survivors

RACGP Acting President Associate Professor Ayman Shenouda said that GPs would be managing the long-term impacts of the virus on some patients for years to come.

The Royal Australian College of General Practitioners (RACGP) is warning government that GPs will need adequate resources to manage the long-term care of COVID-19 positive patients. The RACGP has released a guide for GPs providing care to adult patients who have previously tested positive to COVID-19 or have a history suggestive of undiagnosed COVID-19 and have - or are at risk of - post-COVID-19 conditions. The guide was developed in collaboration with HealthPathways. RACGP Acting President Associate Professor Ayman Shenouda said that GPs would be managing the long-term impacts of the virus on some patients for years to come.

“Some COVID-19 positive patients quickly make a full recovery but that is certainly not the case for all people,” he said.

“Evidence is emerging that some patients are being left with serious physical, cognitive and psychological impairments that will require long-term care. For these patients, it is not a case of contracting the virus, getting better and never thinking about it again.

“Post-COVID-19 conditions include lung scarring, post-viral fatigue as well as ‘brain fog’. Emerging data suggests that up to 80% of people with severe cases of COVID-19 resulting in hospitalisation will experience post-COVOD-19 conditions.

“There is also evidence that people who have contracted COVID-19 exhibit neurological symptoms, from loss of smell, to cognitive impairment, to an increased risk of stroke. There are also potential long-lasting consequences such as post-traumatic stress disorder (PTSD) following severe illness, liver dysfunction, and heart failure.

“These long-term effects are likely to be particularly severe for older people, those with chronic disease and those who experienced severe acute COVID-19. GPs will be crucial in managing the health and wellbeing of these patients in the years ahead.”

The Acting RACGP President said that GPs need government support in caring for the potentially significant needs of patients with post-COVD-19 conditions.

“When we look at the patients most likely to suffer severe post-COVID-19 health concerns it is older people and those with multiple chronic conditions, including patients who have delayed or avoided care during the pandemic,” he said.

“A voluntary patient enrolment model, where clinics receive additional payments for ‘enrolling’ a patient with a regular GP, would be particularly beneficial for these patients. This model enhances comprehensive care for patients and reduces hospitalisations for those who frequently visit GPs.

“Post-COVID-19 health impacts will take a significant toll on many patients including on their mental health. The guide is mindful of this and includes information on accessing mental health services or online supports.

“The Federal Budget included a $100.8 million investment in extending the doubling of Medicare-subsidised psychological therapy sessions for people who have used their initial 10 sessions.

“That is a welcome announcement that will make a real difference. However, in the longer term, many patients including those suffering the after effects of COVID-19 would benefit enormously from new Medicare subsidies for longer consultations.

“Longer consultations allow GPs to take the time to talk through what our patients are experiencing and how we can help them.

“Similarly, new Medicare subsidies for longer consultations for people with chronic conditions would be very helpful. These are the patients who require a bit more time and attention, particularly if they have had COVID-19.”

The guide includes information on:

· infection control precautions and advising patients that having COVID-19 may not confer complete immunity

· collaborating with the patient to develop an individualised plan to support their recovery. This also presents a unique opportunity to optimise the management of existing chronic conditions

· providing care for specific groups recovering from the virus including those with severe COVID-19 requiring hospitalisation, older patients and people with disability

· options for enhancing support for patients including home delivery of medicines, assistance with food and meals and support lines including the Older Persons COVID-19 support line.

Long Term Effects of COVID (“Long-Haulers”)

"Can the people with COVID suffer long term effects? Including long term effects that affect the brain? Yes. These are the so-called “long-haulers.” And it is not necessarily just people with COVID who have required the intensive care unit."

"Dexamethasone, a steroid medication, specifically a glucocorticoid. Yes, it can cause anxiety, irritation, psychosis, delirium, sleep disturbance. This is why when we do give steroids, we try to avoid giving them before sleep. When assessing someone’s mental status, or psychiatric state, its important to know what they are normally like at their baseline. Are they acting differently? That’s really what you’re looking for. Steroids are prescribed very frequently, and these side effects, are not necessarily rare, its not like we give steroids and necessarily expect them to have these side effects. It's very hard to put a number on how often these side effects occur because there are so many different medications that can cause these symptoms and so many other factors that can contribute towards mental status changes. So you will never get a concrete number on how often these mental side effects occur, but if I had to put a number, I would say less than 10%, at least based on my experience of giving thousands of patients steroids.

Well, let me start out by saying there are over 30 million documented COVID cases and 1 million deaths worldwide, and over 200,000 deaths in the US. The clinical spectrum of disease can range anywhere form no symptoms to mild symptoms, to pneumonia, to ARDS and shock with multiorgan failure, and death. Because COVID is a new disease, the possible long-term health consequences, are still not well-known. So these long-term effects of COVID, we can call this postacute COVID, defined as the presence of symptoms extending beyond 3 weeks from the initial onset of symptoms. And Chronic COVID is beyond 12 weeks.

But postacute COVID syndrome is not just seen in those who had a severe illness and were hospitalized. In a telephone survey conducted by the CDC among a random sample of 292 adults (≥18 years) who had a positive outpatient COVID test and were symptomatic, 35% said they did not return to their usual state of health 2 weeks or more after testing. And this occurred in all ages of adults.

The most commonly reported symptoms after acute COVID are fatigue and dyspnea. And this is exactly what I’ve been seeing with some of my patients with COVID. This persistence of fatigue, and feeling short of breath. Other symptoms include joint pain and chest pain. In addition to these symptoms, there are cases of patients with specific organ dysfunction, primarily involving the heart, lungs, and brain. This might be a result of the viral invasion, by hijacking those ACE2 receptors in our body, but it can also be related to the intense inflammation and cytokine storm, or a combination of these.

In a study of 55 patients with COVID, at 3 months after discharge, 35 had persistent symptoms and 39 had abnormal findings on chest x-ray or CT scan, meaning interstitial thickening and evidence of fibrosis, meaning scarring. In 2 different studies that were done, they looked at patients with COVID who were discharged from the hospital. At about three months after discharge, about 25-30% of patients had at least some impairment in lung function, as evidenced by pulmonary function tests.

Heart damage, aka myocardial injury, as defined by an increased troponin level in the blood, has been described in patients with severe acute COVID. Inflammation of the heart muscle, meaning myocarditis, in addition to heart arrhythmias, has also been described after SARS-CoV-2 infection. I dedicated an entire video to this topic, so you can check that out for more details. The virus that causes COVID, SARS-CoV-2, can infiltrate brain tissue when the virus gets in the blood. It can also get to the brain by invading the olfactory nerve, which is the nerve responsible for the smell. This is why the loss of smell is a common symptom. Besides the loss of smell and loss of taste, the most common long-term neurologic symptoms after COVID are headache and dizziness. Less common, but still possible, is stroke, brain inflammation, meaning encephalitis, and seizures. In previous pandemics with SARS, MERS, and influenza, some people who recovered from those illnesses had neuropsychiatric issues that lingered for months. So were talking about cognitive health here, like depression and anxiety. And the post-COVID is known to cause “brain fog” and mood swings, this has been reported up to 2 to 3 months after initial COVID" illness. [Source: Partial transcript accompanying the video above.]

With COVID-19, we should not just be looking at deaths. Deaths may actually be a poor indicator of the damage this virus may do. We should be looking at a continuum, as in: If the proportion of people who contract COVID-19, and who are over 80, die, what happens to those (of any age) who live? Given the ability of this disease (unlike flu) to cause clotting problems all over the body, affecting organs which affect other organs, we should be expecting that a proportion of survivors will have various rates of blood clots and organ damage. What proportion of these will clear, improve, or become chronic and dangerous? How long will how many survivors survive? Check out the following videos by doctors regarding clotting and organ-damage.

[Candobetter Ed: This article was developed from an extract from another, in order to highlight these concepts.]

"More long-term damage caused by COVID-19 than expected | COVID-19 Special" (August 26, 2020)

The above video has many comments of interest, from people who have suffered lingering damage from the virus.

"An NYC Cardiologist Explains the Long Term Effects of COVID-19."

The cardiologist in the above video points out that, even if you are young and fit when you catch COVID-19, you still may not be able to do what you used to do, after you recover. He also says that people should present early for treatment because then treatment can be started to reduce the damage to organs, thus perhaps reducing the severity of chronic conditions that may linger and prevent full recovery. He also says that four years after the 1918 Great Flu epidemic, many survivors still had debilitating symptoms.

"Long-term health effects of COVID-19" (Lung specialist talks about pulmonary fibrosis, which may lead to need for lung transplants.)

Most important to factor in, among all these continuum possibilities, is the incredibly infectious nature of COVID-19, far more than the flu. Cummins does not appear to think much about this.

Perhaps it would be more useful and educative to describe COVID-19 as a clotting disease, than as a respiratory one.