Hit by COVID-19 | The Henry J. Kaiser Family Foundation. https://www.kff.org/coronavirus-policy-watch/growing-data-underscore-communities-color-harder-hit-covid-19/?utm_source=sfmc&utm_medium=email&utm_campaign=covidexternal&utm_content=newsletter. Accessed April 24, 2020.
  6. Floc’h F, Werner GH. Increased resistance to virus infections of mice inoculated with BCG (Bacillus calmette-guérin). Ann Immunol (Paris). 1976;127(2):173-86. [PubMed]
  7. Gursel M, Gursel I. Is global BCG vaccination coverage relevant to the progression of SARS-CoV-2 Pandemic? Allergy. 2020 Apr 27. [CrossRef] [PubMed]
  8. World Health Organization. Bacille Calmette-Guérin (BCG) vaccination and COVID-19. https://www.who.int/news-room/commentaries/detail/bacille-calmette-guérin-(bcg)-vaccination-and-covid-19. Accessed April 14, 2020.

Cite as: Rehman M, Sood A. Does the BCG vaccine offer any protection against coronavirus disease 2019? Southwest J Pulm Crit Care. 2020;20(5):170-2. doi: https://doi.org/10.13175/swjpcc035-20 PDF 

Wednesday
May062020

2020 International Year of the Nurse and Midwife and International Nurses’ Day

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

 

The World Health Organization (WHO) designated 2020 as the International Year of the Nurse and Midwife to acknowledge the contributions of nurses and midwives in promoting the health and welfare of populations across the globe. This recognition is in concert with the 200th anniversary of the birth of Florence Nightingale. Although nurses and midwives make up over half the world’s health care workforce, the WHO estimates that 2020 will see a shortage of 9 million nurses (1,2). International Nurses’ Week begins May 6th and culminates on May 12th, International Nurses Day, the anniversary of Nightingale’s birth with hopes of bringing greater re, cognition nurses play in local to global health.

Defying expected Victorian norms for women born to well-connected, affluent British families in the middle of the nineteenth century, Florence Nightingale chose the art and science of nursing over marriage. “Nightingale” is synonymous with the foundation of professional nursing, as well as her dedicated service as a manager and trainer of nurses during the Crimean War.

Florence Nightingale’s influence, however, encompasses so much more than establishing nursing education. Military and field medicine, epidemiology, early prefabricated hospitals, hospital supervision, community and public health, health policy, establishment of nursing schools and infirmaries, early pioneering in the concept of medical tourism, as well as social reform for women and all sections of society have benefitted from her groundbreaking achievements. Her work continues. The Nightingale Initiative for Global Health (NIGH), for example, fosters Nightingale’s activities grounded in social and environmental justice, preventive medicine, and holistic health from the local to global levels (3,4).

A keen observer of conditions that lead to poor health, Nightingale wrote extensively regarding sanitary reform. Her Notes on Nursing emphasized frequent handwashing that presaged the hygiene required during the current Covid-19 pandemic (5). Nightingale was the first woman admitted to the London Statistical Society (5). She became a member of the American Statistical Association (6). She was the first nurse to conduct and use research. Nightingale showed that physical and social factors influenced health, and that quality of care can be improved through careful data collection, visual displays that used her original “Polar-Area Diagram,” critical thinking, and practice based on evidence (7).

Florence Nightingale’s legacy endures in the face of the Covid-19 pandemic. It was announced on 24 March 2020 that the new “Nightingale Hospital” would be set up at the ExCel conference centre in East London to provide support for up to 4,000 patients with Covid-19 (8). On 3 April 2020, within two weeks of the announcement, the NHS Nightingale Hospital was officially opened by HRH Prince Charles as a coronavirus field hospital. In his remarks, Prince Charles stated, “Florence Nightingale, the lady with the lamp, brought hope and healing to thousands in their darkest hour. In this dark time this place will be a shining light” (9).

The Southwest Journal of Pulmonary and Critical Care congratulates and values the many legatees of Florence Nightingale in this 2020 International Year of the Nurse--the nurses and midwives across the globe for their unwavering dedication to education, research, practice and policy, as well as our valued interprofessional collaborations in promoting health and preventing disease.

References 

  1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
  2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
  3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
  4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
  5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
  6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
  7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
  8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
  9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

 

2020 Año Internacional de la Enfermera y Partera y el Día Internacional de la Enfermera

 

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

 

La Organización Mundial de la Salud (OMS) designó 2020 como el Año Internacional de la Enfermera y la Partera para reconocer las contribuciones de las enfermeras y parteras en la promoción de la salud y el bienestar de las poblaciones de todo el mundo. Este reconocimiento está en concierto con el bicentenario del nacimiento de Florence Nightingale. Si bien las enfermeras y las parteras representan más de la mitad de la fuerza laboral mundial de atención de la salud, la OMS estima que en 2020 habrá una escasez de 9 millones de enfermeras (1,2). La Semana Internacional de Enfermeras comienza el 6 de mayo y culmina el 12 de mayo, Día Internacional de las Enfermeras, el aniversario del nacimiento de Nightingale con la esperanza de brindar un mayor reconocimiento a las enfermeras en la salud local y mundial.

Desafiando las normas victorianas esperadas para las mujeres nacidas de familias británicas acomodadas y bien conectadas a mediados del siglo XIX, Florence Nightingale eligió el arte y la ciencia de la enfermería en lugar del matrimonio. "Nightingale" es sinónimo de la base de la enfermería profesional, así como su servicio dedicado como gerente y formadora de enfermeras durante la Guerra de Crimea.

La influencia de Florence Nightingale, sin embargo, abarca mucho más que establecer una educación en enfermería. Medicina militar y de campo, epidemiología, hospitales prefabricados tempranos, supervisión hospitalaria, salud comunitaria y pública, política de salud, establecimiento de escuelas de enfermería y enfermerías, pioneros tempranos en el concepto de turismo médico, así como reforma social para las mujeres y todos los sectores de la sociedad se han beneficiado de sus logros innovadores. Su trabajo continúa. La Nightingale Initiative for Global Health (NIGH), por ejemplo, fomenta las actividades de Nightingale basadas en la justicia social y ambiental, la medicina preventiva y la salud holística desde el nivel local hasta el global (3,4).

Un observador entusiasta de las condiciones que conducen a la mala salud, Nightingale escribió ampliamente sobre la reforma sanitaria. Sus Notas sobre Enfermería enfatizaban el lavado frecuente de manos que presagiaba la higiene requerida durante la actual pandemia de Covid-19 (5). Nightingale fue la primera mujer admitida en la Sociedad Estadística de Londres (5). Se convirtió en miembro de la Asociación Americana de Estadística (6). Fue la primera enfermera para realizar y utilizar investigaciones. Nightingale demostró que los factores físicos y sociales influyeron en la salud, y que la calidad de la atención se puede mejorar mediante una cuidadosa recolección de datos, exhibiciones visuales que utilizaron su "diagrama de área polar" original, pensamiento crítico y práctica basada en evidencia (7).

El legado de Florence Nightingale perdura ante la pandemia de Covid-19. Se anunció el 24 de marzo de 2020 que el nuevo "Hospital Nightingale" se establecería en el centro de conferencias ExCel en el este de Londres para brindar apoyo a hasta 4,000 pacientes con Covid-19 (8). El 3 de abril de 2020, dentro de las dos semanas posteriores al anuncio, El “NHS Nightingale Hospital” fue inaugurado oficialmente por el Príncipe Carlos como un hospital de campaña de coronavirus. En sus comentarios, el Príncipe Carlos declaró: “Florence Nightingale, la dama de la lámpara, trajo esperanza y sanación a miles en su hora más oscura. En este tiempo oscuro este lugar será una luz brillante” (9).

The Southwest Journal of Pulmonary and Critical Care felicita y valora a los muchos legatarios de Florence Nightingale en este Año Internacional de la Enfermera 2020: las enfermeras y parteras de todo el mundo por su inquebrantable dedicación a la educación, la investigación, la práctica y la política, así como a nuestras valiosas colaboraciones interprofesionales en la promoción de la salud y la prevención de enfermedades.

Referencias

  1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
  2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
  3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
  4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
  5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
  6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
  7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
  8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
  9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

Cite as: Baldwin CM, Dossey BM. 2020 international year of the nurse and midwife and international nurses’ day. Southwest J Pulm Crit Care. 2020;20(5):165-9. doi: https://doi.org/10.13175/swjpcc034-20 PDF

Saturday
Mar282020

Who Should be Leading Healthcare for the COVID-19 Pandemic?

The recent COVID-19 pandemic brought to mind the Oscar Wilde quote, “An expert is an ordinary man away from home giving advice” (1). COVID-19 advice has flooded my inbox and dominated news coverage on television, in print and electronically. Everyone from the President to the hospital secretary seems to think they are qualified to offer advice on COVID-19 prevention and care. I admit to not being an expert on COVID-19 because I am not a virologist. However, despite retiring from the ICU in 2011, I think I know quite a bit about caring for sick patients with pneumonia having done it for over 30 years. For my part, and for many of my colleagues, the non-solicited, non-expert advice offered from these sources should be returned and the sender instructed to place it in that recess of the body most protected from sunlight.

The US government has not provided outstanding leadership during this pandemic. The President and CDC were both initially slow to respond and sometimes issued confusing or contradictory statements (2,3). Occasionally they were just wrong. The news media contributed to the confusion by reporting what was at times nonsense. All would be better off if we followed the guidance of someone like the NIH’s Dr. Tony Fauci who has said the right things while walking a political tightrope of gently contradicting the President.

Most hospitals have not done much better than the White House. I am overwhelmed with advice and sometimes pronouncements that claim to be evidence- or CDC-based. Sometimes they are-sometimes not. These are usually from a non- or minimally qualified administrator lacking medical expertise. We now hear reports that administrators are trying to direct health care providers not to wear personal protective equipment (PPE, masks, goggles, booties, etc.) in hallways or forbidding physicians and nurses from bringing their own PPE from home (4,5).

The hospitals give a variety of reasons for their actions, from conservation of PPE to the belief that it scares patients. Conservation of PPE is good idea. However, having someone change their mask every time they see a potential or a confirmed COVID-19 means using lots of masks while wearing one mask all day would help to conserve. Scaring patients is not good but unnecessarily exposing healthcare providers is worse. In Italy and Spain healthcare workers make up a disproportionately high number of cases (6-7). It is now thought that the hospital may be a primary source of infection and that the lack of doctors and nurses is impairing healthcare (6-8). Patients should be frightened and even more so when someone enters their room without a mask.

Although dealing with this crisis is the first priority, we need to ask ourselves at some point how could the US be so unprepared. We saw what a surge in ICU patients could do with the H1N1 influenza pandemic of 2009 leaving ICU beds and ventilators in short supply (9). In the 11 years since that time, the country did little to nothing. Where are the ventilators, the PPE and the medical personnel we now need?

Healthcare planning and emergency preparation have been done by non-medical people who now must take responsibility for our lack of preparedness. Those same people are now trying to direct care. They should back away and let those best able to deal with the present catastrophe provide the care. In the future we should ask what role they should play in planning for a National healthcare emergency. Will those planning be more concerned about allocating monies for future healthcare emergencies or another purpose? Perhaps we should have the planning done by those more knowledgeable and more concerned for the American people.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Guernsey L. Suddenly, everybody's an expert. NY Times. February 3, 2020. Available at: https://www.nytimes.com/2000/02/03/technology/suddenly-everybody-s-an-expert.html (accessed 3/27/20).
  2. Edwards HS.  The Trump administration fumbled its initial response to coronavirus. Is there enough time to fix it? Time. March 19,2020. Available at: https://time.com/5805683/trump-administration-coronavirus/ (accessed 3/27/20).
  3. Chen C, Allen M, Churchill L. Internal emails show how chaos at the CDC slowed the early response to coronavirus. ProPublica. March 26, 2020. Available at: https://www.propublica.org/article/internal-emails-show-how-chaos-at-the-cdc-slowed-the-early-response-to-coronavirus (accessed 3/27/20).
  4. Ault A. Amid PPE shortage, clinicians face harassment, firing for self-care. Medscape. March 26, 2020. Available at: https://www.medscape.com/viewarticle/927590?nlid=134683_5461&src=wnl_dne_200327_mscpedit&uac=9273DT&impID=2325986&faf=1#vp_3 (accessed 3/27/20).
  5. Whitman E. 'Taking masks off our faces': how Arizona hospitals are rationing protective gear. Available at: https://www.phoenixnewtimes.com/news/arizona-hospitals-rationing-masks-protective-gear-banner-11459400 (accessed 3/27/20).
  6. Van Beusekom M. Doctors: COVID-19 pushing Italian ICUs toward collapse. Center for Infectious Disease Research and Policy, March 16, 2020. Available at: http://www.cidrap.umn.edu/news-perspective/2020/03/doctors-covid-19-pushing-italian-icus-toward-collapse (accessed 3/27/20).
  7. Jones S. Spain: doctors struggle to cope as 514 die from coronavirus in a day. The Guardian. Available at: https://www.theguardian.com/world/2020/mar/24/spain-doctors-lack-protection-coronavirus-covid-19 (accessed 3/27/20).
  8. Begley S. A plea from doctors in Italy: To avoid Covid-19 disaster, treat more patients at home. Stat. March 22, 2020. Available at: https://www.statnews.com/2020/03/21/coronavirus-plea-from-italy-treat-patients-at-home/ (accessed 3/27/20).
  9. Levey NN, Christensen K, Phillips AM. A disaster foretold: Shortages of ventilators and other medical supplies have long been warned about. LA Times. March 20, 2020. Available at: https://www.latimes.com/politics/story/2020-03-20/disaster-foretold-shortages-ventilators-medical-supplies-warned-about (accessed 3/27/20).

Cite as: Robbins RA. Who should be leading healthcare for the COVID-19 pandemic? Southwest J Pulm Crit Care. 2020;20(3):103-4. doi: https://doi.org/10.13175/swjpcc021-20 PDF 

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