Covid-19 care before, during, and beyond the hospitalBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2035 (Published 22 May 2020) Cite this as: BMJ 2020;369:m2035
All rapid responses
We agree with the view discussed in this Editorial that it’s time to shift the research focus to studies on living with this disease. The same is true of research on mental health. With the joint efforts of people all over the country, China's COVID-19 control has made certain achievements. During the COVID-19 outbreak, more attention was paid to the mental problems of medical staff and hospitalized patients with COVID-19. [1,2] However, with the increase in the number of patients with COVID-19 discharged from hospitals, the focus of mental health care may be shifted there.
The First Affiliated Hospital of Nanchang University was the designated hospital for COVID-19 in Jiangxi Province. A total of 215 confirmed COVID-19 patients were admitted to the hospital during the outbreak. At present, like all the designated hospitals admitted for treatment of COVID-19 patients in China, we are also carrying out the follow-up work. Through the feedback from the discharged COVID-19 patients during follow-up, we found that they might suffer from mental problems and were still at a higher risk of developing mental disorders, such as anxiety, depression, sleep problem and even suicidal ideation.
The main reasons are summarized as follows:
The first and most important reason was excessive worry and panic about the recurrence and prognosis of the disease. It was reported that COVID-19 virus was more contagious than SARS or MERS. [3,4] Moreover, the treatment regimen for the COVID-19 is now in its seventh edition in China. This suggests that the treatment option for the disease is still being explored, and that the prognosis of the disease is even less known. Some patients thought that although the nucleic acid test was negative, the virus might still be in their lungs and the disease would recur at any time. Others feared that the disease might have a poor prognosis, which would affect their health, their jobs, families and careers;
Stigma and discrimination from surroundings were important reasons. It's easy to understand that despite the patients having been cured and discharged, people were still afraid of being infected by them;
Lack of social support was another important reason. Some felt sad that they might be alienated or isolated by former friends and relatives.
In view of the various potential mental problems that patients may have after discharge, we should not only care about their physical recovery, but also pay attention to their possible mental problems and underlying reasons. Moreover, the emergence of mental disorders will further reduce the patient's immunity and increase the risk of recurrence.
In order to eliminate the risk factors and reduce the occurrence and development of mental problems, we suggest that under the guidance of the national plan,  mental health professionals should carry out psychological counseling together with medical professionals who participated in the treatment of COVID-19 patients, community workers and patients' family members. The medical staff are mainly responsible for responding to patient's misgivings on the disease. Community workers help patients and their families return to their normal lives and prevent stigma around the disease. Mental health professionals are responsible for providing professional psychological counseling and treatment. In addition, in order to detect possible psychological problems in advance, screening and assessment of common psychological problems should be included in the follow-up of discharged patients in addition to nucleic acid and CT and other common tests.
Mengqian Li 1, Bo Hu 1, Hongguang Chen 2*
1. The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
2. Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.
1. Xiang YT, Yang Y, Li W, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020; 7(3): 228-9.
2. Chen Q, Liang M, Li Y, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020.
3. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020; 395(10223): 470-3.
4. Epidemiology Working Group for NCIP Epidemic Response. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Chinese Journal of Epidemiology, 2020, 41(2): 145-151.(In Chinese)
5. State council. Work plan for psychological counseling during COVID-19 epidemic. http://www.gov.cn/xinwen/2020-03/19/content_5493051.htm (accessed Mar 20, 2020)
Competing interests: No competing interests
A remaining question regarding Covid-19 changes: What is the collective noun for back-to-back-to-back Zoom sessions?
The provision of health-care has fundamentally and irrevocably changed in response to Covid-19. The pandemic has affected the entire world and has shifted how medical services are provided in both community and formal health-care settings. There has been general acceptance of the requisite modifications to individual and group behaviours in medical practice, medical education and medical research. However, there remains one great unanswered question that has arisen from the widespread implementation of social distancing policies; what on earth do we call the back-to-back Zoom sessions that, instead of actual face-to-face contact with patients, peers and students, now fill our days?
The history of collective nouns in the English language can be traced back to the early part of the second millennia, with examples such as The Treatise / Le Tretiz  from the mid 1200s identifying words to describe groups of items, usually animals. Over the subsequent centuries, additional terms, such as a murder of crows,  came into common usage regarding collections of similar objects. Nonetheless, our beautiful tongue has not yet developed sufficiently quickly to determine the correct collective noun for a series of back-to-back Zoom sessions.
In order to address this most pressing of issues, the Faculty of Medicine and Health at the University of New England in Australia recently held a competition for its staff to determine definitively the collective noun for multiple Zoom sessions. Due to totally unforeseen interest and a dramatic under-estimation of the number of submissions, there was an entirely arbitrary separation of entries into two categories. The first category was for “Single descriptors using the word Zoom”. There were 35 separate submissions, with some effectively identical nominations combined.
Following faculty-wide voting, the top 10 submissions for the first category, in reverse order, were:
The winner, which was voted for by 42% of respondents, was ZOOMAGEDDON! This entry was submitted by Dr Karen Hazell Raine.
The second category was for the “Best collective noun to describe a series of Zoom sessions” and featured 32 nominations. The top 10, again in reverse order, were:
10. A depression of Zooms
9. A looming of Zooms
8. A gauntlet of Zooms
7. A cascade of Zooms
6. A cluster of Zooms
5. A Mazda of Zooms (no copyright infringements implied)
4. A pandemic of Zooms
3. An outbreak of Zooms
2. A gloom of Zooms
And, with 37% of votes, the winner of the second category was A BOOM OF ZOOMS! This entry was submitted by Sam Bugden. The lead author’s two personal favourites – an enervation of Zooms and a lamentation of Zooms – sadly did not feature highly in the final voting.
In conclusion, we would like to respectfully suggest that the term “Zoomageddon” and the collective descriptor “A boom of Zooms” both be officially adopted into the international medical lexicon to save future generations from suffering this same level of linguistic uncertainty.
Note: As a competition, no ethical approval for this was sought.
1. Hinton T. Anglo-French in the thirteenth century: A reappraisal of Walter de Bibbesworth's Tretiz. The Modern Language Review 2017; 112(4): 855-881.
2. A Murder of Crows. Oxford Dictionary of English 2010; Oxford University Press: Oxford.
Competing interests: No competing interests
Coronavirus may likely stay with us forever  and you have rightly mentioned in your recent editorial  that it is the time to shift the focus on living with the disease. An approved drug or vaccine to treat or prevent the disease is still far and may not be readily available across the world in the near future, particularly in the low and middle-income countries. Therefore, a comprehensive pharmaceutical care during early CoViD-19 is invaluable in supporting patients under self-isolation or in quarantine to help with their symptoms and preventing them from getting a severe disease needing hospitalisation. A recent preprint  provides a pharmaceutical care plan for the early CoViD-19 as an alternative approach to manage the pandemic in the absence of a ‘breakthrough’ drug or a fully established coronavirus vaccination program. The given approach aims to hit the coronavirus hard within the upper respiratory tract before it goes down to cause a severe disease.
The pharmaceutical care during early CoViD-19 may include inhaling steam infused with essential oils such as those in over-the-counter VapoRubs, for instance, Vicks®. The essential oils have previously shown broad-spectrum activity against various microorganisms to include a range of viruses [3, 5] and may help in attenuating the coronavirus within the upper respiratory tract in conjunction with the inhaled steam.
In addition, antiseptic mouthwashes such as chlorhexidine digluconate (Corsodyl®) can be used as a throat rinse (gargle) to sanitise the oropharynx. Chlorhexidine has been effectively used in dental practice since long and provides a broad-spectrum antimicrobial activity against various pathogenic bacterial, yeasts, fungi and viruses . Moreover, benzydamine containing throat rinse can provide analgesic and anti-inflammatory properties to ameliorate pharyngitis by inhibiting pro-inflammatory cytokines . This is to support the recommendation from Venning et al  in response to your editorial on using low dose aspirin during early disease. Benzydamine throat rinse may provide a substitute offering a more localised effect in managing cytokine storm during early CoViD-19. Another alternative approach could be a throat rinse (gargle) using an aspirin solution that can be freshly prepared in-situ by adding dispersible aspirin tablets in a glass of water.
Antiseptic lozenges such as those containing 2,4-dichlorobenzyl alcohol and amylmetacresol (such as Strepsils®) can further help with the oral and pharyngeal sensitisation. The combination of dichlorobenzyl alcohol with amylmetacresol offers wide spectrum antiseptic properties against a range of bacteria, fungi and viruses including respiratory syncytial virus, cytomegalovirus, influenza and the coronavirus (SARS-CoV-1) [8,9].
There have been reports of gastrointestinal symptoms in CoViD-19 patients in recently published studies [10-12] which can be controlled by various over-the-counter remedies for diarrhoea or constipation, such as Senokot®, lactulose, activated charcoal, ispaghula husk, Movicol®, as the case may be. This will not only help in regulating the bowel but may also facilitate in clearing the virus from the gut via surface adsorption (charcoal, ispaghula). In case of patients complaining gastrointestinal spasm, an antispasmodic agent such as hyoscine or mebeverine may also be offered.
The aforementioned pharmaceutical care plan is in addition to the currently recommended support in early CoViD-19, such as paracetamol, ibuprofen, antihistamines, antitussives, bronchodilators and offering empirical antibiotics if a secondary bacterial infection is suspected.
A comprehensive pharmaceutical care and early intervention can, therefore, prevent the virus to get down the lower respiratory tract, and potentially reduce the number of cases with severe disease involving pneumonia, and consequent reduction in CoViD-19 associated hospitalisation. To the least, it can provide a comprehensive management of symptoms and may give the body the time to produce antibodies and recover naturally from the disease. The author, therefore, reiterates your notion of shifting the focus to provide the care and support to CoViD-19 patients, particularly, during the early disease to help them recover and significantly reduce the disease burden on healthcare systems.
Competing interests: No competing interests
This Editorial addresses the need for better information and studies of care before the hospital; guidance including prevention, transmission, monitoring, home care, integration with primary care.
The BMJ Treatment Algorithm for “suspected COVID-19” describes isolation with monitoring; empirical antimicrobials; supportive care; antipyretic and/or antitussive therapies. NICE guidelines (Last updated: 23 April 2020) make no recommendation for initial therapies in primary care for suspected early or mild coronavirus infection. We suggest consideration within Primary Care of aspirin as early active treatment to limit disease progression and avoid complications.
Mechanisms are involved in severe COVID-19 disease distinct from the direct effects of the virus. Therapeutic interventional trials are addressing different pathological pathways, including anticoagulation and cytokine blockade for example, but require within hospital assessment and treatment initiation.
Covid-19 binds to alveolar macrophages via ACE2 leading to cytokine release including interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) (Mehta 2020). Markers of disease severity include evidence of thrombosis with low platelet count and elevated d-dimers; as well as complement activation. The complement activation involves Neutrophil Extracellular Trap (NET) formation, release of anaphylatoxin C5a and Membrane Attack Complex (MAC) formation (Cao, 2020, Zuo 2020). Histology demonstrates pulmonary deposits of complement C5b-9 (MAC) within a thrombogenic vasculopathy (Magro2020). This thrombotic and inflammatory vasculopathy results from synergy between complement activation, initiation of thrombosis and NET formation and leads to further lung as well as other major organ damage.
The low platelet count directly correlates with disease severity: in a meta-analysis of 1476 patients the in‐hospital mortality was 92.1%, 61.2% and 17.5% in relation to nadir platelet counts of 0-50, 50-100 and 100-150 respectively (Yang 2020).
We suggest considering low dose aspirin therapy (75mg once daily) for patients with suspected early Covid-19 disease. This treatment would target thrombus formation and potentially retard / reduce disease progression. Aspirin could be prescribed in primary care by GPs comfortable with this relatively safe approach for the given patient. At the same time we would propose a rigorous prospective study with treatment and control arms addressing this and possibly other platelet-targeting therapies.
Michael Venning, Consultant Renal Physician, University of Manchester
Ivan Benett, General Practitioner, NHS Manchester
Iren Szeki, Consultant Nephrologist, Manchester Foundation Trust
David Jayne, Professor of Clinical Autoimmunity, University of Cambridge
Mehta 2020. Across Speciality Collaboration, U.K. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet (2020) 395, 1033-1034.
Cao 2020. Clinical Features of Patients Infected with the 2019 Novel Coronavirus (COVID-19) in Shanghai, China, . . Nature Reviews Immunology (2020) doi.org/10.1101/2020.03.04.20030395
Zuo 2020. Neutrophil extracellular traps in COVID-19. J Clin Invest Insight April 24, 2020 JCI Insight. 2020. In-Press Preview 10.1172/jci.insight.138999
Magro 2020. Weill Cornell Medicine. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of 5 cases Transl Res. 2020 Apr 15 doi: 10.1016/j.trsl.2020.04.007- epub ahead of print
(Yang 2020). Thrombocytopenia and its association with mortality in patients with COVID‐19. J Thromb Haemostasis 17 April 2020 https://onlinelibrary.wiley.com/doi/abs/10.1111/jth.14848
Competing interests: No competing interests