Calle Rubio et al. BMC Health Services Research BMC Health Services Research (2023) 23:98 https://doi.org/10.1186/s12913-023-09094-3 RESEARCH Open Access COVID‑19’s impact on care practice for alpha‑1‑antitrypsin deficiency patients Myriam Calle Rubio1,2, José Luis López‑Campos3, Marc Miravitlles4,5, Francisco Javier Michel de la Rosa6, José María Hernández Pérez5,7, Carmen Montero Martínez8, José Bruno Montoro Ronsano9, Francisco Casas Maldonado10,11, Juan Luis Rodríguez Hermosa1,2, Eva María Tabernero Huguet12, José Manuel Martínez Sesmero13, Carlos Martínez Rivera5,14, Francisco Javier Callejas González15 and María Torres Durán16* Abstract Background Patients with alpha-1 antitrypsin deficiency (AATD), commonly categorized as a rare disease, have been affected by the changes in healthcare management brought about by COVID-19. This study’s aim was to identify the changes that have taken place in AATD patient care as a result of the COVID-19 pandemic in Spain and to propose experts’ recommendations aimed at ensuring humanized and quality care for people with AATD in the post-pan‑ demic situation. Methods A qualitative descriptive case study with a holistic single-case design was conducted, using focus groups with experts in AATD clinical management, including 15 health professionals with ties to the Spanish health system (12 pneumologists and 2 hospital pharmacists from 11 different hospitals in Spain) and 1 patient representative. Results COVID-19 has had a major impact on numerous aspects of AATD clinical patient management in Spain, including diagnostic, treatment, and follow-up phases. The experts concluded that there is a need to strengthen coor‑ dination between Primary Care and Hospital Care and improve the coordination processes across all the organizations and actors involved in the healthcare system. Regarding telemedicine and telecare, experts have concluded that it is necessary to promote this methodology and to develop protocols and training programs. Experts have recom‑ mended developing personalized and precision medicine, and patient participation in decision-making, promoting self-care and patient autonomy to optimize their healthcare and improve their quality of life. The possibility of moni‑ toring and treating AATD patients from home has also been proposed by experts. Another result of the study was the recommendation of the need to ensure that plasma donations are made on a regular basis by a sufficient number of healthy individuals. Conclusion The study advances knowledge by highlighting the challenges faced by health professionals and changes in AATD patient management in the context of the COVID-19 pandemic. It also proposes experts’ recom‑ mendations aimed at ensuring humanized and quality care for people with AATD in the post-pandemic situation. This work could serve as a reference study for physicians on their daily clinical practice with AATD patients and may also provide guidance on the changes to be put in place for the post-pandemic situation. *Correspondence: María Torres Durán maria.luisa.torres.duran@sergas.es Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 2 of 8 Keywords COVID-19, Alpha-1-antitrypsin deficiency, Recommendations, Patient management, Healthcare system, Rare disease, Diagnostic, Treatment, Follow-up, AATD Background Therefore, this study’s aim was to identify the changes The ongoing coronavirus disease 2019 (COVID-19) pan- that have taken place in AATD patient care as a result of the demic has disrupted every aspect of our lives. The need to COVID-19 pandemic in Spain, and to propose experts’ rec- provide high-level care to an enormous number of patients ommendations aimed at ensuring humanized and quality with the COVID-19 infection during this pandemic, and care for people with AATD in the post-pandemic situation. the restrictions and lockdowns imposed by governments, has impacted resources and restricted the routine care of all non-COVID-19 conditions [1]. Since the beginning of Methods the pandemic, people living with chronic disorders have not For this study, guidelines for conducting qualitative stud- received the necessary attention that they deserve, this being ies established by the Consolidated Criteria for Reporting even more serious in the case of patients with rare diseases Qualitative Research (COREQ) were followed [17]. [2–4]. Patients with alpha-1 antitrypsin deficiency (AATD), commonly categorized as a rare disease, have been one of the groups affected by the changes in healthcare management Design brought about by COVID-19. AATD is one of the most com- A qualitative descriptive case study with a holistic single- mon genetic disorders leading to a wide spectrum of clinical case design was conducted [18], using focus groups (FGs) manifestations, ranging from no symptoms to a progres- with experts in AATD clinical management. Qualitative sively debilitating systemic disease, most commonly affect- methods are suitable for recognizing the beliefs, values, and ing lung and liver [5]. Adult AATD patients tend to present motivations that underlie individual actions and behaviors the usual symptoms of chronic obstructive pulmonary [19]. A case study is a type of research design that studies a disease (COPD), but with an earlier onset: cough, expecto- specific phenomenon in a real-life setting, and it can be used ration, dyspnea and frequent exacerbations, although the to identify and describe experiences regarding care and dis- main symptom is progressive dyspnea [6]. AATD’s estimated eases [18]. A case study may consist of several units, which prevalence is between 1:2500 and 1:5000 according to stud- together describe a phenomenon in a complete way. These ies from the United States and Europe [7, 8], but it is nec- units may be different participants or experts who are linked essary to emphasize that it’s estimated that a large number by the phenomenon under study [18]. In this project, the of patients are undiagnosed [9], and also that there’s a long phenomenon under examination is COVID-19’s impact on delay between symptom onset and AATD diagnosis [10]. AATD patient management. Two focus groups were con- Recent publications have linked AATD to COVID- ducted, the first was held to evaluate the changes brought 19. It’s been suggested that AAT may act as a protective about by the pandemic situation, as well as the new needs factor against the disease for several reasons, such as and recommendations aimed at ensuring humanized and its inhibition of the TMPRSS2 and ADAM17 proteases, quality care for people with AATD in the current and post- which are key to the virus’s pathophysiology [11, 12]. pandemic situation. In the second focus group, the work car- AAT’s role in SARS CoV-2 cell infection has been stud- ried out during the first workshop was shared with a wider ied, and clinical trials are underway to examine AAT’s number of experts with the aim of gathering additional con- potential usefulness as a treatment for COVID 19 [13]. tributions and reaching a consensus regarding the pandem- On the other hand, the frequently associated comorbidi- ic’s impact on the AATD care process and the unmet needs ties in AATD patients, including a higher prevalence of that have been revealed, as well as the recommendations hypertension, chronic kidney disease, COPD, and diabe- issued in this regard for the post-pandemic situation. Finally, tes, could predispose patients to severe COVID-19 and the insights obtained from both focus groups were compiled a poor prognosis [14, 15]. Consequently, AATD patients and summarized differentiating between impacts (positive would be a vulnerable group for infection with the virus and negative), unmet needs and recommendations. [16]. Change in health system routines due the COVID- The study duration was from March ­ 1st, 2021, to st 19 pandemic and the possible relationship between August ­1 , 2021. AATD and COVID-19 infection means it’s necessary to study the effects on AATD patient management. Unfor- Participants tunately, there’s a knowledge gap in this regard, as no The inclusion criteria consisted of 14 professionals who such studies have been carried out to date. have direct and extensive experience in the clinical man- agement of AATD patients’ (12 pneumologists and 2 Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 3 of 8 hospital pharmacists from 11 different hospitals in Spain) The COVID‑19 pandemic’s impact on AATD treatment and a patient’s representative. Participants were divided management into two groups: the core group was made up of 3 experts In this phase of treatment management, the changes (2 pneumologists and 1 hospital pharmacist) who acted as in protocols brought about by the COVID-19 pan- study coordinators and participated in both FGs. The rest of demic have shown several positive aspects, as the participants took part in the second FG. In addition, the expressed by experts. However, there has been also patients’ perspective was considered. For this purpose, an in- an important negative impact which have resulted depth- interview with the President of the Spanish Patients’ in new issues or exacerbated pre-existing ones. Association (Alfa 1 Spain) who is a patient himself. All the (Table 2). experts reviewed and validated the documentation generated. The COVID‑19 pandemic’s impact on AATD Follow‑up Data collection management In order to examine different perspectives within the The development of new tools for remote assistance have same group, FGs were held to gain an understanding of been an important advancement during COVID-19 for the problems faced by the group and to aid identification AATD patients in the different stages of the care process, of values and norms [20]. This method of data collection especially for follow-up. However, experts identified also is consistent with the case study’s design [18]. The first some negative effects of the pandemic in patient care FG was held on May 4 ­ th,2021, while the second FG was during this stage (Table 3). th conducted on May ­25 ,2021. The COVID‑19 pandemic’s all‑round impact on AATD Results management The COVID‑19 pandemic’s impact on AATD Diagnosis Expert identified certain across-the-board aspects management on AATD management that have been affected by Experts stated both positive and negative effects of the COVID-19 pandemic, some of them in a negative way COVID-19 pandemic on the AATD diagnosis stage whereas others are positive for AATD management (Table 1). (Table 4). Table 1 Positive vs negative effects of COVID-19 pandemic on AATD diagnostic stage Positive efects of COVID-19 on AATD diagnosis Development of telephone consultations and other remote assistance channels as a method for professionals to assess patients Negative efects of COVID-19 on AATD diagnosis Delays and cancellations of diagnostic tests Delays on the initial visits to the pneumologists, which are of great importance for making a correct diagnosis Lack of protocols, tools and resources for remote assistance Greater difficulty for effective communication and coordination between primary care and hospital care Table 2 Positive vs negative effects of COVID-19 pandemic on AATD treatment management Positive efects of COVID-19 on AATD treatment Breakdown of existing administrative barriers, thus facilitating home delivery of medication and home-based therapy Positive change of attitude and convincement for both patients and healthcare professionals with respect to auto-administration of replacement treat‑ ment Lower incidence of influenza and other respiratory viruses because of the lockdown and COVID-19-related measures Increase in smoking cessation Negative efects of COVID-19 on AATD treatment Decline in blood donations due to the security measures adopted by hospitals, redistribution of resources, high pressure of critical patient care and reluctance to donate blood, among other reasons Delays on treatment due to healthcare services saturation, leading some patients to follow a suboptimal treatment regimen Increased difficulties in instructing patients to change inhalers and escalate treatments Increased difficulty in assessing lung transplantations Changes in lifestyle related to lockdown measures which have resulted in problems for patients keeping a healthy lifestyle and a good diet. These changes have also impacted negatively patients’ mental health Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 4 of 8 Table 3 Positive vs negative effects of COVID-19 pandemic on AATD follow-up Positive effects of COVID-19 on AATD follow-up Promotion and positive uptake of remote assistance for patient follow-up, accompanied with the development of new tools for maintaining the conti‑ nuity of care Negative effects of COVID-19 on AATD follow-up Delays and cancellations of follow-up visits due to healthcare services’ saturation Reduced number of complementary tests for patients’ follow-up Lack of protocols, tools and resources for remote assistance, which have led to a sense of uncertainty in patients Table 4 Cross-board impact of COVID-19 pandemic on AATD management Positive cross-board effects Organization of online seminars to reinforce patient’s information and reduce their uncertainty Use of different media and social networks to give best public health advice and recommendations to patients who need it Better communication between different care levels Increased involvement and participation of patients’ associations in the dissemination of information, providing support to patients and strengthening psychosocial monitoring Negative cross-board effects Mistrust on going to the health center for fear of infection Problems in differentiating between patients with respiratory conditions and suspected COVID patients, thus being admitted incorrectly to the special COVID circuit, and consequently making it difficult to access appropriate consultations Professionals’ feeling of loneliness during the pandemic, highlighting the need to establish coordinated criteria among them for decision-making, in line with legal and ethical principles Emotional tension and stress among professionals, the lack of official documents and criteria for managing the pandemic, and treatment continuity for patients with chronic diseases Table 5 Identified needs on the clinical management of AATD due to the COVID-19 pandemic 1. Strengthening Primary Care and Hospital Care: the overflow of health services has caused problems such as delays in diagnosis and/or treatment or problems in follow-up, especially in rare diseases 2. To promote self-care and patient autonomy to optimize their healthcare and improve their quality of life 3. To progress in the coordination and communication between the healthcare systems of the different Autonomous Communities, between health‑ care levels, and between the different agents of the system (public administration, healthcare, industry, and patient associations) 4. Networking and collaboration between different specialties when forming care teams to improve the approach to pathologies such as AATD 5. Develop personalized and precision medicine as a tool for the identification and application of a personalized preventive, diagnostic and therapeutic approach to patients with AATD, as well as patient participation in decision-making 6. To ensure that plasma donations are made on a regular basis by a sufficient number of healthy individuals 7. Promote telemedicine and telecare to offer patients who so wish the possibility of complementing their face-to-face care with remote care 8. Encourage initiatives that promote a holistic conception of healthcare Needs identified in AATD clinical management due with several recommendations for improving the post- to the COVID‑19 pandemic pandemic situation (Table 6). As a consequence of this health crisis caused by the COVID-19 pandemic, a series of challenges have been Discussion identified by the experts regarding the AATD care pro- Although there are studies on COVID-19’s impact on cess (Table 5). COPD management as well as on rare diseases [2, 21], to the best of our knowledge this is the first study to ana- Recommendations for AATD management lyze COVID-19’s impact on AATD patient management. in the post‑pandemic situation Our findings revealed that COVID-19 has had a major After identifying COVID-19’s impact on AATD impact on numerous aspects of clinical patient manage- patients’ clinical management, the experts concluded ment in Spain, including the diagnostic, treatment and Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 5 of 8 Table 6 Recommendations for the management of AATD in the post-pandemic situation 1. Reinforce Primary Care and Hospital Care health services, both in terms of staff and resources, with the aim of minimizing the cancellations and post‑ ponements observed during the health crisis, which delay diagnosis, treatment, and follow-up, especially for rare diseases such as AATD 2. Develop health education programs and information materials for patients, aimed at increasing their awareness of AATD to foster their autonomy: a. Achieve patient self-detection of alarm symptoms, exacerbations, etc b. Inform about the benefits of regular exercise and optimal nutrition for disease management to counteract the inactivity caused by the confine‑ ment c. Maintain awareness-raising messages on the risk of tobacco use, taking advantage of the increase of smoking cessation produced during confine‑ ment d. Inform about the harmful effects of alcohol in order to discourage its consumption e. Raise awareness of the advantages of maintaining in certain cases the measures taken against coronavirus to avoid infection by other respiratory viruses and to protect against harmful substances in the environment that may aggravate COPD 3. Ensure the possibility of self-administration of treatment to increase patient autonomy and self-care. This type of treatment has already demonstrated several positive points in other pathologies (e.g. in hereditary angioedema) and is supported by healthcare professionals at the European level 4. Ensure the availability of TAA replacement therapy from home and inform patients of this possibility. In this way, those patients who prefer this option will be able to opt for it to increase their quality of life, whilst reducing the burden of care on the health center 5. Develop and implement coordination and communication strategies between the different levels of care, between different specialties, as well as between the different agents in the system to improve the approach to the AATD care process 6. Promote the development of personalized and precision medicine in national and regional health strategies and plans. The pandemic has high‑ lighted the relevance of personalized treatments and, in the case of AATDs, it is particularly important due to the variability of their natural history 7. Prescribe individualized physical activity programs, taking into account the capacities and needs of each patient, with the aim of subverting the bad habits acquired during the pandemic, as well as assessing the nutritional status of the patient individually (dietary, anthropometric, and hematological studies, etc.) for the early identification of those patients at a greater risk of malnutrition and establish the degree of nutritional support recommended 8. Promote the development of plasma donation campaigns in coordination with blood banks and raise public awareness of the importance of plasma donation for this type of treatment, such as AATD 9. Develop monitoring instruments that can be used from the patient’s home and provide sufficient information for decision-making in the AATD care process (questionnaires in apps, spirometers incorporated into mobile devices, e.g.) to promote telemedicine 10. Develop training programs in telecare for healthcare workers. In this regard, it is recommended that resources for telecare be increased, so that they are accessible to patients as a complementary tool to face-to-face care 11. Promote psychosocial support, continuous and personalized communication with the patient, assisting patients from a holistic perspective, taking into account their clinical, social, and personal characteristics, their needs, etc follow-up phases. In addition, the pandemic context has can cause great harm to health outcomes in AATD highlighted various needs in AATD patient care; experts patients. have therefore drawn up a series of recommendations in Another aspect highlighted in this study was tel- order to meet these needs and address the impact caused emedicine/telecare’s implementation and growth. On by COVID-19. the one hand, this has had a positive impact, as it’s ena- An overall view of the results highlights some aspects bled awareness and implementation of new tools for repeated in several sections of the study. One of them the health system that didn’t used to exist. However, its is that COVID-19 has caused cancellation or postpone- implementation was forced without prior planning and ment of a large number of medical procedures, impact- this is linked to feelings of insecurity in patients, who ing AATD patients’ diagnosis, treatment and follow-up expressed a mixed perception of this type of care [25]. phases. As a result of health service saturation due to the Implementation of telehealth is a challenge for managing pandemic, chronically ill patients have had their hospital patients with chronic respiratory diseases, as shown in a and primary care consultations cancelled [22]. In Spain, recent study [26]. One of the ways to access these tools’ a survey estimated that 43% of respiratory patients have full potential would be to improve health professionals’ been unable to make face-to-face appointments with a training in telehealth. In this respect, there are several specialist since the first months of 2020 [23], a fact that studies that even point to the need to include telemedi- supports the perception shown by this study’s experts. cine training in the medical school curriculum [27, 28]. Another study concluded that there was a reduction Another issue that’s recurred throughout this study is in the number of complementary healthcare tests con- the relevance of and need for patients to have an active ducted due to the COVID-19 pandemic in COPD [24], role not only in decision-making but also in boost- and rare metabolic patients [3]. Therefore, as described ing their autonomy and self-care. According to experts, by the experts in their recommendations, it would be patient education both on self-diagnosis and self-treat- necessary to strengthen both primary and hospital care ment is necessary and beneficial, based on the experi- in order to prevent these cancellations and delays, which ences lived during the COVID-19 pandemic. Regarding Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 6 of 8 this aspect, there’s a need to make home-care available coordination measures that help to overcome barriers for the AATD treatment. The aim should be to reduce the to achieving more effective and better integrated patient number of doses of replacement therapy, shorten admin- management. istration times and offer the possibility of administering This study has several limitations. Firstly, the results it at home in order to increase the quality of life of those probably cannot be directly extrapolated onto other patients who prefer not to go to the health center [5, 23]. health systems. Therefore, this study’s recommenda- In this regard, the possibility of monitoring patients from tions can be implemented directly in the Spanish con- home by developing instruments that can be used from text but might not be appropriate for other countries or patients’ homes and provide information for decision- regions. Clinicians with experience in other healthcare making in the AATD care process (e.g., questionnaires systems should assess whether each recommendation in on apps, spirometers incorporated into mobile devices) this study can be transferred onto their clinical practice was also proposed as a recommendation by experts. With and adapted or discarded by those who don’t consider it the rise of handheld spirometers, at-home spirometry appropriate. Following the same methods as described in has become common for daily monitoring of the amount this study will enable other researchers to apply the same and/or speed of air that can be inhaled and exhaled [29]. approach in other contexts. Another possible limitation This could be a functional tool used in AATD patients’ in the study is to do with the limited number of health home monitoring, enabling health system resources to be professionals who took part in the FGs. Although we freed up while improving patient follow-up. tried to make it representative and diverse, there’s always Personalized medicine was another point that came the possibility of bias, since not all health profession- up during the study on several occasions. In the field of als involved in AATD in Spain were represented. Addi- AATD patient management, there’s currently increas- tionally, another possible limitation is the use of online ing interest in personalized medicine, especially regard- platforms to conduct the FGs, due to the restrictions ing ATT treatment, and including the use of extended caused by the COVID-19 pandemic. This could lead to dosing intervals and at-home treatment [30, 31]. In the some communication bias, although this technology may near future, increased patient stratification will allow also have advantages such as broadening participation for enhanced application of personalized medicine and [40]. Lastly, it’s important to highlight that, even though pro-active treatment regimens, resulting in reduced it is predictable that the experts’ recommendations costs and improvement in quality of life [32]. Experts could have a positive impact in the clinical care of these have therefore recommended the need to boost devel- patients, they would need to be tested before concluding opment of personalized medicine for AATD patient their utility in real clinical practice. management. Another aspect relating to treatment availability are Conclusions blood transfusions, which during the pandemic have suf- The study advances knowledge by highlighting the chal- fered numerous cancellations due to the decrease in the lenges faced by health professionals and changes in number of donations in Spain, as attested by the study AATD patient management in the context of the COVID- carried out by García-Erce et al. [33]. The importance 19 pandemic. Though many of the issues and problems of this resource, not only for clinically managing AATD identified were also present before the pandemic, they [5, 34], but also in other medical situations [35, 36], has have been exacerbated and are of greater concern in the prompted experts to emphasize this aspect in several sec- pandemic situation. The study also proposes experts’ rec- tions of this study as well as in the recommendations. ommendations aimed at ensuring humanized and qual- Regarding the healthcare system, on several occasions ity care for people with AATD. It could therefore serve during the study, experts expressed the need and recom- as a reference study for all those physicians who’ve had mendation to increase and improve the coordination pro- to suffer COVID-19’s impact on their daily clinical prac- cesses across all the organizations and actors involved. In tice in AATD patient management, and may also provide the end, networking and collaboration between differ- guidance on the changes to be put in place for the post- ent specialties should be encouraged when forming care pandemic situation. or working groups in order to improve the approach to pathologies such as AATD. In this regard, it should be Abbreviations noted that the Spanish healthcare system is quite com- AATD Alpha-1 antitrypsin deficiency plex, due in part to its administrative structure, which COREQ Consolidated criteria for reporting qualitative research sometimes complicates coordination between its differ- COVID-19 Coronavirus disease 2019 COPD Chronic obstructive pulmonary disease ent units [37–39]. It’s therefore necessary to implement FGs Focus groups Calle Rubio et al. BMC Health Services Research (2023) 23:98 Page 7 of 8 Acknowledgements Author details 1 We want to thank Ascendo Consulting for its support throughout the project, Pulmonology Department, Health Research Institute of the Hospital Clínico including manuscript editorial and writing support. We also thank Mariano San Carlos (IdISSC), San Carlos Clinical Hospital, Madrid, Spain. 2 Department Pastor for his contribution to the project as a patient representative on the of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, FGs, as the president of the “Asociación Alfa-1 España”. Spain. 3 Medical‑Surgical Unit for Respiratory Diseases, Biomedicine Institute of Sevilla (IBiS), Virgen del Rocío University Hospital, Seville, Spain. 4 Pulmonol‑ Authors’ contributions ogy Department, Research Institute of Vall d’Hebron (VHIR), Vall d’Hebron All authors have contributed to the conception, design, acquisition, analysis, University Hospital, Barcelona, Spain. 5 Network of Centers for Biomedi‑ and interpretation of the data, and have participated in the drafting and cal Research On Respiratory Diseases (CIBERES), Carlos III Health Institute, reviewing of the manuscript, approving the submitted version. Madrid, Spain. 6 Pulmonology Department, Donostia University Hospital, San Sebastián, Spain. 7 Pulmonology Department, Nuestra Señora de Candelaria Funding University Hospital, Santa Cruz de Tenerife, Spain. 8 Pulmonology Department, This study was funded by CSL Behring. A Coruña University Hospital, A Coruña, Spain. 9 Department of Pharmacy, Vall d’Hebron University Hospital, Barcelona, Spain. 10 Pulmonology Department, Availability of data and materials San Cecilio Clinical University Hospital, Granada, Spain. 11 School of Health All data generated or analysed during this study are included in this published Science, University of Granada, Granada, Spain. 12 Pulmonology Department, article. Cruces University Hospital, Barakaldo, Spain. 13 Department of Pharmacy, San Carlos Clinical Hospital, Madrid, Spain. 14 Pulmonology Department, Research Institute of Germans Trias I Pujol (IGTiP), Germans Trias I Pujol University Hospi‑ Declarations tal, Barcelona, Spain. 15 Pulmonology Department, Albacete University Hospital Complex, Albacete, Spain. 16 Pulmonology Department, Health Research Ethics approval and consent to participate Institute of Galicia Sur (IISGS), Álvaro Cunqueiro Hospital, Estrada Clara Cam‑ This study was performed following the Helsinki Declaration. The study was poamor, 342. 36312 Vigo, Spain. conducted according to national regulations, as described by Royal Decree 1090/2015. According to the aforementioned legislation, due to the nature of Received: 20 April 2022 Accepted: 23 January 2023 the study, approval by an ethics committee was not required. Consent for publication Not aplicable. References Competing interests 1. 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García-Erce JA, Romón-Alonso Í, Jericó C, Domingo-Morera JM, Arroyo- Rodríguez JL, Sola-Lapeña C, et al. Blood donations and transfusions • thorough peer review by experienced researchers in your field during the COVID-19 pandemic in spain: impact according to autono‑ • rapid publication on acceptance mous communities and hospitals. Int J Environ Res Public Health. • support for research data, including large and complex data types 2021;18(7):3480. 34. Miravitlles M, Dirksen A, Ferrarotti I, Koblizek V, Lange P, Mahadeva R, • gold Open Access which fosters wider collaboration and increased citations et al. European respiratory society statement: diagnosis and treat‑ • maximum visibility for your research: over 100M website views per year ment of pulmonary disease in α(1)-antitrypsin deficiency. Eur Respir J. 2017;50(5):1700610. At BMC, research is always in progress. 35. Cai X, Ren M, Chen F, Li L, Lei H, Wang X. Blood transfusion during the COVID-19 outbreak. 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