key: cord-0981871-ge4dtrt3
authors: Kwon, Seungwon; Chung, Heebum; Kang, Younggun; Jang, Insoo; Choi, Jun-Yong; Jung, In Chul; Park, Jae-Woo; Lee, Hyangsook
title: The role of Korean Medicine in the post-COVID-19 era: an online panel discussion part 1 – clinical research
date: 2020-07-17
journal: Integr Med Res
DOI: 10.1016/j.imr.2020.100478
sha: 17b96085d8b62170264948d0567fd17ef0135bf5
doc_id: 981871
cord_uid: ge4dtrt3

BACKGROUND: As it is predicted that large-scale viral diseases will occur more frequently in the future, there are voices that Korean Medicine (KM) community need to discuss the role of KM and what to prepare to play a significant part of national disease control system in the post-COVID-19 era. METHODS: This paper summarizes the edited highlights of an online video meeting by Google meet on 23 April 2020, organized by the Korean Medicine Convergence Research Information Center. Six speakers who are experts in respiratory medicine, cardiology and neurology, gastroenterology, and neuropsychiatry presented what KM community should prepare for the future acute infectious disease outbreaks by learning from experiences of KM teleconsultation center for COVID-19. RESULTS: Unlike in the past infectious disease outbreaks, KM community has played a bigger part in COVID-19 pandemic in spite of regulatory challenges via activities of KM teleconsultation centers. Telemedicine in pandemic could be more actively utilized in light of the present KM teleconsultation center’s achievements. Data from KM teleconsultation centers would be useful to establish an evidence-base for effectiveness and safety of KM treatments if they are properly collected and analyzed. It might be beneficial to adopt an integrative medicine approach in response to acute viral infectious diseases in the future but the inclusion of KM in the national disease control system is required. CONCLUSION: The present online discussion suggested possible directions of clinical research in KM for the post-COVID-19 era.

As of March 1, 2020, Korea had the world's 2 nd largest number of Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infected cases after China 1 . With the dedication of the medical staff, the government's proactive and quick response, and the active participation of social distancing by citizens, the number of new cases is falling from around mid-April 2 . However, going through the Coronavirus Disease 2019 (COVID-19) pandemic, Korean Medicine (KM) community was completely excluded from any stage of responses to COVID-19 including diagnosis, treatment, quarantine, or prevention due to various reasons including political and regulatory barriers and lack of social awareness. Because Korean Medicine Doctors (KMDs) had no way to participate or volunteer in any activities in the national disease control system, the Association of Korean Medicine, of its own accord, opened a KM teleconsultation center for COVID-19, which is run by KMD volunteers and donation.

As it is predicted that large-scale viral diseases will occur more frequently in the future, there are voices that KM community need to discuss the role of KM as medicine and KMDs as healthcare professionals not to repeat the same situation. In this context, Korean Medicine Convergence Research Information Center (KMCRIC), a government-funded research information center for KM, organized an online panel discussion on the theme of "role of KM and its preparation in the post-COVID-19 era". Through this discussion, a constructive and future-oriented direction for KM community to play a significant role in viral infectious diseases is expected to emerge. Below are summarized and edited presentations by the 6 panelists who are experts in respiratory medicine, cardiology and neurology, gastroenterology, and neuropsychiatry. (Table   1 ). Sichuan province wherein people refrained from using Mahuang (Ephedra sinica) as much as possible (in general, it has been noted that people from the Southern provinces do not prefer strong medicines).

Another characteristic we noticed was that these guidelines were distributed in a top-down format, However, if COVID-19 is to be considered within the context of the 5-or 10-year public healthcare system in the future, we should invest the time required to develop immediate countermeasures that can be put into place once we are included in the public healthcare system.

Chung An area wherein the KM community should focus on improvement is linking our data with the utilization of the health insurance system. An infectious disease is particularly addressed by the public healthcare system. Unfortunately, the participation of KMDs in the response to the COVID-19 pandemic occurred outside the public healthcare system provided by the government. Sharing data from the public healthcare system with only the prescriptions that are not covered by insurance is a difficult task. Even a single claim is sufficient to establish an association with public health insurance data. Index data (e.g., death rate and hospitalization due to reactivation) can be viewed by the Health Insurance Review and Assessment Service or the National Health Insurance Service. This approach enables not only simple data analysis but also cohort research using big data. We cannot expect a vaccine or remedy to be developed in the near future because it generally takes long. Based on these situations, the importance A research design that I can suggest at this time is a cross-sectional study on the characteristics of research subjects: we can study the characteristics and emotions that are often expressed and to what extent they are prevalent in patients with pathophobia, particularly those exposed to a relatively new disease. Moreover, the distribution of patterns needs to be identified in the confirmed cases of COVID-19, those who are self-isolated, and those who are not to evaluate the differences among these subgroups. We can include a battery of questionnaires to evaluate the effectiveness and safety of KM interventions administered over the phone. Because well-designed and controlled trials are not feasible in a remote consultation setting, we could try observational research despite its relatively lower evidence level. My suggestion for potential research areas includes prospective observational studies that evaluate changes before and after treatments, and case-control studies to observe differences between groups that received and did not receive the KM treatment for psychiatric symptoms as well as the aforementioned psychotherapy and self-care methods.

J o u r n a l P r e -p r o o f

Chung: What should be done to produce improved safety and validity data?

Park: When preparing for this discussion, I carefully examined the medical charts used at the KM teleconsultation center. Even after considering both limitations that consultation is over the phone and only ready-made herbal prescriptions are available, I was able to identify a few areas for improvement.

Let me begin with the charts. First, bowel movements. If patients used a standardized evaluation tool for bowel movements, the reliability of data could have been relatively higher despite the use of treatment without contact. I noted that KMDs who are involved in the preliminary diagnosis or treatment were regularly taking turns. This can lead to personal biases among the doctors. I believe that this situation could have been avoided by using a standardized tool, e.g. the Bristol stool scale 9 . This scale provides illustrations and descriptions written in easy words, and can thus be used intuitively. If consultation and prescription using telecommunication technology such as video is available, it would make things much easier. I believe the use of a simple smartphone application that requests patients to make a simple choice could lead to increasingly accurate results.

Second, I focus on fever, one of the most important symptoms in infectious diseases. It was noted that patients were asked to check their temperature on their own. However, the charts alone cannot determine when the measurements were taken or to be taken again later, or how patients felt when the temperature was taken. To improve the chart, I would adjust measurement intervals between 2-8 hours, depending on a patient's severity, and would suggest periodic checks for vital sign of the patient.

As patients also experience "chills", I wondered whether the degree of shivers can be measured. I also considered that the presence and absence of "chills" is of higher importance because it can be an accompanied symptom of fever. Increased significance could have been attributed to determining whether or not a patient experienced "chills". In KM, "chills" may refer to how much a person detests cold stimulus or how much a person dislikes feeling cold. Including descriptions regarding the difference between these two types of "chills" would have proven useful.

The symptom assessment also includes fatigue. Because of its subjective nature, deriving an objective assessment of fatigue is a difficult task. However This scale is used to assess the shape of the stool. However, the number is of greater importance. While assessing the number, it is important to consider how many times compared to the last time and average number over a few days. Moreover, a report of accompanying symptoms, such as incomplete evacuation and urgency, should be encouraged to report because it plays a crucial role in determining the prescription of KM.

Another aspect that can be improved is that this chart lacked quality of life assessment because there were many mild cases of COVID-19 as well as recovering patients who benefited from improvements in their quality of life, rather than treating their symptoms directly. Any available simple questionnaires could have been used for this purpose. It can also be used for patients who have already developed symptoms.

Finally, if we consider clinical research, I believe that including the safety data is essential as the general public is worried that herbal medicine can have detrimental effects on the liver. We have received a lot of criticism regarding this issue. In my opinion, including a question about side-effects in the chart currently used at the KM teleconsultation center was a good decision. Furthermore, I believe that continuous monitoring of adverse events can help construct data regarding frequently used herbal prescriptions. We may also conduct a follow-up study with regular observations or introduce a system wherein a patient can receive an objective evaluation, such as a blood test. We could be benefited by considering the possibility of evaluating the complete recovery rate and the time required to complete recovery, the morbidity rate, the rate of reconfirmed cases, and the degree of improvement in the J o u r n a l P r e -p r o o f quality of life among people who received KM treatment through a follow-up study over a specific period of time after their complete recovery.

In conclusion, I believe that constructing a symptom assessment system that minimizes the measurement bias, can increase the reliability of the evaluation and accumulating data, though retrospective, will serve to determine the reliability and safety of KM treatment on COVID-19.

J o u r n a l P r e -p r o o f 11 . Although none of them had underlying medical conditions, there was evidence of electrocardiogram abnormalities and an increase in Troponin-I level, which can occur in the presence of coronary artery anomalies.

Another paper examines how the COVID-19 virus attacks the blood vessel and causes multiple organ injuries 12 . This paper also reviews three cases of patients with COVID-19. In all of the three cases, the blood vessel was attacked via angiotensin-converting enzyme 2 (ACE2) and showed signs of abnormalities in vascular functions, thus leading to vasoconstriction, decreased blood flow, and, ultimately, multiple organ failures through microvascular dysfunctions.

In addition, there were cases wherein 68%, 44%, and 60% of SARS patients developed dyslipidemia, heart abnormality, and blood glucose abnormality, respectively. Similarly, COVID-19 patients can develop cardiovascular abnormality even after the treatment of the viral infection 13 . Therefore, we should develop a long-term prognosis observation. Moreover, I believe that we should control for heart abnormalities that may appear in the future and KM treatment can be used alongside heart failure symptom management. In particular, taking a diuretic may fail to resolve shortness of breath or edema J o u r n a l P r e -p r o o f for some heart failure patients. In my opinion, the most reasonable herbal medicine to recommend is Oryeong-san (Wuling-san in Chinese, Goreisan in Japanese). For older patients with intractable heart failure, there is no other treatment than the so-called Lasix (furosemide) as well as a diuretic called tolvaptan. However, approximately 30% of patients are not benefited with both treatments. This is particularly true among older adult patients: a Japanese study involved two groups of participants, those that responded to Tolvaptan and those who did not, wherein a significant increase in the amount of urine and decrease in brain natriuretic peptide (BNP) level upon giving Oryeong-san to participants who had not responded to tolvaptan. Among tolvaptan-responsive participants, adding Oryeong-san to tolvaptan decreased the frequency of rehospitalization and improved BNP level after a year 14 . Although

Oryeong-san is not covered by health insurance, I believe that it may be useful to utilize the readily available herbal medicine preparations that are not expensive.

Moreover, systematic reviews and meta-analyses on herbal medicine for chronic heart failure suggested that integrative approaches with WM treatment led to better outcomes 15 Chinese, Kamishomyakusan in Japanese). In Japan, Oryeong-san is popular as a dampness-draining diuretic medicine. Regardless of which prescription has been used, we should develop measures to prepare against potential mass incidences of heart failures. Because providing acupuncture treatment at the well-known points, such as PC6, HT8, LI4, and LR3, can help prevent heart failure from deteriorating via autonomic regulation, we can also consider utilizing this approach 16 .

I will now present my suggestions for policymaking. Rehabilitation management programs for patients that have fully recovered from COVID-19 will be useful. If these programs are developed, I believe that participation from internal KM as well as psychiatry is necessary. When the government sets up registry research for a long-term prognosis, because it would include follow-up data for cardiovascular abnormalities, hospitals providing KM treatment should consider arranging similar settings for active participation in the future.

J o u r n a l P r e -p r o o f

COVID-19) Situation Report

The updates on COVID-19 in Korea as of 18

As coronavirus patient numbers rise, telemedicine by primary care doctors can help relieve hospital workloads

Association of Korean Medicine. Korean Medicine Clinical Practice Guideline for COVID-19

Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate

COVID-19-related myocarditis in a 21-year-old female patient

Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

Endothelial cell infection and endotheliitis in COVID-19

COVID-19 and the cardiovascular system

A clinical study of combined effect of Goreisan with tolvaptan in non-responsive patients with heart failure

Oral Chinese herbal medicine for improvement of quality of life in patients with chronic heart failure: a systematic review and meta-analysis

Acupuncture in the treatment of heart failure

The authors thank Dr. Jeeyoung Shin, Ms. Eunji Kim, and Ms. Jooyoung Jo for their administrative work for the online panel discussion event. We also appreciate Drs. Gunwoong Kim and Gajin Han for transcription and proofreading of the manuscript.J o u r n a l P r e -p r o o f