Safety and practicality of high dose inhaled nitric oxide in emergency department COVID-19 patients.

BACKGROUND: Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator and mild bronchodilator that has been shown to improve systemic oxygenation, but has rarely been administered in the Emergency Department (ED). In addition to its favorable pulmonary vascular effects, in-vitro studies report that NO donors can inhibit replication of viruses, including SARS Coronavirus 2 (SARS-CoV-2). This study evaluated the administration of high-dose iNO by mask in spontaneously breathing emergency department (ED) patients with respiratory symptoms attributed to Coronavirus disease 2019 (COVID-19). METHODS: We designed a randomized clinical trial to determine whether 30 min of high dose iNO (250 ppm) could be safely and practically administered by emergency physicians in the ED to spontaneously-breathing patients with respiratory symptoms attributed to COVID-19. Our secondary goal was to learn if iNO could prevent the progression of mild COVID-19 to a more severe state. FINDINGS: We enrolled 47 ED patients with acute respiratory symptoms most likely due to COVID-19: 25 of 47 (53%) were randomized to the iNO treatment group; 22 of 47 (46%) to the control group (supportive care only). All patients tolerated the administration of high-dose iNO in the ED without significant complications or symptoms. Five patients receiving iNO (16%) experienced asymptomatic methemoglobinemia (MetHb) > 5%. Thirty-four of 47 (72%) subjects tested positive for SARS-CoV-2: 19 of 34 were randomized to the iNO treatment group and 15 of 34 subjects to the control group. Seven of 19 (38%) iNO patients returned to the ED, while 4 of 15 (27%) control patients did. One patient in each study arm was hospitalized: 5% in iNO treatment and 7% in controls. One patient was intubated in the iNO group. No patients in either group died. The differences between these groups were not significant. CONCLUSION: A single dose of iNO at 250 ppm was practical and not associated with any significant adverse effects when administered in the ED by emergency physicians. Local disease control led to early study closure and prevented complete testing of COVID-19 safety and treatment outcomes measures.

Siamit: A Novel Academic-Tribal Health Partnership in Northwest Alaska.

PROBLEM: American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. APPROACH: Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. OUTCOMES: Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. NEXT STEPS: During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.