The pandemic is not the great equalizer: front-line labor and rationing in COVID-19 critical care.

BACKGROUND: Framed as "the great-equalizer," the COVID-19 pandemic has intensified pressure to adapt critical care labor and resulted in rationing by healthcare workers across the world. OBJECTIVE: To critically investigate how hospital intensive care units are critical sites of care labor and examine how rationing highlights key features of healthcare labor and its inequalities. METHODS: A practice-oriented ethnographic study was conducted in a United States academic ICU by a medical anthropologist and medical intensivists with global health expertise. The analysis drew on 57 in-depth interviews and 25 months of participant observation between 2020 and 2021. RESULTS: Embodied labor constitutes sites and practices of shortage or rationing along three domains: equipment and technology, labor, and emotions and energy. The resulting workers' practices of adaptation and resilience point to a potentially more robust global health labor politics based on seeing rationing as work. CONCLUSION: Studies of pandemic rationing practices and critical care labor can disrupt too-simple comparative narratives of Global North/South divides. Further studies and efforts must address the toll of healthcare labor.

CONTEXTE: Présentée comme « le grand égalisateur ¼, la pandémie de COVID-19 a accentué la pression pour adapter le travail des soins intensifs et a entraîné le rationnement des travailleurs de la santé dans le monde entier. OBJECTIF: Étudier de manière critique comment les unités de soins intensifs des hôpitaux sont des sites critiques dans le système de santé et examiner comment le rationnement met en évidence les caractéristiques clés du travail de la santé et ses inégalités. MÉTHODES: Une étude ethnographique axée sur la pratique a été menée dans une unité de soins intensifs universitaire des États-Unis par un anthropologue médical et des médecins intensivistes spécialisés dans la santé mondiale. L'analyse s'est appuyée sur 57 entretiens approfondis et 25 mois d'observation participante entre 2020 et 2021. RÉSULTATS: Le travail incarné constitue des sites et des pratiques de pénurie ou de rationnement le long de trois domaines : équipement et technologie, travail, émotions et énergie. Les pratiques d'adaptation et de résilience des travailleurs qui en résultent indiquent une politique du travail potentiellement plus robuste dans le domaine de la santé mondiale, fondée sur une vision du rationnement en tant que travail. CONCLUSION: Les études sur les pratiques de rationnement en cas de pandémie et sur le travail dans le domaine des soins intensifs peuvent perturber les récits comparatifs trop simples des divisions Nord/Sud. D'autres études et efforts doivent porter sur le coût du travail dans le secteur des soins de santé.

Effect of sustained-release Verapamil on the morning systemic arterial pressure surge during daily activity in patients with systemic hypertension.

In a placebo-controlled study of 13 subjects with systemic hypertension, sustained-release verapamil reduced the morning surge in systolic pressure by 10.2 mm Hg (p = 0.04), diastolic pressure by 11.1 mm Hg (p = 0.008), and heart rate by 3.3 beats/min (p = 0.17). Blunting of the morning hemodynamic surge may be a mechanism by which verapamil could reduce the risk of plaque disruption and acute coronary events in the morning.

Hemodynamic and hemostatic responses to morning and evening exertion in systemic hypertension and implications for triggering of acute cardiovascular disease.

The increased morning frequency of cardiovascular disease onset has created concern that morning exertion promotes greater risk than evening exertion. The physiologic responses to isometric exercise (handgrip) in the morning (9 A.M.) versus the evening (6:30 P.M.) were compared in 15 subjects with mild hypertension. Isometric exercise produced similar increases at both times of the day (morning vs evening) in systolic arterial pressure (31 +/- 4 vs 35 +/- 4 mm Hg, p = NS) and heart rate (7 +/- 1 vs 8 +/- 1 beats/min, p = NS). It also produced similar increases in fibrinolytic activity (reduction in euglobulin clot lysis time) at both times of the day (-53 +/- 27 vs -53 +/- 21 minutes). However, because basal fibrinolytic activity was lower in the morning than in the evening (euglobulin clot lysis time 364 +/- 45 vs 220 +/- 33 minutes, p < 0.01), peak fibrinolytic activity after stress was also lower in the morning (312 +/- 44 vs 176 +/- 27 minutes, p < 0.01). The present study demonstrates that in subjects with hypertension, the hemostatic and hemodynamic responses to handgrip are not greater during morning versus evening exertion. This finding, plus the overall benefits of regular exercise and the low absolute risk of an event during exercise, suggests that timing of exertion is not of critical importance. However, to obtain a definitive answer to this question, further studies are needed using different potential triggers and subject populations.

Effects of nadolol on hemodynamic and hemostatic responses to potential mental and physical triggers of myocardial infarction in subjects with mild systemic hypertension.

Although beta-adrenergic blocking agents are known to reduce the risk of myocardial infarction, the mechanism of this protective effect is not well understood. The recent demonstration that beta blockers selectively blunt the increased morning risk of myocardial infarction suggests that these agents block the pathophysiologic consequences of stressors concentrated in the morning. We determined the effect of nadolol on the hemodynamic and hemostatic responses to mental stress and isometric exertion (handgrip), 2 potential triggers of infarction. The study was conducted in 15 subjects with mild systemic hypertension, using a placebo-controlled, double-blind, crossover design. Nadolol reduced systolic pressure and heart rate after mental stress. Poststress systolic pressure was 139 +/- 4 mm Hg during therapy with nadolol versus 161 +/- 4 mm Hg during placebo administration (p < 0.05). Heart rate increased to 61 +/- 2 during nadolol therapy versus 89 +/- 5 beats/min during placebo therapy (p < 0.05). The systolic pressure increase was similar during therapy with nadolol and placebo (29 +/- 2 vs 33 +/- 2 beats/min, p = NS); however, heart rate increase was less during nadolol therapy (4 +/- 1 vs 12 +/- 4 vs beats/min, p < 0.01). The responses to handgrip and their modification during nadolol therapy were similar to those observed after mental stress. Neither platelet aggregability nor fibrinolytic potential was altered by nadolol. Thus, nadolol modified hemodynamic indexes without altering the hemostatic indexes measured. This hemodynamic effect may contribute to the decrease in morning cardiovascular events by beta-adrenergic blockers and their well-documented cardioprotective effect.

Efficacy and safety of cilazapril, a new angiotensin-converting enzyme inhibitor.

Cilazapril (CIL), a new angiotensin-converting enzyme inhibitor, was evaluated for 16 weeks in 29 patients with mild to moderate essential hypertension (diastolic pressure 95 mm Hg to 115 mm Hg). Twenty-four patients (83%) normalized their blood pressure (BP) (diastolic pressure less than 90 mm Hg), 11 with low-dose CIL, six with high-dose CIL, one with high-dose CIL plus low-dose thiazide, and six with high-dose CIL and high-dose thiazide. Three withdrew because of side effects (fatigue, bloating, and polyuria). Statistically significant reductions in sitting and standing systolic and diastolic pressures occurred at 8 and 16 weeks on CIL. There was no change in standing or sitting heart rate, white blood cell count, creatinine clearance, urine protein levels. This is the first long-term data on this new converting enzyme inhibitor in human beings.

Endogenous digitalis-like factors in hypertension and chronic renal insufficiency.

Endogenous digitalis-like factors have been implicated in the adaptations that accompany renal insufficiency and in the pathogenesis of hypertension. We recently described several fractions of normal human plasma that inhibit NaK-ATPase and exhibit apparent digoxin-like immunoreactivity. To determine if hypertension and/or renal insufficiency affect plasma levels of these factors, we examined four patient groups: normotensive controls; hypertensive subjects with normal renal function; hypertensives with moderate renal insufficiency; and chronic dialysis patients. Plasma levels of digoxin-like immunoreactivity and NaK-ATPase inhibitory activity were significantly increased in hypertensive patients with mild renal failure (7.6 +/- 1.1 ouabain equivalents, mean +/- SEM, N = 21 vs 4.1 +/- 1.1 in normotensive controls, N = 20, P less than 0.05). NaK-ATPase inhibitory activity tended to be higher in patients with primary hypertension and normal renal function (5.5 +/- 0.7 ouabain equivalents, P less than 0.07); in dialysis patients, it was not different from controls. There was no correlation between NaK-ATPase inhibitory activity and blood pressure in any group. There was a significant rise in plasma NaK-ATPase inhibitory activity during dialysis (+ 1.8 +/- 0.7 ouabain equivalents, N = 22, P less than 0.03). As we have found that NaK-ATPase inhibitory activity in the plasma of normal humans can be separated into three distinct fractions, EI1, EI2, and EI3, we analyzed the plasma of 10 dialysis patients further. The increase in NaK-ATPase inhibitory activity could be attributed to fractions EI1 and EI3. These results suggest that plasma NaK-ATPase inhibitors increase with chronic renal insufficiency, but not hypertension alone. Although hemodialysis may acutely raise plasma levels, long-term dialysis returns them to the normal range.

Increased sodium-lithium countertransport in red cells of patients with essential hypertension.

This paper describes experiments showing that one of the pathways of sodium transport across the red-cell membrane, sodium-lithium countertransport, is faster in patients with essential hypertension than in control subjects. This transport system accepts only sodium or lithium and is not inhibited by ouabain. The maximum rate of transport shows inherited differences. The mean maximum rate of sodium-lithium countertransport was found to be 0.55 +/- 0.02 (mean +/- S.E.M.) mmol (liter of red cells X hour)(-1) in a group of 36 patients with essential hypertension and 0.24 +/- 0.02 in 26 control subjects (P less than 0.001). The first-degree relatives of eight patients with essential hypertension and 10 control subjects had mean maximum rates of sodium-lithium countertransport of 0.54 +/- 0.05 and 0.23 +/- 0.02, respectively. Five patients with secondary hypertension had normal mean maximum rates of sodium-lithium countertransport. The relation between heritability of red-cell sodium-lithium countertransport and essential hypertension should be investigated further.