Implications for Online Management: Two Cases with COVID-19

Online guidance for treatment regimen during quarantine

Treatment regimen was adjusted by the multidisciplinary team based on the efficacy reported in the online observation form. Case 1 had been taking oral oseltamivir, arbidol, and avelox for 8 days since January 19, and at 6:00 pm on January 28, he began to develop itchy rose spots on both hands with no sign of fever. After online consultation with a dermatologist, case 1 was recommended to take oral antiallergic medication (cetirizine) and apply calamine lotion, which gradually improved his skin rash. Given that the patient had elevated alanine aminotransferase level but improved clinical symptoms, treatment discontinuation and close monitoring were subsequently recommended. The patient’s conditions became stable in the next few days and his mental state gradually improved. Changes in symptoms of case 1 are shown in Figure 2.

Reduction of Susceptibility/Risk and Early Pulmonary Rehabilitation

A reduction in lymphocyte count may impact the immune function of NCP patients. Since there is currently no cure for NCP, the immune system is the key “weapon” for recovery.

Enhanced care, positive mentality, and improved resistance

Care for NCP patients should be enhanced during quarantine. Patients with diarrhea should consume low-sodium diets and avoid oily foods. Patients with fever should mainly consume rice soup, noodle, and vegetables to avoid exacerbation of diarrhea. Mentality is an important factor for overcoming a disease. Previous studies^3,4 have shown that negative emotions, such as anxiety and depression, can adversely affect the cellular immunity of cancer patients and, in turn, affect treatment efficacy. When a person is quarantined alone at home, it is inevitable that he/she may feel physically uncomfortable, scared, lonely, and depressed. Although case 1 lived by himself, he was able to release his negative emotions by regularly talking with his family through phone or video calls and thereby maintain an optimistic attitude.

Early pulmonary rehabilitation and exercise

Patients were recommended to rest, avoid excessive work, and do pulmonary rehabilitation exercises when they feel physically fit. Baduanjin (eight section brocade)⁵ is a traditional Chinese exercise that regulates qi and blood in organs, restores metabolic functions, strengthens the body, activates physical vitality, and improves the immune system. Changes in patient’s blood oxygen saturation and heart rate were monitored in real-time during the exercise. When blood oxygen saturation dropped <95% or heart rate increased >120 beats/min, patients were recommended to stop exercising and to rest and adjust breathing.

Implications

Lesion absorption was slower than clinical symptom improvement, and symptom recurrence should not be neglected during observation and care.

The early imaging features of NCP are multiple small patchy shadows and interstitial changes in the outer zone of the lungs. These features can subsequently progress into multiple ground-glass opacities (GGOs) and infiltration shadows as well as pulmonary consolidation in severe cases. However, pleural effusion was rarely observed. As shown in Figure 1, the CT results of case 1 were normal on day 3 of symptoms, and GGOs were only observed on day 7 in his CT re-examination. Although the patient’s clinical symptoms improved and disappeared by day 11 of onset, his CT results showed significant expansion of GGOs, which suggests that the severity of symptoms in mild cases does not correspond to the severity of NCP detected by CT, and CT changes may emerge later than clinical manifestations during the early stage of the disease. As a result, infected individuals without CT changes are easily neglected, especially individuals without symptoms or with mild symptoms who are not quarantined, and the lack of attention to these individuals can lead to disease dissemination. Therefore, individuals with persistent symptoms such as fever, coughing, chest tightness, and diarrhea that are suggestive of NCP are recommended to seek medical attention immediately.² Chest CT results should be used as an important basis for early screening, and quarantined individuals should return regularly for CT re-examination to allow physicians to monitor the progression of infection and to guide clinical treatment and care.

The multidisciplinary self-management model is worthy of wide application

The patients in this report were enrolled in the multidisciplinary self-management system since the early stage of the disease. The patients have filled out the online quarantine observation form based on the changes in their conditions, and experts in the multidisciplinary team were able to learn about the patient’s conditions timely, monitor the dynamic changes in their conditions, and provide further medical guidance. Nursing experts in the medical observation team provided guidance on quarantine and disinfection, oversaw the patients’ diet and sleeping schedule, and reminded the patients to record their conditions and drug-related reactions online at least twice per day. Rehabilitation experts developed a practical and feasible rehabilitation plan for the patients, and psychotherapists encouraged the patients to keep an optimistic attitude. All of these measures are very helpful for improving the patient’s immune response. It is also important to note that a quarantined individual is not alone as the medical observation team is always present to keep a close eye on the individual’s conditions and provide appropriate guidance. If continuous deterioration in conditions, <90% blood oxygen saturation, persistent fever and diarrhea, or reduction in mental state score, is observed, the quarantined individual is urged to seek medical attention to prevent delayed treatment. Our model enabled medical experts to closely monitor disease progression in both cases (one mild case and one severe case), which allowed the classified quarantine and treatment of the patients that ultimately resulted in satisfactory recovery. Given that the number of NCP patients is currently increasing, home quarantine may serve as an effective measure for controlling the source of infection as it reduces patient mobility.⁷ Active participation in self-monitoring by patients with mild symptoms not only improves the patient’s initiative but also helps compensate the overloaded medical system. It is worth noting that individuals must strictly adhere to the principles of quarantine when they are quarantined at home to avoid familial clustering of infection. As more shelters continue to open, our model may prove to be useful for the observation of sheltered and discharged patients as well as for the improvement of patients’ self-management capabilities.

In addition, the rapid spread of NCP has led to increased number of confirmed cases in other countries including South Korea, Japan, and Italy, posing a major threat to public health worldwide. Our online/offline multidisciplinary epidemic management model has demonstrated some success in the management of mild cases and screening of severe cases. Furthermore, clustered infection was not observed in cases 1 and 2 during the quarantine period. Our management model was not only helpful for the screening of confirmed or suspected cases during the early stage when there was a lack of knowledge about the infectious disease, but it was also useful for the management of mild and severe cases during the epidemic as well as for the follow-up of discharged patients. We believe that our model has great potentials in providing effective control of NCP in other countries and serves as a feasible response to a widespread infectious disease.

In summary, confirmed or suspected NCP patients with mild symptoms should ensure sufficient rest, have a balanced diet, and keep an optimistic attitude during the quarantine period. These patients should also monitor their conditions closely, improve self-management of the disease, fill out the quarantine observation form in time, report their conditions, and return for chest CT re-examination regularly under the guidance of the medical observation team. Our online/offline multidisciplinary management model has potential application in our specific quarantine sites and treatment facilities as well as in other countries with severe epidemic.

Ethical Approval

Ethical approval was obtained for this study from Ethical Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. TJ-C20200136). The two patients gave written consent for their personal or clinical details along with any identifying images to be published in this study.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by the special fund for novel coronavirus pneumonia from Huazhong University of Science and Technology (Grant No. 2020kfyXGYJ023).

Supplementary Material

Supplementary Data S1