Right from Florence Nightingale in the Crimean War to Fatu Kekula who helped treat Ebola patients in Liberia, nurses have been at the forefront of any healthcare crisis. They are the critical link in the healthcare system that not only helps people recover back to health, but become the biggest support for the family of the sick.

During this pandemic, the roles of nurses have changed and brought great responsibilities and a lot of challenges. A typical day in the life of a nurse on the Covid war front is filled with great uncertainty and a constant marathon. Every single shift has the potential to be momentous, exhilarating, exhausting, energizing, or all of the above. On any given day, nurses can see people at their weakest and most vulnerable, or at their strongest and most resolute. Moreover, a single breach in infection prevention practice can cause life-threatening infections to any patient, especially for critical Covid patients who are immune-compromised, considering the use of steroids, raised blood glucose levels, and use of medications that suppress immunity. Nurses acts as patient advocates to ensure that the right treatment reaches the patient in the right manner. They witness the results of life-ending injuries and illnesses with regularity. Yet, this just the tip of the iceberg. The stories and experiences that nurse have had since the pandemic is beyond compare but the lessons learnt are here to stay.

LESSONS FROM THE PANDEMIC

This pandemic has put the entire healthcare community in trial mode – a trial that tested each and every healthcare provider’s endurance and resilience. Nurses were no different. The challenges were many, but amid these challenges, healthcare transformed itself to accommodate the dynamic needs of the community. Infrastructural and process changes like the creation of specialised isolation units, negative pressure areas, availability and efficient utilization of manpower and PPE, frequent mock drills, patient flow management drills, etc. have been implemented to tackle even the most extreme situations smoothly.

CRITICAL ROLE IN EMERGENCY CARE

Nurses are an integral part of the disaster management team. They are the ones who triage (sort) the patients on their arrival which requires the right knowledge and critical thinking, and depending on her assessment the doctors treat those patients first who require urgent attention and treatment. Nurses are vital in mobilizing resources, ensuring appropriate patient monitoring, and providing the right care to needy patients. Nurses are also a major part of decision-making when it comes to risk mitigation.

BUILDING RESILIENCE

Doctors and nurses have braved various crisis situations hand-in-hand with much dedication throughout ages, but it is only after the pandemic that their true worth has emerged. Each young doctor and nurse, despite being overwhelmed with stress and anxiety, witnessing deaths every now and then, getting infected, and even passing on the infection to their families, have not stopped coming back to work.

Nurses have started having bigger roles when it comes to patient care in Covid-19 units. Frequent rounds and monitoring, ensuring patients receive food and medications round the clock, risk prevention and mitigation, attending to doctors and following specific instructions, collecting blood samples, escalating warning signs, etc., such tasks have placed nurses on a higher pedestal in terms of responsibility and accountability.

The biggest challenges faced were to be flexible with changing protocols, nurse training, and wearing PPEs for several hours together. The fear of being infected and infecting near and dear ones added to the anxiety. Despite these, they did not lose spirit; they had to go on. This is one of the biggest healthcare crises the country had ever faced in many years. Most hospitals, although having an Infection Control Unit, were still not prepared for a crisis of this magnitude. They had to be deft in learning and help others learn too. They had to handle patients and extremely frightened relatives who weren’t even sure they would see their people again. Moreover, the burden of short staff and limited resources made matters worse. Having said that, the lessons from the pandemic have also empowered nurses.

ROLE OF THE NURSING HEAD IN INFECTION CONTROL

Infection prevention and control became a priority for healthcare staff across all areas of clinical practice. The nursing staff became a critical link in infection control. They had to formulate new protocols and update skills accordingly. This includes segregation of patients as per their clinical conditions, creating isolation units for Covid-positive and suspected cases, ensuring adequate availability of PPE for all healthcare staff, skilled manpower and resources, and the well-being of all healthcare workers by providing them with prophylaxis, nutritious food, and psychological support. This is one part of the planning and establishing Standard Operating Procedures (SOPs). The next step is preparedness implementation that includes infrastructure and inventory planning to ensure all patients get the required medicines and oxygen or ventilator support. Strict protocols had to be followed by each and everyone entering the Covid units.

NURSES WILL HAVE A BIGGER RESPONSIBILITY IN EPIDEMIOLOGY STUDIES

As part of the community nursing program, we are trained to partake in epidemiology studies. Indirectly in many ways, we do contribute to understanding epidemics, an outbreak which becomes an important element of disease management. But going forward, the role and responsibilities will increase. During this pandemic, nurses have already been involved in data collection and analysis, understand the disease patterns, peaks, and more. They identify and investigate the problem, formulate the causal factors and alternative interventions, and implement to prevent and control the problem, also evaluating the effectiveness of the intervention. They participate in data collection, data analysis, planning, implementation, and evaluation. They have an active role in the prevention and control of communicable diseases which include:

• Identifying sources of infection and methods of spread of infection

• Health education of people in general

• Notification of Covid-19 to the health authority

• Teaching and supervising other workers in surveillance activities

Today, Infection Control Nurses are empowered to collect and analyze the data from Covid patients. They are the ones who collate and send data to local authorizes for notification of Covid patients. Mass sensitization drives are also helmed by nurses by actively taking part in webinars, online sessions in order to create awareness regarding the prevention and management of the infection.

Minimole Varghese is Chief Nursing Officer, Fortis Hospital, Mulund, and Mohini Chandrashekhar is Chief Nursing Officer, Hiranandani Hospital, Vashi, a Fortis associate.

With oxygen deprivation and lung infections becoming common problems faced by patients during the second wave of Covid-19, many patients have been recommended to use oxygen concentrators and cylinders at home to maintain oxygen levels and avoid fatalities. However, with oxygen therapy, one needs to be doubly careful and be aware of the risks and dangers as well. Here are the answers to some common queries that will help you make the right decision regarding oxygen support.

WHEN SHOULD YOU TAKE OXYGEN SUPPORT?

Oxygenation should be preferred when blood oxygen levels (SpO2) readings drop below 94%. Ideal oxygen levels should be between 95% and 99%. While no oxygen therapy can instantly boost oxygen levels or restore them to normal, Covid-positive patients should aim to achieve a saturation of up to 92%. Experts also advise that achieving 100% saturation shouldn’t be done when the body is sick. More so, this may exhaust your resources quicker, whether it is a concentrator or cylinder that you use.

WHAT IS AN OXYGEN CONCENTRATOR? HOW DOES IT WORK?

An oxygen concentrator is an electronically operated device that separates oxygen from room air. It provides a high concentration of oxygen directly to you through a nasal cannula. These devices work on the principle of ‘rapid pressure swing absorption’ which is where the nitrogen is removed from the air using zeolite minerals which absorb the nitrogen, leaving other gases to pass through and capturing oxygen as the primary gas. The collected oxygen is 92-95% pure.

WHAT IS THE DIFFERENCE BETWEEN OXYGEN CONCENTRATORS AND CYLINDERS?

The difference is that a concentrator purifies the air and makes it available for patients who have low oxygen levels in their blood. It just needs to be pulled into a power source. Cylinders accomplish the same, but the oxygen is already compressed within the tank. That supply is gradually reduced until the tank runs out and needs to be refilled or replaced.

WHAT TO KEEP IN MIND BEFORE BUYING OR RENTING AN OXYGEN CONCENTRATOR?

Normal air will have 21% oxygen. If 1 litre oxygen is provided to the patient through the concentrator, the oxygen percentage (or fraction of inspired air) in the lungs rises to 24%, with 2 litres it rises to 28% and with 10 litres it rises to 60%. Depending on the need, the litres of oxygen per minute must be regulated. There is a need for monitoring this from time to time to ensure that the flow of oxygen is proper and that the patient is not over oxygenated. Seek your doctor’s advice to decide how many litres per minute of oxygen is required for your patient. Keep a pulse oximetre handy to check oxygen levels from time to time. Oxygen concentrators can supply between 0.1 litres per minute (LPM) to 5 to 10 LPM.

WHO IS ELIGIBLE?

Only mild to moderately ill patients, who have an oxygen saturation level between 90% and 94%, should depend on an oxygen concentrator and can use it at home. We must understand that hoarding such life-saving equipment will only worsen the country’s problem. Anyone with oxygen saturation depleting below 80-85% may need a higher flow of oxygen and will have to switch to a cylinder or liquid medical oxygen supply and may eventually need hospitalization.

TYPES OF OXYGEN CONCENTRATORS

There are two types of oxygen concentrators— continuous flow and pulse dose. Continuous flow oxygen will provide the same flow of oxygen every minute unless it is turned off, irrespective of whether the patient is breathing it in or not, while pulse dose oxygen concentrator detects breathing patterns and dispenses oxygen when it detects inhalation. The oxygen dispensed per minute will vary in the second case.

WAYS TO IMPROVE OXYGEN LEVELS FOR COVID PATIENTS

Oxygen delivery can be increased by using prone positioning. Physical position affects the distribution and volume of air in the lungs and can have direct effects on the expansion or collapse of the delicate alveoli that permit the exchange of oxygen and carbon dioxide in the blood. It involves turning a patient with precise, safe motions, from their back onto their abdomen so that the individual is lying face down, to improve breathing and oxygen flow in the body. Having said that, getting the right advice on how proning can be complemented with oxygen supply is significant. Talk to your doctor today to understand when to opt for oxygen support at home, if your patient is eligible for oxygen support at home, and how it can be best utilized.

The author is Consultant, General Physician, Fortis Hospital, Mulund.

London: The first global review of complementary medicines (herbal and dietary supplements) for weight loss in 16 years — combining 121 randomised placebo-controlled trials including nearly 10,000 adults — suggests that their use cannot be justified on the basis of current evidence. The findings of two studies, being presented at The European Congress on Obesity (ECO) held online this year, suggest that although some herbal and dietary supplements show statistically greater weight loss than placebo, it is not enough to benefit health, and the authors call for more research into their long-term safety. “Over-the-counter herbal and dietary supplements promoted for weight loss are increasingly popular, but unlike pharmaceutical drugs, clinical evidence for their safety and effectiveness is not required before they hit the market”, says lead author Erica Bessell from the University of Sydney in Australia.“Our rigorous assessment of the best available evidence finds that there is insufficient evidence to recommend these supplements for weight loss. Even though most supplements appear safe for short term consumption, they are not going to provide weight loss that is clinically meaningful.”

The authors report on herbal supplements, containing a whole plant or combinations of plants as the active ingredient, and dietary supplements containing naturally occurring isolated compounds from plants and animal products, such as fibres, fats, proteins, and antioxidants. They can be purchased as pills, powders and liquids. Between 1996 and 2006, 1,000 dietary supplements for weight loss included on the Australian Register of Therapeutic Goods weren’t evaluated for efficacy. Supplements can be sold and marketed to the public with sponsors (who import, export or manufacture goods) required to have, but not necessarily provide, evidence backing their claims. Just 20 per cent of new listings are audited annually to make sure they meet the requirement. In some countries, the only requirement is that supplements contain acceptable levels of non-medicinal products. Estimates suggest that 15 per cent of Americans trying to lose weight have tried a weight loss supplement, a USD 41 billion global industry in 2020. Despite their increasing popularity, it has been 16 years since the last review of the scientific literature on all available herbal and dietary supplements. To provide more evidence, Australian researchers did a systematic review of all randomised trials comparing the effect of herbal supplements to placebo on weight loss, up to August 2018. Data were analysed for 54 studies involving 4,331 healthy overweight or obese adults aged 16 years or older. Weight loss of at least 2.5kg (5.5lbs) was considered clinically meaningful. They also evaluated study design, reporting, and clinical value. Herbal supplements included in the analysis were: green tea; Garcinia cambogia and mangosteen (tropical fruits); white kidney bean; ephedra (a stimulant that increases metabolism); African mango; yerba mate (herbal tea made from the leaves and twigs of the Ilex paraguariensis plant); veld grape (commonly used in Indian traditional medicine); liquorice root; and East Indian Globe Thistle.

The analysis found that only one single agent, white kidney bean, resulted in a statistically, but not clinically, greater weight loss than placebo (-1.61kg; 3.5Ibs). In addition, some combination preparations containing African Mango, veld grape, East Indian Globe Thistle and mangosteen showed promising results but were investigated in three or fewer trials, often with poor research methodology or reporting, and the findings should be interpreted with caution, researchers say. A new systematic review up to December 2019, also identified 67 randomised trials comparing the effect of dietary supplements containing naturally occurring isolated compounds to placebo for weight loss in 5,194 healthy overweight or obese adults. Dietary supplements included in the analysis were: chitosan; glucomannan; fructans and conjugated linoleic acid.

A new research being presented online this year, suggests that a measure of body shape should be used alongside body mass index (BMI) to help determine the risk of obesity-related cancers. The research was presented at the European Congress on Obesity. BMI is a simple way of measuring body fat from the weight and height of a person. But its reliability is often criticised, because it does not distinguish fat from muscle, or consider where body fat is stored or an individual’s sex or age. Similarly, waist circumference takes into account belly fat, which is linked to several health risks including cardiovascular disease, type-2 diabetes and cancer, but fails to account for height. A new metric to measure obesity, called ‘A body shape index’ (ABSI), takes into account an individual’s age, sex, weight, height and waist circumference–and it may provide a more accurate estimate of cancer risk than BMI. To explore this further, researchers from the University of Glasgow and the University of Newcastle, combined data from 442,614 participants (average age 56 years) from the UK Biobank prospective cohort who were followed for an average of 8 years, during which 36,961 individuals were diagnosed with cancer.

Participants were broken down into three groups (tertiles) according to their body shape to examine the associations with the risk of 24 different types of cancer, and to examine ABSI and BMI as predictors of cancer risk. Results were adjusted for age, sex, ethnicity, deprivation, education, income, smoking, alcohol consumption, dietary intake, physical activity, and sedentary time. The analysis found that body shape and BMI predicted different obesity-related cancer risks in adults. Specifically, ABSI was linked with an increased risk for three cancers. Participants in the highest ABSI tertile were 38 per cent more likely to develop liver cancer, 40 per cent more likely to develop lung cancer, and had a 17 per cent increased risk of bowel cancer, compared to those in the lowest ABSI tertile, regardless of BMI.

However, researchers found that high ABSI and high BMI combined were linked with an increased risk for seven different types of cancer–uterine, oesophageal, liver, stomach, kidney, bowel, breast cancer. For example, participants in the highest ABSI tertile who were also overweight or obese were at twice the risk of developing uterine cancer than those with the lowest ABSI and normal BMI.

“Our findings underscore the importance of measuring more than just BMI when predicting cancer risk, and suggest that people’s body shape may increase their risk of certain cancers”, says lead author Dr Carlos Celis-Morales from the University of Glasgow, UK. “Whatever method you use, being overweight or obese is the single biggest preventable cause of cancer after smoking. More urgent actions are needed to help people maintain a healthy bodyweight and shape throughout their lives, starting at an early age.” Having excess body fat can lead to biological changes that alter levels of sex hormones, such as oestrogen and testosterone, cause levels of insulin to rise, and lead to inflammation, all of which have been linked with increased risk of 13 different types of cancer. This is an observational study, so cannot establish cause, and it is not a representative sample of the UK adult population, so the results cannot be generalised to the general population.

London: A group of UK academics recently called for targets for mental health in order to meet the healthcare challenges of the next decade. Published in Journal of Mental Health researchers set out four overarching goals that will speed up the implementation of mental health research and give a clear direction for researchers and funders to focus their efforts when it comes to better understanding the treatment of mental health. The treatment of mental illness currently brings substantial costs to not only the NHS, but also to the individual and wider society, and the need for innovation to promote good mental health has never been greater. In an effort to catalyse this innovation, the researchers have set out four ambitious targets:

Halve the number of children and young people experiencing persistent mental health problemsImprove our understanding of the links between physical and mental health, and eliminate the mortality gapIncrease the number of new and improved treatments, interventions and supports for mental health problemsImprove the availability of choices and access to mental health care, treatment and support in hospital and community settings.

The number of goals was limited to four in an effort to easily promote cross-sector partnerships, and to track their impacts. Professor Dame Til Wykes, Corresponding author from King’s College London’s Institute for Psychiatry, Psychology & Neuroscience (IoPPN) said “While there is a wealth of research taking place to better understand the treatment of mental illness, we must have a clear idea in our heads where we are heading. Without clear targets and goals for mental health we will be amassing information without any clear trajectory, or worse, no clear understanding of achievements or the expected timescale. “The four goals that we have set out are in response to this problem, providing a roadmap forwards for all researchers, funders, and policymakers. We have undoubtedly set ourselves a high bar, but they have been designed to give us all a clear sense of purpose.”The research comes at a particularly pertinent time. At least 1 in 6 adults in the UK are likely to experience mental health difficulties in any given week, and the British Medical Association has recently warned that the mental health consequences of covid will be “considerable”. The research has been welcomed by several sector voices, including funders, researchers, and NHS Trusts.

Professor Chris Whitty, Chief Medical Officer and co-lead of the National Institute for Health Research, said: “Few could disagree that mental health research is crucial in driving innovation in current mental health care and in bringing hope for the future. Working with clinicians, academics, major mental health research funders, mental health research charities and representatives from service users groups, as well as representatives from Public Health England and NHS England has been key to identifying those areas of most concern and transforming them into four distinct research goals which the mental health community can sign up to.” Professor Elaine Fox of the University of Oxford said that “National high-level goals that focus our research efforts are an important part of ensuring that good will and good intentions are translated into genuine innovations and impact.”Professor Peter Jones of the University of Cambridge said, “It’s been a pleasure supporting the development of these important mental health research goals. Involving a wide range of stakeholders, they provide us all with focus, direction, and challenge. The goals will galvanise mental health science while holding it to account.”Lea Milligan, CEO of MQ Mental Health Research said “MQ’s vision is to create a world where mental illnesses are understood, effectively treated and one day preventable. The research goals that came from an extensive consultation are an opportunity for us bring the mental health research community together in a united and impactful way like never before.”

Dr Nev Jones of One Mind, a US-based non-profit organisation, said “the paper sets the stage for organizations to “all pull in the same direction”. Collaboration has been a cornerstone of One Mind’s strategy to accelerate research, and this framework will be helpful moving forward.” Professor Dame Til Wykes said, “The pandemic has and will produce a double whammy – the effects of lockdown and the effects of an economic slowdown that exacerbate existing socio-economic inequalities. “With so many people facing an increased risk, it’s vital that we act now to proactively meet the challenges of the next 10 to 20 years head-on.”

“The spread of COVID-19 has demonstrated that widespread changes can be implemented rapidly when everyone is working to the same goal. If we can emulate our response to the pandemic in the care of mental illness, we would see positive impacts very quickly.” The four goals were produced following a consultation process that was organised by the Department of Health and Social Care and convened by the Chief Medical Officer.

London: Mild Covid-19 infection is very unlikely to cause lasting damage to the structure or function of the heart, according to a study. The study was led by UCL (University College London) researchers and funded by the British Heart Foundation (BHF) and Barts Charity. The researchers say the results, published in JACC Cardiovascular Imaging, should reassure the public, as they relate to the vast majority of people who had Covid-19 infections with mild or no symptoms.This study of 149 healthcare workers recruited from Barts Health and Royal Free London NHS Trusts is the largest and most detailed study to date into mild Covid-19 infection and its longer-term impact on the heart.It follows concerns that because severe hospitalised Covid-19 infections are associated with blood clots, inflammation of the heart and heart damage, mild infections may cause similar complications. However, up until now, there has been little information specifically looking at this group of people and the effects on the heart further down the line after infection.

Researchers identified participants with mild Covid-19 from the COVIDsortium, a study in three London hospitals where healthcare workers had undergone weekly samples of blood, saliva and nasal swabs for 16 weeks. Six months after a mild infection, they looked at the heart structure and function by analysing heart MRI scans of 74 healthcare workers with prior mild Covid-19 and compared them to the scans of 75 healthy age, sex and ethnicity matched controls who had not previously been infected. They found no difference in the size or amount of muscle of the left ventricle – the main chamber of the heart responsible for pumping blood around the body – or its ability to pump blood out of the heart. The amount of inflammation and scarring in the heart, and the elasticity of the aorta – which is important for blood to easily flow out of the heart – remained the same between the two groups. When the researchers analysed blood samples, they found no differences in the two markers of heart muscle damage – troponin and NT-proBNP – six months after mild Covid-19 infection.

Now, the team of researchers and cardiologists suggest that there is little benefit from screening the hearts of people who’ve had a mild infection, and research should focus on those who’ve suffered severe Covid-19, high-risk groups or those with ongoing symptoms. Dr Thomas Treibel (UCL Institute of Cardiovascular Science and Barts Health NHS Trust), said: “Disentangling the impact Covid-19 has on the heart has been a challenge. But we’re now at the stage of the pandemic where we can really start to get a grip on the longer-term implications Covid-19 has on the health of our heart and blood vessels. “We’ve been able to capitalise on our incredible frontline staff who’ve been exposed to the virus this past year and we’re pleased to show that the majority of people who’ve had Covid-19 seem to not be at increased risk of developing future heart complications. We now need to focus our attention on the long term impact the virus has on those who’ve been hit hardest by the disease.” Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation and consultant cardiologist, said: “These findings one year on from the start of the pandemic are welcome reassurance to the hundreds of thousands of people who have experienced Covid-19 with mild or no symptoms. “Throughout the pandemic, BHF researchers have made progress investigating the short and long-term effects of Covid-19 on the heart and circulatory system. There’s still a lot more work to be done, but for now, it seems the good news is that mild Covid-19 illness does not appear to be linked to lasting heart damage.”There were small abnormalities identified by MRI but these were not found more often in people who had mild Covid-19 than those that have never had it. The changes could have been caused by something other than coronavirus and they may not make any noticeable difference to the health of that person.