COVID Scouts — Edmonton’s Fall Expedition


Let’s clean up COVID-19, Edmonton!


Community-led education can help protect Edmonton residents from COVID-19.

COVID SCOUTS (Safer Community Outcomes & Utilization Through Support) — Edmonton’s Fall Expedition

It is a well-known fact that arguing with someone to change health behaviours doesn’t work well. In many cases, these confrontations can make people become more defensive or adversarial. Most people believe that they have personal control over their health. Therefore, being told to adopt even simple health-promoting behaviours without participation in the process can feel threatening and produce strong emotions. This is a common & normal process of health change.

In the context of COVID-19, media reports and social media influencers have recently encouraged strict enforcement and publicly shaming “COVIDIOTS”. These practices were essential and a key part of ensuring public awareness of emergency measures. More recently, however, enforcement measures have become one of the only tools used to persuade people to make simple health changes. These strategies persist despite extensive evidence that health professionals motivate others to change best when they “roll with resistance”, addressing personal values as part of process of health change.

Together, Edmonton can clean up COVID-19 once and for all. We need to build community leaders who can safely invite people to take additional precautions to prevent disease in high-risk communities. We need social proof to help change minds and save lives.

The Project

COVID SCOUTS are a small but mighty group of volunteer leaders who want to promote health behaviours as quickly as COVID-19 spreads in our community. A key focus of the project is to empower Edmonton residents to prevent COVID-19 together, through inspiring and motivational health marketing tactics.

What is the problem?

In the context of COVID-19, critical media reports and social media influencers have encouraged enforcement and publicly shaming “COVIDIOTS”.  These practices were essential as part of the early pandemic response, but they persist despite extensive evidence they may increase resistance to health change, increase public antipathy and increase health disparities.

What is the ‘big’ idea?

COVID SCOUTS are a cadre of volunteers and social media influencers who seek to shift COVID prevention discussions towards more fun and engaging conversations.  We will focus on supporting Edmonton neighbourhoods at increased risk of disease spread with awareness and education.

Why us?

To date, there does not appear to be any systematic effort to work with communities to prevent COVID-19 transmission.  Enforcement approaches may also not reach the community most at need of education and support.  This risks increasing personal responsibility for a disease that is best controlled by a coordinated grassroots response in affected communities.


Current Projects

Volunteer Sign-up – Edmonton, AB

Volunteer recruitment now closed. Please e-mail us at nursing@consortiacare.ca to ask about the status of our project or to join in our work.


Developing a Virtual Initiative – Phase I

Our core group is currently developing a virtual initiative to prevent COVID within the Edmonton area.

Enhanced Recovery after COVID-19 Exposure


As novel coronavirus (COVID-19) continues to spread, there has been a lack of discussion of basic nursing interventions known to improve outcomes for other infections. Many caregivers have also reported concerns after coaching their loved ones through upsetting signs of COVID-19 at home, like difficulty breathing and extreme tiredness. It is predicted that the ability to manage symptoms in the community has a significant impact on hospitalization rates for COVID-19. The aim of this document is to support communities — especially health professionals — with knowledge on how best to manage coronavirus symptoms among adults (18 years or older) currently in isolation/quarantine.

This working document starts the work of building a framework for COVID-19 symptom management. Following a review of research literature, four pillars of COVID-19 symptom management were identified. The current framework draws inspiration from evidence-based Enhanced Recovery after Surgery (ERAS) principles, which have dramatically improved post-surgical recovery times using a set of routine supportive care practices.

The 4 pillars of COVID-19 symptom management include:
  1. Home Exercise
  2. Breathing Exercises
  3. Management of Fever
  4. Nutritional Supplementation
Symptom Management Domains for COVID-19, Coronavirus
This content is provided for informational purposes only and is not intended to be a substitute for the advice of a health professional.

Please refer to official government information to assess your current risk of exposure to COVID-19, and to access appropriate health supports in your area.

Home Exercise

[Last Review: Mar. 22, 2020]


General Consensus | Home exercise is an important factor in preserving function during a period of acute pulmonary illness. At the same time, home exercise can be unsafe for some people depending on the severity of Novel Coronavirus (COVID-19) symptoms or cardiovascular risk. Family or friends should initially observe all physical activity from a safe distance (e.g. greater than 2 meters distance or via videoconferencing) and it should be possible to contact emergency services from the exercise setting. Low-intensity physical activity is recommended as an initial starting point for home exercise among persons managing symptoms of COVID-19. People should stop exercising immediately and call for medical attention if they experience the following symptoms:

  • Rapid loss of breath/extreme breathlessness
  • Cannot speak after a short rest period
  • Feeling dizzy or faint
  • Chest pain or symptoms of a heart attack
  • Severe pain
  • Feeling ‘off’

Does strenuous exercise lower viral immunity, increasing the risk that COVID-19 will progress?

In the early 1990’s, it was commonly believed that vigorous or endurance exercise created a brief period, or “open window” period, for contracting an upper respiratory tract infection (URTI). This continues to be discussed within the literature, primarily because it is known that cortisol (a stress hormone with immuno-suppressive functions) temporarily spikes in response to vigorous or endurance exercise. Key studies informing this hypothesis include epidemiological studies of distance runners. Compared to matched controls, it was found that runners who participated in a distance running event reported twice the amount of URTI symptoms in the two week period following the race. This finding was also confirmed across multiple large-scale observational studies of marathon runners in the late 1980’s. These findings suggested the existence of a “J-shaped” curve, where people who over-train experienced more frequent and severe symptoms of a URTI. The mechanism behind these changes are that the body is known to temporarily modulate non-specific immune responses in order to reduce the inflammatory response immediately following exercise.

However, it has been suggested more recently that other factors associated with strenuous exercise may actually have a greater influence on the development of URTI symptoms. For example, specific nutrient deficits — such as protein deficiency — can temporarily impair immune function. Other influencing factors include: fatigue, psychological stress (anxiety), exposures to pathogens and exposures to large crowds. Therefore, for the common cold, vigorous exercise does not independently increase the intensity of URTI symptoms when related factors are controlled. It remains unknown whether vigorous or endurance exercise would cause a worsening of viral symptoms for persons living with COVID-19.


Does exercise enhance the body’s ability to identify and kill cells infected with the SARS-CoV-2 virus?

Although there is limited information available on how SARS-CoV-2 — the infectious agent that causes COVID-19 — interacts with the host immune system, emerging data suggests that the virus activates a cascade of non-specific (innate) immune responses which contributes extensively to the development of inflammation and flu-like symptoms. This inflammatory response eventually leads to atypical pneumonia, and appears to also produce an acute decline in respiratory function. In some people, this progresses further to acute respiratory distress syndrome, or ARDS.

Emerging evidence suggests that SARS-CoV-2 will progress to a symptomatic COVID-19 infection when a person exhausts their supply of cytotoxic T lymphocytes (CTLs) and natural killer (NK) cells, which are necessary for the effective control of new viral infections in the body. While individuals continue to have an inflammatory response, the virus itself appears to exhaust the antiviral component of both non-specific and specific immune responses.

Interestingly, a single bout of vigorous exercise is widely known to produce a profound rise in circulating lymphocytes. The rise in lymphocytes in peripheral blood is also one of most commonly reproduced findings in human exercise physiology. There is also known to be a dramatic but transient rise in the functional capacity of lymphocytes after vigorous exercise. Similarly, strong evidence supports the idea that exercise induces a state of “immune surveillance” for viral pathogens. So, while exercise does dampen the non-specific component of immunity, it does not appear to cause immune suppression within the acquired (specific) branch of immunity which is important to viral protection.

Therefore, vigorous exercise is likely to enhance a person’s immune system capacity in the short term by augmenting specific immune responses. This temporarily enhances the ability of the body to detect and destroy SARS-CoV-2 infected cells. Exercise also appears to reduce non-specific immune responses which, in turn, reduce the negative impacts from inflammation in the body. These positive impacts are likely counterbalanced by several functional limitations that the disease creates, making it difficult to exercise safely.


What are the risks of exercising with COVID-19 symptoms?

The main risk of exercise among people with respiratory illness is related to the added stress it can place on the body. Many people with flu-like symptoms report significant muscle aches, fatigue and exertion in response to simple movements like walking on level. In the case of COVID-19, there is the additional pressure of breathlessness among many people affected by the disease. These limitations are important, as a person can easily overload their cardiac or respiratory capacity during exercise. The main risk, therefore, is a serious cardiac or respiratory concern during exercise.

Extensive research supports the idea that early mobilization and therapeutic exercise — even while ventilated — can positively impact the course of Acute Respiratory Distress Syndrome (ARDS) in ICU. The positive effect of exercise on ARDS outcomes in ICU settings appears to be mediated by:

  • Reversal of the process of Acute Lung Injury (ALI) induced muscle wasting
  • Reduced systemic inflammation, by modulation of non-specific host defenses (lower neutrophilic influx into alveolar space, reduced GCSF and reduced cytokine expression)
  • Increase in diaphragmatic strength, reducing the physical work of breathing at rest
  • Improved blood flow (perfusion) to key structures within the lungs, improving gas exchange

Therefore, it is wise for a person exercising at home to initially have supervision (at a distance) by a family or friend. It is also important to have telephone access to emergency medical responders, should exercise induce a major event. To prevent these risks, exercise should initially be well-tolerated and not induce any significant distress. A review of evidence for ICU patients with ARDS found that low to moderate exercise intensity (5-25 min twice daily) seemed to be protective and induce significantly positive outcomes in a controlled setting.


Do home exercise programs exist for people with mild COVID-19 symptoms?

Yes. Low-intensity home exercise programs exist, and are especially safe when supervised (at a safe distance) by a care provider, family member or friend. The Canadian Centre for Activity and Aging has endorsed the Home Support Exercise Program, which is commonly used as a safe exercise program among older-adults with respiratory conditions in home care settings. Some exercises may need to be adapted to ensure safety among people living with COVID-19 symptoms.


References

Bermon S, Castell LM, Calder PC, Bishop NC, Blomstrand E, Mooren FC, et al. Consensus statement immunonutrition and exercise. Exerc Immunol Rev (2017) 23:8–50.

Bredin SD, Gledhill N, Jamnik VK, Warburton DE. PAR-Q+ and ePARmed-X+. Can Fam Phys (2013) 59 (3) 273-277.

Campbell JP, Turner JE. Debunking the Myth of Exercise-Induced Immune Suppression: Redefining the Impact of Exercise on Immunological Health Across the Lifespan. Front Immunol. 2018;9:648. Published 2018 Apr 16. doi:10.3389/fimmu.2018.00648

Nieman DC, Johanssen LM, Lee JW, Arabatzis K. Infectious episodes in runners before and after the Los Angeles Marathon. J Sports Med Phys Fitness (1990) 30(3):316–28

Nieman DC. Exercise, infection, and immunity. Int J Sports Med (1994) 15(Suppl 3):S131–41. doi:10.1055/s-2007-1021128

Peters EM, Bateman ED. Ultramarathon running and upper respiratory tract infections. An epidemiological survey. S Afr Med J (1983) 64(15):582–4

Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol (2020) [in print] doi:10.12932/AP-200220-0772

Rovina N, Koutsoukou A, Koulouris N. Therapeutic exercise in improving acute lung injury: a long distance to be covered. Ann Transl Med. 2015;3(18):273. doi:10.3978/j.issn.2305-5839.2015.09.13

Spence L, Brown WJ, Pyne DB, Nissen MD, Sloots TP, McCormack JG, et al. Incidence, etiology, and symptomatology of upper respiratory illness in elite athletes. Med Sci Sports Exerc (2007) 39(4):577–86. doi:10.1249/mss.0b013e31802e851a

Zheng, M., Gao, Y., Wang, G. et al. Functional exhaustion of antiviral lymphocytes in COVID-19 patients. Cell Mol Immunol (2020). [in print] doi:10.1038/s41423-020-0402-2


Breathing Exercises

[Last Review: Mar. 25, 2020]


General Consensus | Difficulty breathing at rest or while lying flat may indicate an urgent respiratory condition requiring immediate assessment by a health professional. In the case of Novel Coronavirus (COVID-19), breathlessness is also a sign of more severe disease presentation. Shortness of breath at rest, in fact, is often accompanied by other severe symptoms. It is recommended to seek professional health advice if shortness of breath occurs at home.

If coping with shortness of breath at home, deep breathing is generally recognized as safe to reduce symptom distress. It is recommended to start with a deep breathing technique where the person breathes in deeply through their nose, and breathes out fully through their mouth. This is to ensure that the person completing deep breathing exercises will breathe out longer than they breathe in, while also providing an opportunity for full lung expansion. Forced expiratory methods are also generally known to improve obstructive processes associated with inflammation in the bronchi of the lung. However, these additional techniques may require coaching and professional support.


How do breathing exercises relieve shortness of breath from COVID-19?

Unlike other chronic respiratory conditions (like COPD or asthma), COVID-19 typically progresses to atypical pneumonia. This type of pneumonia is often called “walking pneumonia” as it can be accompanied by few respiratory secretions and a non-productive (dry) cough. If a chest computed tomography (CT) scan is performed on a person at this stage of COVID-19 infection, ground glass opacities are likely to be visible. These opacities — small black voids within the lung — are likely caused by alveoli and other air spaces of the lungs filling with fluid as a side-effect of a severe inflammatory response. Much like an acute exacerbation of COPD, this is likely a neutrophil-mediated inflammatory response.

Because of the pathophysiology of COVID-19, persons suffering from shortness of breath are not likely to require help clearing thick secretions from the lungs, nor do they need to improve the effectiveness of their cough. Instead, the primary goals of breathing exercises among a person with COVID-19 include improving lung capacity by:

  • Promoting drainage of transudate (thin, clear fluids) within the alveoli
  • Reversing obstructive processes (trapped air) due to bronchoconstriction and inflammation of the lung
  • Improving perfusion (circulation) to inflamed areas of the lung

The primary goal of respiratory exercises, therefore, is to adapt breathing to accommodate an acute inflammatory response in the lung.


What breathing techniques can help manage shortness of breath symptoms from COVID-19?

Many breathing techniques exist to manage breathing difficulties. Especially if wheezing is present, one effective strategy is to combine abdominal breathing with pursed-lip breathing — see Video Example 1. This combined breathing technique can help someone to catch their breath.

Another powerful breathing exercise that is easily taught is the Active Cycle of Breathing Technique (ACBT)— see Video Example 2. This strategy was designed to help to clear mucous from the the lungs, although it may also have an effect on clearing thin fluids (transudate) that is common with COVID-19 infection.

ACBT breathing consists of 3 phases:

  1. Breathing Control
  2. Deep Breathing
  3. Huffing or Controlled Coughing
Video Example 1 – Managing Shortness of Breath

Video Example 2 – Active Cycle of Breathing Technique

Breathing Control | Breathing control helps relieve chest tightness and symptoms of panic by giving people back conscious control over their breath. The primary goal is to start by decreasing the sense of panic, and then helping the person regain control over their breathing pattern. It is recommended to continue practicing breathing control until a person feels more able to control their breathing, and relaxed. If someone cannot catch their breath after some time, urgent medical attention is warranted.

Basic Strategies for Breathing Control
  • If you can, breathe in and out gently through your nose.
  • If you must breathe through your mouth, try breathing with ‘pursed lips’ to increase the time spent in expiration.
  • Let go of any muscle tension with every breath out. Relax your your shoulders with each breath out.
  • Slowly, with each breath, try to slow your breathing rate.
  • Relax and focus on your breathing. Try closing your eyes to focus on your breathing more effectively.

Deep Breathing | Deep breathing exercises promote maximal inspiration to help expand the lungs. This is known to increase blood oxygenation as well as induce a relaxation response in the body. Deep breathing exercises are usually enhanced with coaching from a trained health professional such as a Respiratory Therapist, nurse specialist or physiotherapist.

Basic Strategies for Deep Breathing
  • Continue to relax your muscles with every breath out. Focus on relaxing your chest muscles (ribs) and shoulders as you breathe out.
  • Take a long, slow, deep breath in your nose.
  • After breathing in fully, hold the air in your lungs for about 3 seconds before breathing out.
  • Without forcing the air out, breathe out with relaxed muscle tone. Do not force the breath out, so it sounds like a sigh.
  • Repeat 3 – 5 times. If feeling light-headed, go back to the breathing control (1st step) of the cycle.

Huffing or Controlled Coughing | In the case of COVID-19, huffing may help displace transudate (thin, clear fluids) within the alveoli into the bronchioles where they can be coughed up as sputum. Huffing is simply a forced (strong) expiration, where there person breathes forcefully out with an open cough (like they are trying to fog up a mirror). People can try different intensities of huffing. However, this final stage of breathing often induces productive coughing. Producing phlegm which is a sign of effective huffing technique, or forced expiration, and is encouraged.


Are there other more advanced breathing strategies that a health professional can administer?

Aside from medication therapies, a physiotherapist trained in respiratory care can provide advanced chest physiotherapy modalities to persons with acute respiratory symptoms related to atypical pneumonia. Postural drainage is a promising intervention for persons with COVID-19 related shortness of breath.

Video Example 3 – Postural drainage for COVID-19 symptoms


References

Cabillic M, Gouilly P, Reychler G. [Manual airway clearance techniques in adults and adolescents: What level of evidence?] Revue des Maladies Respiratoires. 2018 May;35(5):495-520. doi:10.1016/j.rmr.2015.12.004.

Lewis LK, Williams MT, Olds TS. The active cycle of breathing technique: a systematic review and meta-analysis. Resp Med. 2012; 106(2):155-172. doi:10.1016/j.rmed.2011.10.014

Pan F, Ye T, Sun P, Gui S, Liang B, Li L, Zheng D, et al. Time course of lung changes on Chest CT during recovery from 2019 Novel Coronavirus (COVID-19) pneumonia. Radiology. 2020; e200370 [in print] doi: 10.1148/radiol.2020200370

Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol (2020) [in print] doi:10.12932/AP-200220-0772

The Active Cycle of Breathing Techniques. Association of Chartered Physiotherapists in Respiratory Care. Leaflet GL-05. 2011. https://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf


Management of Fever

[Last Review: Mar. 23, 2020]


General Consensus | Most mild cases of Novel Coronavirus (COVID-19) produce a fever and dry cough. It is important to note that people with COVID-19 who have fever are highly contagious, even if they suppress fever with medication. Rest and other supportive care strategies are commonly recommended during this period. This includes preventing dehydration by consuming plenty of fluids, and monitoring for urgent signs (e.g. acute confusion, seizures or loss of consciousness) which require assessment by a medical professional. There is currently scientific debate on whether or not it is helpful to suppress mild-to-moderate fevers (body temperature ≤ 39.9 °C) with certain NSAIDs — like ibuprofen — among persons with COVID-19. However, in cases where an adult develops a core body temperature exceeding 40.0°C (104.0°F) or when they are short of breath at rest, it is recommended to take immediate action to reduce fever symptoms.

Generally safe interventions to alleviate fever symptoms include:

  • Wearing light clothing and removing heavy blankets
  • Applying a cool cloth to the forehead
  • Promoting adequate intake of clear fluids
  • Using OTC medications as directed to reduce fever
  • If shivering, using a blanket to reduce shivering. (Shivering increases body temperature and places increased metabolic demands on the body.)

Does fever help or harm the body’s ability to clear viral infections?

In response to cellular damage as well as the actions of specific immune system cells, the body will commonly undergo an acute phase prior to the onset of fever. This response occurs after the release of acute phase proteins into the blood. Acute phase proteins — also known as cytokines — are sensed quickly within the bloodstream by the hypothalamus. The hypothalamus is a small part of the brain that regulates body temperature, among other things. Because many cytokines start a cascade of inflammatory responses within the body, fever is typically accompanied by other flu-like symptoms like muscle aches. In most cases, a mild-to-moderate fever will work in tandem with other inflammatory processes to help the body to clear a viral infection.

Across a broad selection of animal species, fever is generally considered to be a protective immune response against viral infection. Hippocrates had even claimed that he could heal any disease if only he could provoke a fever. (It is worthy of note that infectious diseases were a commonly untreatable medical concern in Ancient Greece.) Provoking someone to live with a low-grade fever over an extended period of time is also known to enhance the clearance of some viral pathogens, like Hepatitis C. Finally, emerging research on viral pneumonia (e.g. Influenza-like Illness) also encourages a permissive approach to treating fever symptoms in order to enhance the immune system response to illness.


Is it dangerous to not treat a mild fever if I have symptoms related to COVID-19?

It depends. Febrile illness will dramatically increase the metabolic demands placed on the body and, therefore, oxygen and caloric demands. As a result, sustained symptoms of fever are potentially dangerous for people experiencing:

  • Core body temperature > 40.0°C (104.0°F)
  • Shortness of breath at rest
  • Dehydration or malnutrition
  • Heart or lung disease
  • Acute neurological concerns (e.g. brain injury or stroke)
  • An inability to sleep
  • Severe, disabling symptoms
  • Other medical conditions, such as endocrine disorders

Fever may also present additional risks for people suffering from acute kidney injury following a period of dehydration. In many of these cases, it is recommended to consult with a health-care provider via phone for specific management advice.

On the other hand, a growing number of researchers assert that a mild-to-moderate fever between 38.0 – 40.0°C (100.0 – 104.0°F) may be protective for most patients. A randomized controlled trial was initiated on antipyretic treatments and its impact on clinical outcomes in ICU. It is noteworthy that this trial was halted prematurely after interim data analysis because there were 7 deaths within the aggressively-treated fever cohort (multiple interventions for fever > 38.5°C ) compared to only 1 death in the permissive fever cohort (treatment initiated when temperature > 40°C). Other studies have found no significant difference in clinical outcomes among patients who received antipyretic treatment, suggesting treatment to suppress fever does not improve clinical outcomes among most acutely-ill patients. Finally, although high-grade fevers commonly cause seizures among children, there is limited evidence that the use of antipyretics actually prevents these complications.


Is ibuprofen safe to take for fever symptoms related to COVID-19?

The safety of non-steroidal anti-inflammatory drugs (NSAIDs) — including ibuprofen — for treating COVID-19 symptoms is currently unknown. For people already prescribed NSAIDs, they are encouraged to continue taking these medications until they can speak with a medical professional. That said, some experts within the U.K. and Europe have recommended against use of anti-inflammatory medications (specifically, ibuprofen) based on anecdotal associations between high-dose NSAID use and more severe trajectories of COVID-19 illness among young adults in France. On Mar. 23, 2020, the European Medicines Agency clarified that the use of ibuprofen for the control of COVID-19 symptoms remains under investigation. Until these questions are answered, other OTC medication options (like acetaminophen) could be a safer first-line option for fever suppression in COVID-19.

Prior to the onset of COVID-19, there have been documented concerns with the cardiovascular, gastrointestinal and renal safety profile of many NSAID’s when used above the maximum recommended dosage. There has also been research into the use of anti-inflammatory medications among people facing infection with traditional coronaviruses. The immune response against other coronaviruses are typically mediated by mast cells, which release cytokines and other inflammatory factors to isolate the virus in lung tissue. NSAIDs, on the other hand, work by inhibiting the cycloxygenase enzyme which in turn reduces mast cell activity in lung tissue.

While this temporarily helps to reduce inflammation alongside fever, the use of NSAIDs may also mildly reduce the ability of mast cells to respond to novel pathogens in lung tissues. It is yet unknown whether this produces a net positive or negative effect on the course of the disease. Since the majority of COVID-19 cases do not result in death, subtle changes in morbidity and mortality are not easily detected. However, emerging evidence suggests the sustained use of anti-inflammatory drugs could increase morbidity and mortality for other (non-COVID-19) viral pneumonias.


References

Aronoff DM, & Neilson EG. Antipyretics: Mechanisms of action and clinical use in fever suppression. American Journal of Medicine. 2001; 111, 304-315. doi:10.1016/S0002-9343(01)00834-8

Day M. COVID-19: Ibuprofen should not be used for managing symptoms, say doctors and scientists. BMJ. 2020; 368:m1086 [in print] doi:10.1136/bmj.m1086 (Published Online 17 March 2020)

Day M. COVID-19: European drugs agency to review safety of ibuprofen.
BMJ. 2020; 368:m1168 [in print] doi:10.1136/bmj.m1168 (Published Online 23 March 2020)

Holtzclaw, BJ. Chapter 2: Alterations in Thermoregulation. In: Pathophysiological Phenomena in Nursing: Human Responses to Illness (3rd Ed.) Eds: Carreri-Kohlman V, Lindsey AM, & West CM. 2003; 15-34. Saunders: New York.

Kluger MJ, Kozak W, Conn C, Leon L, & Soszynski D (1996). The adaptive value of fever. Inf Dis Clin of North Amer. 1996; 10(1), 1–20. doi:10.1016/S0891-5520(05)70282-8

Kritas SK, Ronconi G, Caraffa A, Gallenga CE, Ross R, & Conti P. Mast cells contribute to coronavirus-induced inflammation: new anti-inflammatory strategy. Journal of Biological Regulators and Homeostatic Agents. 2020; 34(1). doi:10.23812/20-Editorial-Kritas

Nikhil P, Dipak R, Nina S, Leena MD, Richard NW, Martin O, et al. Febrile seizures. BMJ. 2015; 351 :h4240 doi:10.1136/bmj.h4240

Mackowiak PA. Physiological Rationale for Suppression of Fever. Clinical Inf Diseases. 2000; 31(S5):S185–S189. doi:10.1086/317511

Plaisance KI, Mackowiak PA. Antipyretic Therapy: Physiologic Rationale, Diagnostic Implications, and Clinical Consequences. Arch Intern Med. 2000;160(4):449–456. doi:10.1001/archinte.160.4.449

Ray JJ, Schulman CI. Fever: suppress or let it ride?. J Thorac Dis. 2015;7(12):E633–E636. doi:10.3978/j.issn.2072-1439.2015.12.28

Zhang J, Zhou L, Yang Y, Peng W, Wang W, & Chen X. Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics. Lancet Resp Med. 2020; 8, e11-e12. doi:10.1016/S2213-2600(20)30071-0 2020


Nutritional Supplementation

[Last Review: Mar. 28, 2020]


General Consensus | Specific nutrient deficiencies are known to impact the immune response to viral pathogens, including Novel Coronavirus (COVID-19). Especially within northern climates, many people are Vitamin D deficient and can benefit from taking a Vitamin D supplement. Correcting specific nutrient deficiencies — particularly Vitamin D serum levels — is generally recognized as safe and effective at augmenting the natural immune response within the body.

Emerging data also suggests that COVID-19 infection may reduce a person’s ability to smell and taste food, potentially making food less palatable. This is of concern because severe flu-like symptoms associated with COVID-19 are likely to produce mild-to-moderate anorexia and dehydration. If COVID-19 also affects taste and smell, it is generally accepted that fever symptoms would be accompanied by significantly reduced food and fluid intake. This is expected to significantly increase the risk of malnutrition occurring during the acute period of COVID-19 infection. It is highly recommended for persons with flu-like symptoms from COVID-19 to:

  • Consume plenty of clear fluids through the day.
  • Consciously seek out high-protein foods, even if not hungry.
  • Consider the value of trying stronger-flavored or bland foods if your usual go-to foods suddenly taste unpleasant.

Does a short period of malnutrition lower the body’s ability to fight COVID-19 infection?

Yes. Malnourished patients are more vulnerable to viral infection, and are also more likely to have a more severe course of Influenza-like Illness. Protein-calorie malnutrition also has a significant cumulative impact on immune response. Malnutrition resulting in protein catabolism (breakdown) results in an immediate reduction in the number of circulating B and T lymphocytes within the blood. The production of key inflammatory proteins — such as IL-6 and TNF-α — is also significantly reduced when protein catabolism occurs. Both lymphocytes and inflammatory proteins are necessary for a sustained viral response in the body.

Malnutrition is associated with worse clinical outcomes and increased risk of death among persons with active Influenza infections. Similarly, among patients who were provided with supplemental protein, their viral immune response is known to be significantly stronger against common pathogens. This effect is well-documented, particularly as a cause of primary immune deficiency within developing countries with food scarcity. Among severely malnourished patients, almost all host immune responses are diminished.

Among patients who died from COVID-19 infection, emerging data about their patient characteristics also appears to the significant role that nutrition plays in disease recovery. This is an expected finding, as both the action and expression of lymphocytes is significantly reduced during periods of malnutrition. Paradoxically, the innate immune response (particularly inflammatory proteins such as IFN) are can cause anorexia and protein catabolism, or breakdown. This response generally results from the interaction of inflammatory proteins with the hypothalamic-pituitary axis, causing the release of multiple proteins including leptin and catecholamines. While this stress response can promote healing of damaged tissues and neutralization of ROS over time, it also leads to loss of appetite, muscle breakdown and immunosuppression.

At the same time, protein overload is also not beneficial. Multiple studies of Acute Respiratory Distress Syndome (ARDS) in ICU settings have found that early enteral feeding is actually associated with worse clinical outcomes. There is also no evidence that the early initiation of parenteral (IV) nutrition among persons hospitalized for ARDS has any benefit on clinical outcomes. Protein-calorie supplementation appears to augment the body’s natural immune response to viral respiratory illnesses. Similarly, malnutrition is associated with worse outcomes in this group.

Despite the positive clinical impact of protein-calorie supplementation on acute respiratory infections, overfeeding is not recommended. Overfeeding, in fact, has been known to suppress autophagy. Autophagy is a key cellular repair process whereby cells “eat” themselves as a means to rebuilding healthier cells and tissues. While the significance of suppressing autophagy remains up for debate, it is hypothesized that overfeeding prevents the body from clearing intracellular damage through this process. Therefore, one promising area for the treatment of COVID-19 related malnutrition is inducing a rapid-cycling fasting state where a person has a bolus intake of high-protein meals amidst short (3 hour) fasting periods during the day. It is currently unclear, however, whether this approach would improve or worsen clinical outcomes.


Can some nutritional supplements improve the immune response against COVID-19?

While there is much speculation on particular micro-nutrients that may help fight COVID-19, there is limited clinical data available from which to draw any solid conclusions. There are, however a few emerging perspectives within the research literature on COVID-19:

  • Antioxidant Support. The pathophysiology of the SARS-CoV-2 virus (COVID-19) is complex. However, one key process associated with COVID-19 infection is that neutrophils eventually move into the lungs, releasing Reactive Oxygen Species (ROS) in the process. These chemical mediators damage cellular tissues, in turn producing a stronger inflammatory response. While this is often effective for bacterial infections, the non-specific immune response tends to be an inefficient method for fighting viruses in the lower respiratory tract. Antioxidants are likely to neutralize ROS somewhat, and are mentioned as a possible intervention to preserve lung function as COVID-19 progresses. Many potent antioxidants come from food, including colourful vegetables and fruit.
  • Zinc. Although it is currently unknown whether hydroxychloroquine (HCQ) can effect a COVID-19 cure, one scientific explanation is that HCQ appears to alter cellular uptake of zinc within infected cells in the lung. There is extensive study of the effect of zinc lozenges on reduction in the frequency and severity of traditional coronavirus infections, and it appears that zinc does have some positive impact on recovery from the common cold. Emerging laboratory research also suggests that zinc may inhibit the replication of SARS-CoV-2 RNA, among other things.

Other theories have cited the positive potential of specific nutraceuticals (e.g. Vitamin C) which remain largely uninvestigated and of unknown clinical significance. While the science behind the SARS-CoV-2 virus continues to be investigated, it is possible that these supplements may help. However, it is also possible that the use of specific natural health products may cause a more rapid progression of COVID-19. For these reasons, adjunct treatments and nutraceuticals are not mentioned in the ERACE working document at this time.


References

DeBoer MD, Scharf RJ, Leite AM, et al. Systemic inflammation, growth factors, and linear growth in the setting of infection and malnutrition. Nutrition. 2017; 33: 248-253. doi:10.1016/j.nut.2016.06.013

Dushianthan A, Cusack R, Burgess VA, Grocott MP, Calder PC. Immunonutrition for acute respiratory distress syndrome (ARDS) in adults. Cochrane Database Syst Rev. 2019;(1). doi:10.1002/14651858.CD012041.pub2

Li X, Wang L, Yan S, et al. Clinical characteristics of 25 death cases infected with COVID-19 pneumonia: a retrospective review of medical records in a single medical center, Wuhan, China. medRxiv. January 2020:2020.02.19.20025239. doi:10.1101/2020.02.19.20025239

Paules CI, Marston HD, Fauci AS. Coronavirus Infections—More Than Just the Common Cold. JAMA. 2020;323(8):707–708. doi:10.1001/jama.2020.0757

Osman AH. Protein energy malnutrition and susceptibility to viral infections as Zika and Influenza viruses. J Nutr Food Sci. 2016;6(3):1000489. doi:10.4172/2155-9600.1000489

Skipper A, Coltman A, Tomesko J, et al. Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults. J Acad Nutr Diet. 2020;120(4):709-713. doi:10.1016/j.jand.2019.09.011

Shi Q, Zhao K, Yu J, et al. Clinical characteristics of 101 non-surviving hospitalized patients with COVID-19: A single center, retrospective study. medRxiv. January 2020:2020.03.04.20031039. doi:10.1101/2020.03.04.20031039

Sundaram ME, Coleman LA. Vitamin D and Influenza. Adv Nutr. 2012;3(4):517-525. doi:10.3945/an.112.002162

Umbrello M., Radrizzani D., Iapichino G. (2017) Acute Respiratory Distress Syndrome: Metabolic Support. In: Chiumello D. (eds) Acute Respiratory Distress Syndrome. Springer, Cham

Van Dyck, L., Casaer, M.P. and Gunst, J. (2018), Autophagy and Its Implications Against Early Full Nutrition Support in Critical Illness. Nutr Clin Practice, 33: 339-347. doi:10.1002/ncp.10084

Yaseen M. Arabi, Hasan M. Al-Dorzi and Musharaf Sadat. Protein intake and outcome in critically ill patients (2020). Current Opinion in Clinical Nutrition and Metabolic Care. 2020; 23(1): 51-58. doi:10.1097/MCO.0000000000000619


What Wuhan lacks, Alberta already has

Imagine living in Wuhan, China during the Novel Coronavirus (2019-nCoV) outbreak. The street outside your apartment is eerily quiet, but you see a City worker in protective equipment walking down the street. The worker is rather gracefully spraying disinfectant on benches and railings. Looking out your window, you smell the disinfectant and feel a bit nauseated as your stomach growls. Pangs of hunger are setting in. You boil a pot of water and prepare the last of your noodles from the pantry with some leftover fish from the fridge.

As you contemplate going to back to the local supermarket to again forage for scraps of food, a loud speaker in the street can be heard in the distance echoing warnings to stay at home. The Wuhan local government is urging you to stay inside. Meanwhile, you see that there is much needed nutritious food and supports being delivered to a Downtown district of Wuhan. There is nothing to support a normal life in your part of the city. Against your own wisdom, you make the trek to a more centralized part of Wuhan that is rife with essential resources but also unknown risks.

Fear is a funny thing. While fear can encourage people to take appropriate precautions to protect their health, the emotion can also activate our survival instincts. In these cases, sick patients will congregate around trusted institutions (like hospitals) to gain a sense of control over their health. Fear is partly why humans do not easily comply with quarantines and travel bans. So, how do we work with fear?

Wuhan’s Unspoken Risk Factor

You may assume that Wuhan lacks basic resources to control the spread of 2019-nCoV. However, that is simply not true. Health insurance is mandatory for most Wuhan residents and directly financed by local government (REF). As a result, public hospitals are very accessible to almost all Wuhan residents. There is also a good supply of clinics across most of Hubei province. While Wuhan’s healthcare system is vastly different from Canada, the city apparently does a pretty good job providing illness care. Where Wuhan fails is around coordinating community services, like home care. These community-based services are unfunded, and in many major Chinese cities (like Wuhan) they hardly exist at all.


“The definitive factors in determining whether someone is in good health extend significantly beyond access to care and include the conditions in their life and the conditions of their neighborhoods and communities.”

— John Auerbach, U.S. Centers for Disease Control and Prevention

Imagine going back to Wuhan. You feel lightheaded and have some muscle aches, but you don’t actually know if you need to go to a hospital. You need to speak with a nurse or doctor and get their opinion about your health condition. Better yet, if a community nurse could take your temperature and assess you at home, your worst fears would be allayed without spreading the virus throughout the streets of Wuhan. Without any access to basic services in your immediate neighborhood, you have no choice but to make the trek to a centralized Wuhan hospital to be assessed. Here you will likely wait for hours in a crowded hallway alongside thousands of other Wuhan residents, waiting for an exhausted health professional to assess your condition.

As “the Chicago of China”, Wuhan is a major urban center that operates on a centralized model of illness care. Sick residents, therefore, are expected to present at a outpatient clinic or hospital to be assessed. In some instances, this centralized model of care can increase the spread of viral diseases and chaos in the face of disease.

Photo of Wuhan, China prior to Coronavirus outbreak
Wuhan is the largest city in Hubei province and the most populous city in Central China. The city of over 11 million people is sometimes referred to as “the Chicago of China” by foreign sources.

Alberta’s Unspoken Protective Factor

Enter Alberta, Canada. A province currently rated at low risk of exposure to the Novel Coronavirus (2019-nCoV), partly because we do not have direct flights or travel routes to areas currently affected by the virus. But, even in the event that new cases crop up in Toronto or Vancouver, Alberta is not likely to have the same response. Why?

Alberta’s health care system is perhaps the greatest gift to residents in times like this. In the unlikely event that multiple cases of 2019-nCOV are detected in our province, the level of system integration here allows health professionals to openly share information and coordinate a unified response. China might be able to build a hospital in 10 days, but Alberta can transform its entire health system in 10 days.

Aside from obvious differences in both urban density and environment, Alberta has spent over a decade integrating all levels of it’s health response. And, while the province is perfectly designed to respond to a Coronavirus outbreak, its very design may prevent an outbreak from happening in the first place. That is because Alberta is well-positioned to mobilize its entire health sector to form a coordinated response plan. The province can also rest assured that this has already be done before. For example, Alberta efficiently evacuated all the patients from both Slave Lake and Fort McMurray during rather unexpected forest fires. The same system that worked then is the same one that will work now.

In a nutshell, conservative Alberta has achieved a level of government control over its health system that Communist China could only dream of. Imagine the worst case scenario of a 2019-nCoV outbreak in Alberta. The government could easily alert all residents to call 8-1-1 if they have any symptoms of disease. From this point, people would access standardized assessments and information overseen by Registered Nurses… from the comfort of their own home. This telephone service could also provide real-time surveillance data to the health system, providing health care managers with a birds-eye view of emerging cases in the community. Public health teams would be activated early, primary care networks could support family doctors manage patients in the community, home care could assist vulnerable patients before transfer to hospital, and hospital managers could prepare specific units to safely contain the influx of patients. The province has the capacity to deploy an entire workforce to tackle 2019-nCoV with existing resources.

I would argue that Alberta has a precious public health resource that Hubei province could only envy. Since the advent of SARS in 2002, Canadian provinces (like Alberta) have already prepared extensively for epidemics and pandemic events. Alberta, in particular, has spent the last decade building a provincial backbone for a coordinated community response.

So, while 2019-nCoV is nothing to gawk at… Alberta residents shouldn’t worry too much. Your provincial health care system is built for this. Even more reassuring, Alberta’s health care system will likely to prevent an outbreak before it even starts.

Addendum — Mar. 15, 2020

This article was published prior to the existence of any COVID-19 cases within Alberta. As a result, it does not reflect nor intend to represent the current opinion of any government authority or agency.

Please refer to government information for official updates & to assess your current risk of exposure to disease. In Alberta, official information is available at alberta.ca/covid.

Introducing Trauma-informed Empathy (TiE™)

According to the latest research, 1 in 5 Canadians are trained in basic first aid or C.P.R. This number is dangerously low, but thankfully most health professionals remain current in these basic skills. Empathy is also a basic skill required before people can help others in distress. The practice of empathy helps us relate to others and respond effectively, and is also a core skill required of professionals in health & social service positions. In many cases, empathy feels easy… until it isn’t. For example, empathy is not easy when we feel rejected by the other party, or when there is conflict. Empathy also feels difficult when barriers impede natural communication. And, a lack of empathy impacts our mental health. We need a basic toolkit for these situations, so we can leave difficult situations feeling less stress.

What is empathy?

Empathy does not necessarily predict helping behaviours; however, the act of empathy is known to make helping others easier. Empathy is also different from pity or compassion. Although empathy feels like an ancient concept, the word itself was developed in the late 20th century from the German term Einfühlung, meaning ”em-” (in)  and “pathos-” (feeling).  The theme of connecting with the senses (Einfühlung) was popular among German artists, and to a lesser extent within psychology.  Early German psychologists researched the different somatosensory sensations produced in response to different environmental stimuli.

The concept of empathy, however, evolved in the mid-1950’s as social psychologists generated new understandings of how people form groups and relationships.  Empathy came to describe a social phenomenon that blurred the boundary between the self and other.  At this time, empathy research also moved beyond psychology and to other social sciences like sociology.  Researchers like Jane Goodall eventually challenged human-centered models of empathy by meticulously documenting how primates – and other mammals – also formed altruistic and affectionate attachments. From that point onward, a growing base of research has distinguished emotions from rational thought. This has also impacted the conceptualization of empathy in the literature. Our current understanding of empathy has defined universal yet flexible processes whereby people connect in predictably irrational ways.


Trauma-informed Empathy (TiE™) Toolkit*

TiE™ Working Algorithm

While many health professionals associate empathy with active listening, listening alone doesn’t ensure understanding. Behind empathy are a set of critical skills (e.g. presence, safety and belonging) which open minds to deeper connection. Our goal in creating this algorithm was to utilize the emerging science of connection to improve the quality of brief clinical interactions.

TiE™  Companion Guide

Want to co-author next year’s empathy guide?  With your help, we plan to publish our 2020-2021 empathy methods in a peer-reviewed journal.  Please e-mail us at nursing@consortiacare.ca if you would like to join our Community of Practice.

TiE™ Competency Tool

Looking to provide feedback on your team’s empathy skills?  Try out this Core Competency Tool that integrates core skills from Rapid Response Empathy™ training.


* The Trauma-informed Empathy (TiE™) toolkit is published as an open-source set of tools. These tools are intended to support Regulated Health Professionals in enhancing their awareness of empathy and rapport-building techniques. These tools can be shared freely (with attribution) and are licensed under the Creative Commons CC-BY-4.0 License. To view a copy of this license, visit:  creativecommons.org/licenses/by/4.0/

Can stress cause Type 2 Diabetes to progress?

Most people know that chronic stress is hard on our bodies. But, many do not realize that Type 2 Diabetes can progress quicker when people cope with either physical or psychological stress over a long time.   In fact, most patients are never told about the strong link between chronic stress, inflammation and diabetes.

In many cases, the anti-inflammatory effects of diet and exercise are the prime mechanism behind most lifestyle interventions for Type 2 Diabetes.  Multiple large-scale studies have also demonstrated a strong link between chronic stress and Type 2 Diabetes.   The link is so strong, physiologists commonly measure Allostatic Load (or chronic stress exposure) as a routine part of metabolic research.

But, how exactly does stress impact diabetes?

Inflammation is part of our body’s most basic architecture.  Both our brain and body regulate inflammation because of its’ powerful effects on the body.  Too much inflammation, and we fail to achieve health.   Too little, and there is no reliable way to defend and repair our bodies after injury or illness.

Stress hormones (the main class being glucocorticoids) help us respond to stress, and are well-known for turning down our inflammatory response.  Glucocorticoids specifically shut off inflammation to conserve energy, so more blood sugar is available to run away from that tiger or fight that infection.  Therefore, all stress hormones cause your liver and muscles to “dump” sugar into your blood – and lots of it at that.

In order to sustain higher blood sugars, stress hormones also change our glucose metabolism.  For example, the stress hormone cortisol increases insulin resistance in  skeletal muscle cells.   Therefore, muscles exposed to stress are less likely to use blood sugar and instead use their own glucose and protein stores to do the work of moving.  If exposed to cortisol for a long time, skeletal muscles will start to shrink as they consume their own protein energy stores.

So, inflammation results in higher blood sugars precisely because our body must use glucocorticoids to manage the resulting stress response.   Inflammation is, therefore, a stress-linked pathway.  And, it’s one reason why people with Type 2 Diabetes find it difficult to exercise.  Their muscles are already depleted, after months (or even years) of being deprived of glucose stores.   At the point of diagnosis for diabetes, most muscle cells will have lost insulin receptors on their cell membranes.

Thankfully, insulin resistance is highly reversible.  After only a couple of moderate-to-vigorous exercise sessions, both cardiovascular and resistance exercise dramatically increases the insulin sensitivity of our muscle cells.  Because exercise itself is stressful, it yields the capacity to shut off stress once we stop exercising, and it moderates our inflammatory response.

Great. Now, what should I do?

Conventional approaches for diabetes treatment typically ignore the role of inflammation in Diabetes progression.  There are also many varied factors that cause diabetes, so there is not one single cause of diabetes.  However, all treatments – insulin, oral medications, diet and exercise – have important impacts on metabolic pathways which in turn reduce inflammation and stress levels within the body.  Failing to measure changes in chronic stress and inflammation can sometimes “paralyze” diabetes treatment, making the disease highly resistant to traditional treatment approaches.

At Consortia Care, we assess and treat inflammatory disease while drawing from the latest research into the links between chronic stress, inflammation and metabolic disease.  We do this because the evidence is compelling, and we see dramatic changes in diabetes control using this approach.

The ‘Blink 182’ Method for Dry Eyes

Dry eyes are one of the most commonly reported health concerns on the Prairies. And, although this Summer looks like an anomaly, Alberta actually has some of the driest, Sunniest conditions in Canada. It’s common to see people squinting and rubbing their eyes year-round. Red, inflamed eyes are even more prevalent among those working in industrial settings – like oil rigs – or outdoors. Some days, it almost feels normal to have irritated eyes.

But, unfortunately, dry eyes aren’t normal or healthy to have long-term. Two main factors have culminated to produce the local “dry eye” epidemic. This includes:

  • A dry, windy climate with low humidity
  • Higher concentrations of environmental allergens (e.g. dust, mold, pollen, etc.)

Many Albertans also have higher rates of exposure to industrial and manufacturing irritants (e.g. workplace particulate/dust), computer screen glare (due to longer daylight hours in the Summer months) as well as higher rates of smoking and drinking. Unfortunately, it all culminates in an epidemic of dry, tired eyes on the Prairies.

Do I have dry eyes?

There are actually many signs and symptoms of dry eye disease, which goes beyond simply feeling like your eyes are dry. These include:

  1. Dryness & irritation
    • Dry, scratchy eyes
    • A feeling of dust in your eye
    • Burning sensation in the eyes
  2. Changes in your vision
    • Blurry or double vision
    • Increased squinting/eye strain
    • Increased sensitivity to light
  3. Changes to the eye
    • Watery (teary) eyes
    • Mildly red or inflamed eyes
    • Feeling like you can’t keep your eyes open (heavy eyelids)

It’s important to see your doctor if any of these symptoms do not improve after trying some self-care strategies. Within Alberta, all medically necessary visits to an Optometrist are covered by provincial health insurance. So if you have dry eyes, professionals can advise how to maintain optimal eye health at no cost to you.

Can having dry eyes cause problems?

In most cases, dry eye disease is best treated with self-care strategies. This includes reducing eye strain (e.g. limiting glare and computer screen time), using lubricating eye drops when needed, and applying gentle heat or massage to the eyes. If these strategies don’t work, your optometrist or physician can prescribe special eye drops or perform certain procedures (e.g. punctal plugging) for severe dry eye symptoms. In all cases, your nurse or doctor should conduct a medication review to determine if any medications might be causing problems. Many different medications – including allergy medications – actually cause dry eye as a common side-effect.

Perhaps the greatest risk of dry eye is an increased risk of eye infections and inflammation. The inside of your eyelids and outer lining of your eye contains a very thin, transparent membrane called the conjunctiva. This film protects your eye from dust, allergens and bacteria. Your conjunctiva keeps your eye moist and lubricates the white of your eye so your eyelids glide easily on its surface. Conjunctivitis – or Pink Eye – is a common complication of dry eye disease.

Severely dry eyes can also damage surface lens of your eye, called the cornea. This can cause permanent visual changes, inflammation that effects your vision or corneal abrasions/ulcers. As the window to your eye, your cornea is critically important for clear vision. Untreated dry eye disease is one of the more common reasons for corneal transplantation.

A note of caution about “red eye” drops…

If you struggle with red eyes, you may be tempted to clear the red from your eyes with redness-relieving eye drops. These eye drops contain more than just eye lubricants, and also work by making the cause blood vessels on the surface of your eye constrict. Although they work quickly, eye experts warn that redness-relieving eye drops also have many side effects.

First, redness-relieving eye drops should not be used for more than 72 hours…. and preferably only when absolutely needed. With long-term use, there is a risk that the pressure inside your eye could increase and other eye structures can be impacted. It should also be noted that your eyes may actually appear more red after the effects of these drops wears off, usually in a few hours.

The ‘Blink 182’ Method

In our experience, many people know exactly how they strained their eyes… and cope with a flare-up of dry eyes afterwards. Most do not want to take medications, or even find that using eye drops was just not feasible in their workplace. The result was coming home after a day’s work staring at a computer screen with even drier eyes.

If you can’t use eye drops at work, what can you do? We developed this insanely simple 2-Step method for the temporary relief of dry eyes:


Warm compress to face

(1) Rinse with warm water

With your eyes closed, rinse your face with warm water. For better results, you can also soak a cloth in warm water and let it sit over your eyes for 30-60 seconds. This helps your Meibomian glands in your eyelids release an oily film that lubricates your eyes, and also clears potential irritants (e.g. lotions and makeup) from around your eye.


Blinking Eye for Dry Eye Disease

(2) Blink 182 times

Start by blinking slowly (about once every second), and then slowly increase the speed of blinking until you are blinking as fast as feels comfortable for you. Count your blinking at this point, blinking 182 times.

While most people know that blinking will relieve dry eye symptoms, they do not blink nearly enough to restart tear production or the lipid flow from Meibomian glands. The “182” number is arbitrary, but most people see substantial improvement in dry eye symptoms about 15 minutes after conducting at least 150 rapid blinks.


CAUTION: You should not excessively blink if you are wearing contact lenses or have any appliance on or near your eye. This intervention is also not appropriate if you have certain eye diseases, have recently sustained any eye injury or have undergone surgery of the eye or areas around the eye. Please consult a health professional prior to trying this intervention if you have any significant past or current concerns with eye health, or are wearing contact lenses.

Should I take the medication I was prescribed?

You’ve probably been told to take your medications a certain way. And, that you can’t share prescribed medications with others. But, why all the fuss? If taking medication carries such risk, shouldn’t you just stop taking them? (Spoiler Alert: Never stop taking any prescribed medication without first discussing the benefits and risks of making a change with a regulated health professional.) It’s important to note that we can’t share medications because, in most cases, medications affect people differently… even another person who has the exact same disease condition. And, we can’t “double dose” most medications to achieve stronger results because in some cases they may work less effectively, and can even cause toxicity if the dose is too high.

On the flip side, medications are powerful tools when used appropriately. Inappropriate prescribing occurs when the expected risks of medication use outweigh the benefits. For many reasons, inappropriate prescribing is more common among older adults and those with complex disease conditions. Inappropriate prescribing also impacts your health, because the practice is associated with negative outcomes like: (1) increased side-effect burden, (2) worsening disease control, (3) hospitalization and (4) emergency room visits.

So, what might make some medications a “bad fit” for you?

Safe medication use occurs when the benefits of taking a medication outweigh potential harms. To accomplish this, the medication must be well-matched to the patient’s needs. Pharmacists and physicians typically work together to support safe medication use. Both professionals are trained to identify key risks when prescribing, and best practices for medication use to treat disease. They also should openly discuss their treatment decisions (with rationale) with patients. However, nursing professionals are also increasingly part of medication reviews and related conversations. Registered Nurses and Nurse Practitioners can thoroughly evaluate medication side-effects, medication impacts on daily life, and other factors like affordability and adherence. Combined with your physician and pharmacist review, an expert nurse may be the missing link in your annual care plan.


The “Top 5” Reasons Medications Need to be Reviewed by a Health Professional


5. Old medications get ‘grandfathered’ in

Over time, clinical guidelines change. What was once a “state-of-the-art” medication could still be the gold-standard treatment, or it could be associated with disease progression. Some patients get stuck taking old but risky medications simply because they are doing “well-enough” on the old medication. In one example, a patient with depression was prescribed a first-generation anti-depressant (phenelzine/Nardil®) many decades prior. After becoming ill from a cold, they suddenly experienced multiple unexplained symptoms, including: dry mouth, dizziness and high blood pressure. These side-effects all resolved after phenelzine was discontinued, and the patient switched to a newer anti-depressant with substantially less side-effects.

4. You improve, but medications don’t change

We sometimes keep “old medications” on board after disease conditions improve. This is best practice, but sometimes health professionals end up over-treating the condition at hand. For example, a patient with Type 2 Diabetes comes to see their nurse to complain about all the low blood sugars they get after taking dinner-time insulin. Over the past month, they started biking to work and started on a low-carb diet. The nurse recommends stopping their rapid-acting insulin with dinner and taking a lower dose of long-acting insulin. The patient continues to see great blood sugar control with no lows after adjusting therapy to accommodate for the hard-work of managing diabetes with lifestyle. In this case, the patient benefited from a reduced insulin dose.

3. We start treating side-effects

Sometimes we can start treating medication side-effects… which would stop if we simply switched to a different medication. For example, after starting on amitriptyline/Elavil® for arthritis pain, an older patient developed constipation, loss of bladder control and dry eyes. The clinical team quickly started laxatives, oxybutinin (for loss of bladder control) and eye drops. The patient was later admitted for a surgical procedure and had to hold non-essential medications for 3 days, at which point the side-effects completely resolved. Many medications were stopped after surgery, as it became clear that they were not needed.

2. You get older

Medications affect older adults differently. What once worked fantastically may now cause serious side-effects in older age. For example, after turning 70, a patient told their nurse that they think they have Alzheimer’s Disease. They recently started sleeping past lunch and had difficulty walking up stairs without falling. The patient also worried about feeling brain fog & confusion, which was unusual for them. They recently started taking dimenhydrinate/Gravol® to help them sleep. It always seemed to work like a charm. However, the medication’s anticholinergic effects now cause significant drowsiness for about a day after taking it (instead of just for a few hours). After stopping Gravol®. the patient felt significantly better.

1. You forget how to take medications properly

Although we assume prescribed medications are taken consistently, only one half (50%) of patients actually take long-term medications as originally prescribed (1). Most patients don’t want to take medication long-term, and we all must fit these medications into our daily life. For example, a patient was prescribed a salbutamol/Ventolin® inhaler as a child, and insists it doesn’t work and even causes a dry throat as an adult. So, they avoid takingVentolin® until a “severe” asthma attack comes on. This was perplexing to the nurse, who asked them to demonstrate how they use the inhaler. The patient promptly misted Ventolin® into their mouth and inhaled after a few seconds. It was clear at this point that none of the drug would even reach their lungs. After inhaler education was provided, the Ventolin® worked considerably better to control symptoms with no side-effects of a dry mouth/throat… and adherence to therapy improved.


Never adjust or stop prescribed medications without first speaking with a regulated health professional. If you have any questions or concerns about your medications, book an appointment to speak with a regulated health professional you trust in your local community.

References

(1) DiMatteo, M.R., Giordani, P.J., Lepper, H.S. & Croghan, T.W. (2002). Patient adherence and medical treatment outcomes: a meta-analysis. Medical Care. 40(9), 794-811. doi: 10.1097/01.MLR.0000024612.61915.2D

Keto vs. Vegan: Understanding the Modern Diet War

Chances are you’ve watched a documentary on Netflix, or read a few magazine articles. It doesn’t take long to discover that there’s a diet war going on in the popular media. On one side, you have the “carbs are evil” hypothesis.  People who promote very-low-carb diets (e.g. Keto and Paleo diets) often cite population health studies showing a correlation between carbohydrate intake and metabolic diseases like diabetes, fatty liver disease, obesity and heart disease.   In 2013, a meta-analysis of thirteen clinical trials examining the Keto diet versus low-fat diets (LFD) found that people assigned to a Keto diet experienced greater weight loss over a twelve month follow-up period.(1)  For people who have medical clearance & support from a health professional to adopt a Keto diet, the very-low-carb approach appears to yield significant weight loss over the short-term.

However, medical support for Keto diets is likely to disappear in the coming decade.  That is because, in 2018 new research has linked long-term adoption of Keto diets to an increased risk of death.  A recent study published in The Lancet-Public Health journal found that both low-carb and high-carb diets increased the risk of death, with more pronounced negative effects occurring for people who subscribe to very-low-carb diets.(2)

It’s also interesting to note that the Keto diet is ranked 2nd last (#39 out of 40) in the U.S. News Best Diet Rankings.  Key concerns are that this diet is known to negatively impact your body’s metabolism when used long-term.  Patients who stop the Keto diet – even after several months of dieting – often experience rapid weight regain.  Long-term adherence to a Keto diet can also result in muscle loss, fatigue, electrolyte imbalances and GI symptoms.  Since very-low-carb diets appear to reduce insulin resistance and fat storage, people sensitive to carbohydrate overload or weight gain might benefit from this approach.

It may seem paradoxical, but a high-carbohydrate vegan diet is an equally popular approach to modern dieting.  The “animal fats are evil” hypothesis maintains that people who adhere to a vegan diet – eliminate animal fat and proteins, but increase plant-based foods – have better health outcomes, including lower rates of heart disease and obesity.  A two-year clinical trial comparing a vegan diet to a conventional LFD found that weight loss outcomes were superior among those assigned to the vegan group.(3)  While this study reported a large effect size, its overall sample size was quite limited (n=62).  So, evidence for a vegan diet is compelling, but not as robust as that for a very-low-carb (Keto) approach.

Vegan diets are also quite restrictive, and require professional advice to carry out safely.  While a Keto diet is well-studied with disease states (like diabetes), vegan diets have not always shown superiority to other diets in lowering blood sugars.  The power of a vegan diet, therefore, appears to reduce heart disease incidence with a high nutrient, blood pressure and cholesterol lowering approach to food consumption.  Much like the Keto diet, veganism has some limitations.

The Verdict

You may have noticed that both Keto and Vegan diets are difficult to sustain, and are less commonly recommended by health professionals.  While not discussed here, there are more sustainable “vegetarian like” diets (such as the Mediterranean diet) that are a better fit for most people.  In some contexts, either a Vegan or Keto diet can be recommended after a medical and nutritional assessment.  Neither diet should be started “on a whim”, and would benefit from advice from professionals like a Registered Dietitian.

Interestingly, many other powerful diets within the research literature (e.g. the Mediterranean diet) incorporate the best features of a Vegan diet with a higher margin of safety.  Many clinical diet regimens will encourage a reduction in carb and saturated fat portion size, alongside more nutrient-dense (less processed) food choices.  Even for these diets, however, consultation with a dietitian or health professional is recommended.


Resources for Alberta Residents

People who live in Alberta, Canada can access a Registered Dietitian for free through their local Primary Care Network (PCN), typically by asking their family doctor for a referral.  In many cases, you will be referred to a Registered Nurse for lifestyle review & coaching prior to your dietitian appointment.


Cited Research

(1)  Bueno, N. B., de Melo, I. S. V., de Oliveira, S. L., & da Rocha Ataide, T. (2013). Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. British Journal of Nutrition, 110(7), 1178–1187.

(2)  Seidelmann, S. B. et al. (2018). Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. The Lancet-Public Health, 3(9), 419-428.

(3) Turner‐McGrievy, G. M., Barnard, N. D. and Scialli, A. R. (2007), A Two‐Year Randomized Weight Loss Trial Comparing a Vegan Diet to a More Moderate Low‐Fat Diet. Obesity, 15: 2276-2281. doi:10.1038/oby.2007.270

What is Flow?

Chances are, at some point in your life, you have experienced flow. Athletes call it being “in the zone”, and Buddhist monks refer to it as a “heightened state of consciousness”. Flow describes those times where you get lost in the moment, becoming so involved in a task that you lose some sense of awareness of yourself and time.

As a nurse, I typically encounter flow when I succeed in tackling complicated topics with patients.  In these highly engaging visits, it sometimes feels like a hour has gone by only to see it has been only a few minutes.  Flow produces such a powerful therapeutic effect, that both the patient and myself react to it positively.  We both finish the appointment in awe, with the patient often feeling like I “blew their mind” and myself feeling highly skilled and effective.

What exactly happens psychologically when we experience flow?  And, why is this state of heightened consciousness inherently peaceful and relaxing?  These mysteries are at the center of new moment in psychology (called “positive psychology”) which aims to better understand human flourishing and positive emotional states.

Flow was first described by Dr. Mihaly Csikszentmihalyi, a psychologist who in 2002 wrote a popular book on the subject and became well-known for this research in the realm of positive psychology.  Through Mihaly’s work, psychology discovered one of the first underlying mechanisms to happiness and relaxation.  The concept of flow was exciting because it appeared to be universal across all cultures.


Ever wonder why life seems so easy for some people? Or, what is behind the science of mindfulness meditation? Join Adam at Consortia Care as he talks about flow. ?/? to let us know what you think!

What Produces Flow?

Over a decade later, extensive research has been conducted on flow.  It has been found that flow occurs when we experience a state of psychological tension that is manageable for us.  That level of challenge heightens our perception, but also preoccupies our consciousness with the task at hand.  So, if flow is anything, it is simply a state of hyper-focus.

Flow is more likely to happen in situations of:

  • High Achievement:  The desired outcome of the activity is highly rewarding.
  • High Concentration:  The task is sufficiently challenging.
  • High Control:  As an individual, you can effect change in the outcome.
  • Sensory Connection:  Where you have to connect deeply with your environment (or sensory experience) in order to succeed at the task.
  • Immediate Feedback:  The environment or situation produces a real-time sense of achievement or progress towards goals.

Flow & the Sense of Self

Most people in a state of flow report losing awareness of their existence.   Paradoxically, however, the experience of flow actually strengthens the awareness of self over time.  So people who experience flow regularly typically have a stronger sense of self.

This effect is believed to be the reason why flow states can help reduce depressive symptoms.  This is also the primary theory why some interventions (like mindfulness meditation) are effective in treating depression.

The Loss of Flow

Conversely, people who previously have experienced flow often report strongly negative experiences when they can no longer achieve it.   For example, Olympic athletes who become injured (and can no longer compete in their sport) have a concordantly higher risk of depression.  Aside from simply losing their identity and accomplishments, these athletes also lost the ability to attain flow.

Flow may also be the primary mechanism behind workaholism, or people who become so intensely focussed on work that they neglect themselves and/or their family.

So, flow is not inherently good or bad.  It just is.  We can use flow as a powerful tool to dramatically impact how we feel in a given moment.  To change our state of mind.  Because of this, flow is a crucial component of attaining mastery and purpose in life.

Shifting Perspectives on Chronic Disease

We all carry different beliefs about our health. Health beliefs, in turn, guide much of what we do. They guide whether we choose to walk or drive to the store. Also, what and how we eat. Health beliefs shape our capacity to take action, to see ourselves as healthy (or flawed) and to avoid risks. Beliefs around health, however, rarely reflect our true potential.  For many, they are situated in past realities.  They reflect our past struggles for survival or life sufferings.  Simply caring for others with debilitating illness can shape our beliefs around life expectancy.  Some of us live health pessimistically, while others perhaps too optimistically.

Take COPD, for example.  Respiratory diseases remain a leading cause of hospitalization in Canada (1). And, the breathlessness of COPD can feel so debilitating that patients meticulously plan their days to avoid it.  Shortness of breath is also so unpredictable in the early stages of disease that it almost seems to be a natural part of aging and not a true disease.

So, given the variable nature of breathlessness, patients also vary widely in their health beliefs around COPD.  About 37% of patients prescribes an inhaler twice daily comply with treatment (2), suggesting the majority do not perceive any health risk from not treating their condition.  As COPD progresses, many underestimate the positive impact quitting smoking would have on disease progression (3).  The internal disagreement helps patients to avoid the extreme inconvenience of quitting smoking.

Patients can have opinions about their health, skewed either to the positive or negative.  When beliefs lack congruence with actual health events, many patients begin to report distress (or anxiety).  Patients with advanced disease will often think themselves into a panic, especially when they can no longer make meaningful health changes.  It is estimated that up to 67% of people who live with advanced COPD will experience a panic attack (4).

So, health beliefs are powerful motivators for health change (or inaction).  Yet, they may not always be true.

Health as a Present State

The Shifting Perspectives Model of Chronic Illness (5) challenges traditional theories that chronic disease progresses on a linear trajectory.  Instead of progressing inevitably towards worsening health, the fact is that many patients with chronic illness shift back and forth between events that make them feel “sick” and feel “well”.


Health in the Foreground

When patients feel healthy, they are likely to report greater life satisfaction. They feel happier and greater mastery over their disease. Putting health in the foreground, however, is not entirely positive. Patients who feel healthy are less likely to sustain health changes. Many lack the constant drive to monitor their health, or undergo discomforts in the name of disease.

Health and Wellness in the Foreground


Infirmity/Illness in the Foreground
Illness in the Foreground

When patients feel “sick”, they are actually suffering from their illness experience.  Such suffering, however, is not entirely negative.  Putting illness in the foreground can create a short-term impetus for health change.  Patients who encounter sickness long-term typically encounter higher rates of depression and chronic stress.


We all know feeling sick all the time is not sustainable.  When people place infirmity in the foreground, they run the risk of social isolation and health-related anxiety.  But, they also have tremendous power to achieve better health.

The key differentiator is hope.  Having a sense of progress and purpose in our life is powerful.  We can accept our “illness” and put it in the foreground only when we have hope.  Hope for a better future helps us to grow, to work against our reality, to seek support and stave off health-related depression and anxiety.

3 Ways to Check Your Health Beliefs

1. ASK YOURSELF

Health beliefs come from our past experiences. But, our health changes on a daily basis. It is easy for us to get stuck with dated health beliefs that no longer serve us well. Ask yourself. “When did I start believing X about my health?” And then ask: “Is this still true for me today?”

2. COLLECT EVIDENCE

Many people ignore what their bodies are telling them, in part because the facts do not jive with their story about their health. Be open to collecting data (symptom tracking, blood pressure readings, physical fitness levels, mood & diet records) and update your personal story about health to reflect current evidence.

3. SEEK FEEDBACK

Present your health beliefs to a professional, with the goal of seeking their honest opinion about your current health state. Depending on your provider’s health discipline, they may conduct physical exams or order diagnostic tests. Some may make referrals to investigate presenting concerns. Your provider will order tests judiciously, discussing the benefits and risks of testing.  But, ultimately, professional advice can help update your personal health beliefs to keep them accurate.