Q: The number of cases in China is very low now. Are you relaxing your vigilance, and what is happening in society now in China?


Although the numbers are low, there are still more than 4,000 cases in Wuhan [as of early to mid-March 2020], and most of the cases are severe or critically ill patients. We are still fighting against the virus. 

During the past two months, COVID-19 has imposed an enormous impact on our daily life and healthcare. We suspended all elective procedures, ordinary clinics, except for the fever clinic and emergency department. We used the telephonic or telehealth visits to substitute for in-person routine visits for chronic diseases patients to avoid nosocomial infection. With the stringent containing measures, now the epidemic has been well contained in China. In Wuhan, there are no new confirmed, suspected cases reported for one week now. In other areas outside of Hubei province, most things have returned to prior status. For example, in 26 provinces, all the social and life order has restored to normal. All the hospitals and factories re-opened. Most of the schools will re-open one week later.  We really hope the epidemic in the U.S. will be effectively contained soon.

Q: It is interesting because we have seen a couple of patients already develop a new cardiomyopathy. I wonder if the elevated troponins you are seeing are more from demand ischemia? Are you doing echocardiograms and seeing


Among my patients, the elevated troponin is one of the most important negative prognostic indicators. However, the patients who have elevated troponins don’t show hypokinesis related to myocardial infarction and ECG changes from demand ischemia. I think the myocardial injury is another manifestation of multiple organ dysfunction caused by coronavirus. On the other hand, I do suspect that the coronavirus may have a predilection for attacking the myocardium over the liver and kidney. Additionally, the general duration of the virus is about 30-40 days, while the elevation of troponin always begin at the 10th day. Greater elevation in troponins is also clearly correlated with a worsening prognosis, so the protection of heart is necessary. 

Q: One thing I find interesting is that I have not heard of any meningitis or encephalitis. Have any physicians in China detected any COVID-19 in the cerebral spinal fluid?


I have not heard of this either. All of my patients are conscious, and no symptoms caused us to suspect meningitis or encephalitis, so there was no indication for performing a spinal tap. 

Q: It has been said the mortality of severe patient is > 60%. How is the patient that survives the illness? Do they need special care like tracheostomy, feeding tubes, dialysis? In other words how is quality of life?


It is hopeful that the mortality of severe patients will be cut down to less than 50% through strengthening nursing, increasingly effective treatment options and prevention with vaccines. However, in answer to your question, we found that in the patients who survived the illness, their respiratory and renal function returned to baseline as the hypoxia corrected. Of course, in patients with preexisting chronic renal failure there was ongoing need for dialysis. There were a small number of  isolated patient cases with residual pulmonary fibrosis who have had some chronic respiratory insufficiency and needed oxygen treatment occasionally.  

Q: What’s the role D-dimer?


Because of the damage of alveoli and capillaries in the COVID-19 patients, we can see the formation of pulmonary microthrombus of the autopsy results of the patients. At the same time, microthrombus formation has also been observed in the blood vessels of critically ill patients, so the d-dimer is generally high in all patients. The results of our retrospective study showed that elevation of the D-dimer level was more significant in the non-survivors, and was an independent risk factor of death. If these patients have no contraindications for anticoagulants, we would recommend the routine use of low molecular weight heparin as an anticoagulant for critically ill patients. For critical COVID-19 patients who need to be bedridden for a long time or who are on a non-invasive/invasive mechanical ventilation ventilator, anticoagulants should be routinely used to prevent thrombosis in the lower extremities and pulmonary thrombosis.

Q: The mechanism of elevation of NT-proBNP and cTnl?


At present, the mechanism of myocardial damage (elevated NT-Pro-BNP and cTnI) caused by COVID-19 infection is not much clear. The possible reasons are as follows: 

1) direct damage: viral infection can directly cause damage to myocardial cells; 

2) immune damage: the excessive activation of the immune system results in an extremely immune response, releasing a large number of cytokines, and the conversion into a triggered cytokine storm may be one of the mechanisms of myocardial damage; 

3) Hypoxemia: severe COVID-19 patients affected blood gas due to diffuse alveolar injury and pulmonary clear film formation, leading to severe hypoxemia, sustained hypoxia will increase anaerobic fermentation, cause acidosis, increase intracellular oxygen free radicals, intracellular calcium overload, and cause damage to myocardial cells;

4) Angiotensin converting enzyme 2 (ACE2): currently known as ACE2, an important target for COVID-19 infection, and ACE2 receptors are widely expressed in the cardiovascular system. Therefore, ACE2-related signaling pathways may also cause myocardial damage.

Q: The reason of increased D-dimmer?


The coagulation function in patients with SARS-CoV-2 is significantly deranged compared with healthy people, but monitoring D-dimer and FDP values may be helpful for the early identification of severe cases. 

Q: Liver dysfunction?


Answer:There are four major reasons for liver injury associated with COVID-19: 1) immune damage; 2) drug use; 3) systemic inflammation; 4) ischemic hypoxia-reperfusion injury.

Q: Is that just elder people go to hospital? Any strong relationship bwtween age and outcome?


The age of inpatient ranged from 20s to 90s in our hospital. In our department, we have received 80 patients, 26 cases for≥65 years old (32.5%) and 17 for ≥70 (21.25%). The age of all fatality patients were ≥65 years old in our hospital, the duration for the COVID-19 RNA negative and pulmonary inflammation absorption was much longer for old patients then young patients. Recent online report also showed similar result (https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm). Therefore, we agree that there is strong relationship between age and outcome.

Q: For those doctors who developed COVID-19 and then recovered, do they have any residual pulmonary symptoms? Do they feel back to “normal”?


One doctor from Wuhan's response:  After I was discharged, I just had some coughs and maybe some shortness of breath when I have to engage in strenuous activity.  No other symptoms.  Until now (4 weeks after recovery), I feel better and better and have had no cough in the last 4 weeks.  I did not find any recurrence of COVID-19 in those patients who recovered for those that I followed up with.  Their families also did not get infected after they were discharged.

Q: What about countries like Korea, which are relying on testing and not isolating people and keeping them at home. Is this a viable long term strategy if the test sensitivity is low?


South Korea culturally is the same as China and you can see enough obedience to social distancing and isolation policies.  When the government asked people to wear masks, you can see people wore them immediately.  It is the same in all of East Asia, where we share the same Confucius culture.  At the very begining, the virus broke out in a very specific small city with some regious groups in Korea.  South Korea is also testing people and isolating confirmed and suspected people, and all people are wearing masks.  You can see that in South Korea the case decreasement is not like Wuhan.  Wuhan already reached 0 case.

Q: How can an isolation policy work for any single country in a global environment where some countries still have the virus in the population. Is the long term hope only herd immunity or a vaccine?


Prerequisite of isolation policy work: 1. Relevant laws and regulations formulated by the country; 2. Sufficient living materials, including drugs, food, water and electricity, and communication; 3. The rational allocation of medical resources, and the allocation of sufficient medical personnel to key epidemic areas; 4. The volunteer system, let strong young people go out to buy daily necessities for community residents.  Long term hope is vaccine.

Q: Generally, do we know the average age of those that die (fail to recover) because of COVID-19?


The average age is 49.  59% patients are male. Median incubation period is 4 days.

Q: Are healthcare workers that work with infected patients in China isolated from their families?


Absolutely.  They must be isolated.

Q: Thoughts on which specialists (doctors) were at highest risk of death?


The mortality rate of medical staff in China is not higher than other groups.But medical staff do face the highest risk of infection, and they must be well protected.

First, people are general susceptible with COVID-19. But there is more exposure chances to the COVID-19 patients or contaminated objects, doctors from pneumology department , infectious disease department, Critical Care Medicine, Stomatological Department are easier to be infected with coronavirus. Second, elderly doctors with obesity, chronic respiratory disease, cardiovascular disease are easier to become severe cases. Last, doctors like below are at high risk of death.