The Skagit County choir COVID-19 outbreak - have we got it wrong?

OBJECTIVES: Over time, papers or reports may come to be taken for granted as evidence for some phenomenon. Researchers cite them without critically re-examining findings in the light of subsequent work. This can give rise to misleading or erroneous results and conclusions. We explore whether this has occurred in the widely reported outbreak of SARS-CoV-2 at a rehearsal of the Skagit Valley Chorale in March 2020, where it was assumed, and subsequently asserted uncritically, that the outbreak was due to a single infected person. STUDY DESIGN: Review of original report and subsequent modelling and interpretations. METHODS: We reviewed and analysed original outbreak data in relation to published data on incubation period, subsequent modelling drawing on the data, and interpretations of transmission characteristics of this incident. RESULTS: We show it is vanishingly unlikely that this was a single point source outbreak as has been widely claimed and on which modelling has been based. CONCLUSION: An unexamined assumption has led to erroneous policy conclusions about the risks of singing, and indoor spaces more generally, and the benefits of increased levels of ventilation. Although never publicly identified, one individual bears the moral burden of knowing what health outcomes have been attributed to their actions. We call for these claims to be re-examined and for greater ethical responsibility in the assumption of a point source in outbreak investigations.

The use of single-use devices in anaesthesia: balancing the risks to patient safety.

Single-use devices are designed, manufactured and sold to be used once and then discarded. This paper addresses growing concerns about the quality of some devices. Single-use devices, manufactured at a lower cost to justify their disposal, are perceived to have a lesser efficacy, which may threaten patient safety through iatrogenic harm. There is, in addition, growing scepticism about the actual risk of contracting variant Creutzfeldt-Jakob disease and other blood-borne diseases from reused surgical instruments. Interview data suggests that when choosing to use a single-use device, clinicians balance concerns about the risk of infection against those about the risk of injury. However, despite reservations about induced harm and the unknown risk of an iatrogenic disease, most clinicians would want single-use devices used on themselves and their family if they were patients.

Disease management: definitions, difficulties and future directions.

The last decade has seen a wide range of experiments in health care reform intended to contain costs and promote effectiveness. In the USA, managed care and disease management have been major strategies in this endeavour. It has been argued that their apparent success has strong implications for reform in other countries. However, in this paper we ask whether they are so easily exportable. We explain the concepts involved and set the development of managed care and disease management programmes in the context of the USA. The constituent elements of disease management are identified and discussed. Disease management is considered from the perspectives of the major stakeholders in the United Kingdom, and the differences between the models of health care in the United Kingdom's National Health Service and the USA are noted. A review is presented of evaluations of disease management programmes and of the weaknesses they highlight. The prospects for disease management in Europe are also discussed.

Evaluating medical information systems: ethnomethodological and interactionist approaches.

This paper examines how qualitative research can contribute to the evaluation of medical information systems. Most qualitative studies of the use of medical computer systems adopt either an interactionist or, less commonly, an ethnomethodological perspective. The paper compares and contrasts the two approaches through the detailed discussion of two case studies, one rooted in each tradition. It identifies the implications of using these different analytical approaches and assesses their strengths and weaknessess. The paper argues that the preference for interactionism has led qualitative researchers to overlook important aspects of the social processess which surround the use of computer systems and that, consequently, a shift in emphasis towards ethnomethodological research is necessary. Nonetheless, it concludes by asserting that both strands of qualitative research can illuminate the organizational impact of medical computer systems.

Research directions in genetic counselling: a review of the literature.

There is a growing body of literature considering genetic counselling services in a variety of clinical settings. This literature encompasses both predictive and diagnostic testing, from the viewpoints of service providers and recipients. It also embraces a wide range of conceptions of the nature and goals of genetic counselling. However, research in this area has been criticised for a focus on outcome rather than process, and it has been suggested that this focus limits its practical use. The purpose of this review is twofold: (1) to describe the varying concepts of counselling which appear to be utilised in published work and (2) to discuss the possible applications of this work to practice.

The implications of healthcare reforms for the profession of nursing.

This paper offers a wide-ranging analysis of concerns that the value of emotion work within nursing is being eroded. We examine the occupation's historical development to argue that, in so far as emotion work has any essence within nursing, it is as an occupational myth which has been deployed to legitimate nurses' jurisdictional claims. We argue that recent developments in health-care raise questions about the benefits of claims of this kind and suggest that a little more realism about the nature of nursing work might make for a more sustainable professional future.

Catching goldfish: quality in qualitative research.

This paper reviews the contribution of qualitative methods to health services research (HSR) and discusses some of the issues involved in recognizing quality in such work. The place of qualitative work is first defined by reference to Archie Cochrane's agenda for HSR and the limitations of the recent focus on randomized trials as the standard method. Health care practice involves large elements of improvisation which cannot be captured by evidence-based approaches. Qualitative methods offer ways of understanding this improvisation and of identifying more efficient and effective practices, as well as considering the traditional topics of equity and humanity. The methodological procedures of qualitative work reflect a long-established inductive tradition in scientific practice. The logic of grounded theory provides a contemporary specification. In its application, it is quite different from the methodological anarchy of postmodernism. The use of qualitative research and the theoretically stated generalizations which arise from it inform reflective work by health service managers, planners and clinicians.

Living with renal failure: the psychological issues.

Since the earliest days of dialysis, researchers have been drawn to this patient group attracted no doubt to the new phenomena of a machine dependant existence. There is considerable research data available on a whole range of psychological problems encountered by our patient population, indeed a brief look through the list-increased suicide rates, depression, sexual problems, relationship difficulties etc. etc. makes me wonder why so many of our patients make the effort to stay alive! Yet the vast majority do. They are a resilient group who, in general, maintain a positive attitude to life and get as much out of each day as they possibly can.

Estimating the cost of compensating victims of medical negligence.

The current system in Britain for compensating victims of medical injury depends on an assessment of negligence. Despite the sporadic pressure on the government to adopt a "no fault" approach, such as exists in Sweden, the negligence system will probably remain for the immediate future. The cost of this system was estimated to be 52.3m pounds for England 1990-1. The problem for the future, however, is one of forecasting accuracy at provider level: too high a guess and current patient care will suffer; too low a guess and future patient care will suffer. The introduction of a mutual insurance scheme may not resolve these difficulties, as someone will have to set the rates. Moreover, the figures indicate that if a no fault scheme was introduced the cost might be four times that of the current system, depending on the type of scheme adopted.

Hormonal induction of lactation in non-pregnant ewes.

Exogenous hormone treatments designed to induce nonpregnant ewes to lactate at levels sufficient to rear orphan lambs were investigated in three breeds (Blackface, Dorset and Greyface) and in a total of 14 groups. The hormone treatments consisted of an induction phase lasting 1-6 weeks during which most ewes received daily subcutaneous injections of 75 mg of progesterone and 100 microg of oestradiol-17beta, and a trigger phase lasting 1 or 2 weeks during which 5 mg of oestradiol-17beta and/or 10 mg of dexamethasone were given daily and the daily dose of progesterone was reduced to zero. From the end of the trigger phase for at least 2 weeks, milk production was determined three times daily by hand milking after prior intravenous injections of 5 IU of oxytocin. The linear dimensions of the udder were measured in each ewe at 5-6 day intervals throughout the induction and trigger phases. Udder sizes increased in response to hormone treatment in all cases, and the rate of increase was usually 1.75-11.3 times greater during the trigger phase than during the induction phase. Accumulation of milk in the udder during the trigger phase resulted in mean milk yields of 212-763 ml on the first day of milking, which were higher than the mean yields of 130-354 ml on the second day. Thereafter the mean daily milk yields increased progressively to reach 579-1301 ml after 14 days of milking. Group comparisons revealed the following: an induction phase of at least 4 weeks duration was required to ensure that all hormone-treated ewes produced 800 ml or more of milk/day by 14 days of milking; during the trigger phase, oestradiol-17beta alone was a more effective lactogenic agent than dexamethasone alone, and dexamethasone apparently hindered the lactogenic actions of oestradiol-17beta when both hormones were given together; extending the duration of the trigger phase from 1 to 2 weeks did not improve subsequent milk yields; and there were no significant breed differences in milk yield responses to similar hormone treatments. It is concluded that a 4-6 week induction phase followed by a 1-week trigger phase using the progesterone and oestradiol-17beta doses noted above but excluding dexamethasone would induce in most nonpregnant ewes lactation at levels sufficient to rear orphan lambs. Compared to the compositions of normal colostrum and milk, the milk from some of the present ewes had lower dry matter contents, fat concentrations and immunoglobulin-G concentrations and generally similar lactose concentrations. These differences were not considered to be sufficient to jeopardize the survival of lambs reared by such ewes.

Successful fostering of orphan lambs by non-pregnant ewes induced to lactate using exogenous hormone treatment.

Six nonpregnant ewes were induced to lactate by an exogenous hormone treatment lasting 6 weeks. At the end of the treatment one alien lamb was adopted by each ewe. Each ewe was initially indifferent to the alien lamb and required only mild restraint to allow the lambs to suck successfully. Maternal interest subsequently increased and strong ewe-lamb bonding was evident by 80 minutes (n=1), 10 hours (n=4) or 24 hours (n=1) in different cases. The lambs required supplementary milk for 4-6 days while milk production by the ewes increased to adequate levels. Thereafter they were reared entirely by the ewes. Another four nonpregnant ewes were induced to lactate by a similar hormone treatment and were then hand-milked thrice daily for 23 weeks. One alien lamb was then removed after 10-30 minutes. The ewes were then injected subcutaneously with 5 mg of oestradiol-17beta and were placed in fostering stocks. After a further 3-5 hours the lambs were re-introduced. Strong ewe-lamb bonding occurred during the subsequent 10 hours in all cases. All 10 lambs were reared successfully by these ewes until at least 3 months of age, when observations stopped. It was concluded firstly that nonpregnant ewes induced to lactate artificially will adopt and rear orphan lambs successfully, provided that additional milk is given to meet shortfalls during the first 4-6 days; and secondly that a 5 mg injection of oestradiol-17beta may facilitate fostering of lambs by ewes in established lactation whether the lactation is induced artificially or not.