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Post-COVID Syndrome

Dr Neal Tucker - 18 Jun, 2020

In the early days of this pandemic, every call seemed to be about fever, cough and breathlessness. Can you even remember back to when this kicked off 4 months ago and we were all gripped with the unknown and pervasive uncertainty?

But while for most of us around the UK new cases have waned, they have been replaced with another uncertainty – post-COVID syndrome. It is increasingly recognised that a subgroup of patients who survive COVID-19 have symptoms, some enduring, some intermittent, some which improve over weeks, some which still continue months after infection with no known timeframe for resolution.

In itself this is not a surprise or unique to SARS-CoV-2. The pattern of illness, recovery, then recurrence of certain features such as sweats and fatigue (often extreme) similar to experiences of patients post-Dengue fever. Persisting impact on lung function was seen with MERS and SARS – it remains unclear if the frequently seen fibrosis post-ventilation will improve in the longer term - as was post-infective fatigue.

We also should not be surprised that patients who were critically ill have long-lasting complications. Existing data shows that 10% of critically ill patients from any cause develop chronic fatigue – this could translate in to thousands of people from this pandemic.

And we shouldn’t focus solely on the physical – there is significant impact on mental health as well. Of critical care patients with ARDS at 2 years later 4 in 10 have anxiety, 3 in 10 depression and 2 in 10 PTSD. 70% in critical care have delirium in hospital, 1 in 5 still have some after 6 months, and studies have linked coronaviruses with the development of neurodegenerative disorders such as Alzheimer’s.

None of all this accounts for the elephant in the room – for all those diagnosed “clinically” in the community in the early days when there was no access to tests we simply have no idea if what we are dealing with was SARS-CoV-2. We all hoped antibody testing would provide clarity but instead it has proved another source of confusion. Post-COVID syndrome may not be covid at all in many.

So what can we do? There is no data to help us – there just hasn’t yet been enough time - thankfully first principles of good general practice can. So here’s some suggestions for managing patients with continuing symptoms:

  • Keep an open mind
    • Even with confirmed COVID cases, persisting or new symptoms could be something else. History remains key, examine where necessary. Target investigations based on your findings rather than testing everything – we will only dig ourselves a hole.
  • NHS England/NHS Improvement have published a detailed document on how to manage hospital inpatients with their recovery after discharge, which is also applicable to community cases. This covers a wide range of physical and mental sequelae and unsurprisingly there is a strong emphasis on community care. There are some specific recommendations:
    • Patients with radiological signs of COVID-19 should have a repeat CXR at 12 weeks (or 6 weeks if there’s any concern about possible lung cancer) to ensure there are not persistent changes.
    • Persisting respiratory symptoms, physiological impairment or CXR abnormalities should be referred for lung function tests and CT.
    • Refer for pulmonary rehab 6-8 weeks post-discharge for persistent breathlessness – there is a similar recommendation for cardiac rehab if myocardial injury.
    • If a patient has persisting mental health issues signpost self-referral to IAPT services. Ideally, there should also be post-ICU-specific support from secondary care.
  • Particularly for persistent breathlessness the Post-COVID Hub website, set up by Asthma UK and the British Lung Foundation, has practical tips to help patients manage and improve their symptoms.
  • And for ongoing fatigue, while the debate about the best way to manage this will continue to rage, the Royal College of Occupational Therapists have published practical advice on how to manage post-COVID fatigue in a step-wise fashion.

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Psychological First Aid - A useful tool for General Practice

Dr Rob Walker - 3 Jun, 2020

It is not controversial to suggest that the psychosocial impact of COVID-19 is going to have significant effects on people’s mental health down the line; the Royal College of Psychiatrists have warned of an impending tsunami of mental health problems over time, putting huge pressures on mental health services (and us in primary care). But what about the here and now? I’m sure we have all already seen a significant increase in mental health difficulties related to COVID-19, with many patients phoning us in psychological distress, the reasons for which are likely to be multifactorial. And this is where PFA may be helpful.

So, what on earth is PFA? Until a few weeks ago I would have made a stab at ‘profunda femoris artery’, but in this context it stands for Psychological First Aid, and an excellent document from the International Federation of Red Cross and Red Crescent Societies gives guidance on how to deliver PFA remotely during the COVID-19 outbreak. There is considerable overlap in their guidance with our basic principles of primary care consulting, but there were some really useful learning points and phrases to help us deal with distressed patients.

PFA is ‘a method of helping people in distress so they feel calm and supported to cope better with their challenges. It is a way of assisting someone to manage their situation and make informed decisions. The basis of psychological first aid is caring about the person in distress and showing empathy.’ That word empathy again…Very distinct from sympathy, it is ‘the art of stepping imaginatively into the shoes of another person, understanding their feelings and perspectives, and using that understanding to guide your actions’ (Krznaric, 2014) - which nicely encapsulates what we try to do in all our consultations, but is particularly important in the context of speaking to distressed patients….I fully understand that you are feeling this way….

So what are some of the other principles and ideas of PFA? One phrase that has really helped me is the aim to ‘normalise worry and other emotions’…. In this situation, your reaction is quite natural…; we are living through extraordinary times, and many of the feelings and emotions people are experiencing are normal, given the situation they are in - we should not underestimate the importance of validating peoples feelings and emotions. ‘Listen actively’ is also a phrase I liked - easier said than done, and exhausting, but something to strive for. Time limits? Interestingly the guidance does suggest time limiting the call e.g. 10 minutes for listening, and 5 minutes for summarising and making practical suggestions, which fits well with our current remote consultations….When we have talked for 10 minutes we can take stock and decide how to proceed… And finally ‘Look for or inject humour into the situation if appropriate’..as the guidance recognises a laugh, or even a smile, can provide relief from anxiety and frustration.

Recently we have had mental health awareness week, with the theme of kindness, so it is a pertinent time to remind us about the importance of kindness to both ourselves and our colleagues. Whilst we are seeing lots of patients in distress, we need to recognise the toll COVID-19 could have on health care workers. A recent BMJ editorial (BMJ 2020;369:m1815) discussed the potential impact, and highlighted PFA as an important tool to help healthcare workers in acute psychological distress or trauma. It could easily be one of us taking that call from a distressed ICU nurse, porter, nursing home carer, GP receptionist, doctor, or any one of the brilliant people that make up our health and social care system, who is in need of an empathetic ear. Using some of the PFA principles may be invaluable.

Dr Rob Walker


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Hormones in a time of COVID

Dr Stephanie De Giorgio - 10 Jun, 2020

The last months have been difficult, isolated from friends and family, learning how to work from home or perhaps working face to face seeing patients with COVID. Job losses and a shortage of work and income. For those with caring responsibilities, trying to juggle these with work. Just a trip to the shops feels like planning an epic adventure.

We have all struggled, but there has been a challenge during this time which is unique to women who have a uterus and ovaries that came to my attention through personal and then professional circumstances.

I am now going to overshare. I had presumed COVID beginning on 17th March. I had a grim period at the time and remember thinking that this double whammy really didn’t seem fair. Since then……….nothing. Not a peep. Some significant PMDD symptoms, but no bleeding.

This was weird, so I took to social media a few weeks ago, to see if other people were noticing this, either personally or in their working lives as HCP. The huge numbers of people responding, and the resulting feedback was significant.

  • Women and HCPs reported all sorts of menstrual cycle disturbance
  • Women having very late periods or even entire missed cycles. This seemed more frequent in those who had been poorly
  • Women having more than one bleed per cycle
  • Women suffering from significant breast pain
  • Postmenopausal women having bleeds for the first time in months/years
  • Women having much more severe PM 
  • Women having more severe period pain, particularly those with endometriosis
  • One woman with no ovaries and on HRT having extra dysfunctional bleeding

As we increase the understanding of this virus, we know it seems to be a disease of the blood vessels. As yet, we do not know if there is a direct effect on the hypothalamic-pituitary axis (HPA) and the hypothalamic—adrenal-gonadal axis (HPG) that controls the menstrual cycle.

What we do know and have known for many years (although interestingly there isn’t a huge amount of formal research) is that stress does have a significant effect on these hormonal pathways. And goodness knows, this has been a time of huge stress – that horrible gnawing feeling that just sits in your head and the effect it has on your body.

The mechanism for stress affecting the menstrual cycle seems to be that high levels of glucocorticoids released in response to prolonged stress, predominantly cortisol in humans, impact all levels of the female reproductive system. The most significant effect seems to be that it suppresses GnRH release and thus LH release, suppressing ovulation and therefore the second half of the menstrual cycle. It is likely to also, therefore, be an effect on progestogen and oestrogen balance which will, in turn, cause a variety of symptoms.

The more one learns about women’s health, the more one realises the massive variety of symptoms that women experience as part of their menstrual cycle. This holds true for this time as well. What, however, is really important, is that we don’t fail to differentiate the deeply unpleasant but not dangerous symptoms, from those that need urgent assessment and act accordingly.

As always, make sure a proper history is taken including:

  1. The timing of symptoms and bleeding
  2. the type and amount of bleeding
  3. what contraception is on board
  4. the risk of pregnancy
  5. the risk of STI
  6. abnormal discharge
  7. pelvic pain
  8. Vulval symptoms

It is also very important to ask questions about

  1. the possibility of domestic abuse 
  2. associated symptoms such as mood disturbance, which can be very serious
  3. breast pain, acne etc.

Depending upon the above, you will need to decide whether you need to bring a patient in for a face to face. This would be highly recommended for pelvic pain, post-coital bleeding, post-menopausal bleeding, severe breast pain, and new vulval symptoms.

I would caution against asking for any genital or breast photographs to be sent during remote consulting as there are significant potential legal issues and absolutely never accept or ask for any genital pictures of children, even in this clinical context. It is illegal. These patients would be better-assessed face to face.

Patients should be seen with PPE as advised for all face to face consultations currently.

The distress amongst those who responded to my social media questions was significant. The fear of pregnancy, the fear of serious illness, debilitating pain, the added difficulty of managing severe mood disturbance during an already stressful time and the inconvenience of extra bleeding, especially at a time when it’s harder to shop, particularly if relying on others to do it for you.

At a time of such huge uncertainty, being aware of the effects of stress and possibly COVID illness on the wellbeing of women and their menstrual cycles is really important. We need to ensure we don’t miss significant pathology whilst being reassuring about the huge variety of symptoms that can be caused by stress.


Stephanie De Giorgio

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What's the NEWS for primary care?

Dr Simon Curtis - 18 Jun, 2020

I was in a patient’s home, let’s call her Sarah, during those chaotic early weeks of the pandemic in March. Naturally, I was not wearing a mask or gloves (at that time I still thought PPE was just a degree that future Tory politicians did at Oxford). In front of me was a young woman with asthma, her worried husband holding her hand. Sarah was breathless at rest, having to work to breathe, and febrile. Her hair was stuck to a damp, sweaty brow. But her chest was clear with a few wheezes. She was tachypnoeic, but her obs were not as bad as she looked. My gut feeling though was that she needed to go in, and to go in quickly. I called the local acute admissions unit and also the paramedics, and both asked me a question I hadn’t been asked before: ‘What is her NEWS score?’.

Now, being a bit of a dinosaur, back in my hospital days, there was no National Early Earning Score NEWS score. To be honest, there wasn’t much of anything systematic back then apart from a hand-written, occasionally glanced at chart on a clipboard hanging off the end of the bed. But in recent years through trainees, newer GPs, and discharge summaries I have come to understand what the NEWS score is: an observation-based, physiological scoring system used in secondary care to predict clinical deterioration, whether patients’ care needs escalation and the urgency needed of that escalation. The crucial phrase of course there is ‘secondary care’ because that is where it has been researched, validated, and used.

But, by mission creep, NEWS (or the updated NEWS2) has now started to filter into primary care. It’s easy to see why. It is tempting to have a simple, objective measure to make complex clinical decision making easier, to iron out variations in care, and to get us to speak a ‘common language’ which is understood by paramedics and secondary care. In 2018 NHS England made use of the score mandatory in ambulance trusts and said that paramedics should use the score for ‘pre-hospital patients who are ill and at risk of deteriorating’ i.e. in the community. Since then GPs have started being asked by ambulance trusts what the score is before transferring a patient to hospital, and anecdotally it has been in much wider use since the onset of the COVID-19 pandemic. The NICE COVID-19 guideline has a specific recommendation that ‘NEWS2 may be useful’, but that a face to face consultation should not be arranged solely to measure it given that it includes BP and O2 saturation measurement.

But where is the evidence that this is a validated and robust tool to use in primary care? Well, there is the rub. There hasn’t been. A recent evidence review by the Centre of Evidence-Based Medicine in Oxford conclude that ‘NEWS2 has not been validated in COVID-19 patients nor in primary care’ and that enthusiasm for use in primary care may be ‘premature’. In addition, there are other problems with the score. It takes no account of age and co-morbidities, and as every GP knows it is how things evolve over time that is more important than single snapshots. And as every amateur statistician knows, tests that have a good predictive value in a high prevalence environment (i.e. hospital) will have lower predictive values in low prevalence environments (i.e. the community). 

So, should we be using this score in primary care? This sunny month of June, the BJGP has published an excellent editorial on the use of NEWS in primary care in response to new research done in primary care. This research suggests that the use of the score in pre-hospital care improves outcomes in patients with suspected sepsis and that a high NEWS score in the community predicts faster transfer and clinical review in secondary care. However, these are both small observational studies and the editorial warns against widespread adoption yet in primary care. The editorial stresses the complexity of clinical decision making, and states ‘before supporting NEWS it needs to be established that this tool will provide safer care than communicating a full set of clinical observations’. There are clearly risks of both over and under-diagnosis if we are over-reliant on a score, and as the editorial states ‘no score can communicate the gut feeling of an experienced clinician’.

So, what happened with Sarah? Her NEWS2 score was only 3, and yet 5 is the usual level that mandates an escalation of care. But my ‘gut feel’ was that she was sick and needed hospital care. To be fair, both the hospital and the ambulance were happy to take her (she was subsequently diagnosed with pneumonia and admitted) but if we become over-reliant on such scores will that always be the case?

NEWS2 is seductive as it seems to give us a pure and simple tool to guide clinical decision making. But, as Oscar Wilde famously said, ‘the truth is rarely pure and never simple’. We need more robust evidence before adopting this score widely in primary care. In the meantime, it can be used to help communication with ambulance crew and secondary care but should not replace clinical decision making.

Simon Curtis

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Mental Health - Knives and forks, belly breathing and pupating caterpillars

Dr Rob Walker - 18 Jun, 2020

Thank you all for logging on and giving up your Tuesday evening last week to tune into our live Mental Health Webinar - it was a fascinating evening and one which was really made by all the interesting insights, stories and feedback on mental health resources that you sent through to us during the evening. Many of you asked for a compilation of the resources mentioned which we attach as a separate document for you to download and share with your colleagues and patients (I’ve deliberately done it on 2 pages so you can print/download page 1 for your patients and keep page 2 separate for you and your colleagues). Thank you to you all (including my GP colleagues, especially our ace Mental Health lead at CGH!) for sharing these excellent ideas and resources, and I would like to reiterate our thanks to Dr Catherine Sykes (Clinical psychologist) and Rosie Weatherley (from the fantastic mental health charity MIND) for giving up their time for free for the evening and for their resources and ideas.

Thank you all too for your honest assessments and stories from front line primary care during this most difficult of times. Many themes came out of the evening, most notably the confirmation from you all that the data Simon presented at the beginning was indeed a true reflection of our surgeries currently - we are seeing a LOT of people with mental health difficulties, in many many guises, with a concern that this is only the tip of the iceberg; many of you are clearly frustrated by the lack of access to mental health services in your areas and are concerned about how to cope with the increased demand we are seeing, with limited service provision. Many of you were also reflecting on how the stressors in peoples lives are changing now - initially much of it was related to fear of the virus itself and how to manage in isolation. Now lockdown is being eased, people are increasingly worried about the risks of opening up society, what are the risks when our children go back to school, and the longer-term finical impact COVID will have on them. However, it is important to put in context that many people have had some improvements in their wellbeing during the pandemic - a more simple life, less travelling and more time with immediate family have been really beneficial for many people; it’s important sometimes to try to look for the positives, even in such challenging times….

Isolation is inevitably a concern and impacts on everyone, but it was interesting that the data actually suggests younger people are more likely to have had their mental health affected during the COVID-19 pandemic than older people, with many of you rightly pointing out we need to be particularly aware of new mums who may be struggling with post-natal mental health issues, as many of the usual social interactions for new parents are unavailable. Previous pandemics have suggested we may see a significant increase in PTSD presentations and many were asking how we can help deal with this in primary care. Locally to me, a free 35-minute webinar has just been produced, specifically to help primary care with PTSD presentations - see the resources document for this.

How do we safely assess people with mental health illness remotely? A common question asked during the webinar, and one I’m sure we all have thought about. We are all feeling our way through this as there just isn’t the data/evidence to suggest how best to do this. Personally, I’ve found remotely assessing people with mental health difficulties not as hard as I thought, but it does have its challenges - we just don’t get that direct real-time visual feedback that we are so used to. Video consultations can help provide some of this and some people have found screening questionnaires (e.g. GAD-7 and PHQ-9) useful adjuncts. However, for a person we are really worried about, especially if they are vulnerable or have difficulty with communication, we do need to be thinking about how we can safely bring them down to our surgeries for face-to-face consultations.

So what have I learnt from this webinar, and from you? We should not 'under-estimate the power of our own clinical interaction’ as one of our colleagues rightly said - active listening, using empathy, and using ‘listening as a therapeutic tool’ can be incredibly powerful ‘treatments’. On the theme of treatments, one colleague gave a lovely ‘fork and knife’ analogy to help discuss with patients the psychological vs medications options - you can eat with just a fork (psychological therapies) but if things are tough you may need a knife (meds), however, it is best not to only eat with a knife, and a knife and fork together may give the best options!

Dr Catherine Sykes quite rightly discussed the importance of not being judgemental during such uncertain times - as the recent mental health awareness week has highlighted we need to be kind to ourselves and others and accept everyone is feeling their way through these difficult times, often with no right or wrong answers. The importance of relaxation exercises - Catherine talked about ‘breathing with your belly’ (see further information in the resources document). Many of you rightly pointed out the importance of exercise and activity to help wellbeing - whether it’s running (?couch to 5K? https://www.nhs.uk/live-well/exercise/couch-to-5k-week-by-week/), going for a walk, Pilates, Zumba or Yoga (free sessions can be accessed through the NHS website - see link in resources document), or even digging out your old skipping rope (one thing I’ve done!). Many of you also pointed out the importance of enjoying nature in various ways - in our house, we have had caterpillars delivered via post (!) and they are currently pupating in their tub ready to transform into butterflies (https://www.insectlore.co.uk) - no DOI needed! And one colleague directed us to Let’s share our nature (https://www.instagram.com/lets_share_our_nature/) where people can help share pictures for those not able to access nature directly.

And finally, we must not forget US. We need to look after ourselves to look after our patients. In the attached resources document I’ve pulled together some of the resources I/you have come across to help support us and our colleagues. ‘White space’ was an idea suggested by a colleague - 1-2 hours/week for staff to have some ‘me time’ either alone (meditation, reading etc) or together with other staff (e.g. socially distanced walk), but principally to get away from the computer. And don’t forget the importance of humour - whatever tickles your fancy, having a good laugh can often be ‘the best form of medicine’!

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