Academic EM blog (1)

Dear all,
These are extraordinary times. In the medical literature, fast-tracked articles relating to COVID-19 are appearing in journals on a daily basis, and I for one am finding it difficult to keep up, and to sort the wheat from the chaff.
We thought it might be useful to provide an occasional update on the evidence related to COVID-19, as well as a reminder that there is still a clinical world outside febrile respiratory illness, and a pointer towards other non-clinical articles that might be of interest. In other words, to act as a filter and sanity check.
 
COVID-19
The main issue at the moment is that although evidence is emerging in front of us, we are in danger of drawing conclusions from incomplete or poor-quality data. We are all trained in critical appraisal and now, more than ever, is the time to use those skills. Some of the articles related to COVID-19 that are being published in the most prestigious medical journals are.. less than high quality evidence (a British understatement).
 
One COVID-19 article that might be of interest, but (spoiler alert) doesn’t give us all the answers, is by Wynants et al, published recently in the BMJ. It can be found at https://www.bmj.com/content/bmj/369/bmj.m1328.full.pdf
This is a systematic review and critical appraisal of prediction models for the diagnosis and prognosis of COVID-19. After all, it would be great to know who has the disease, who needs to be admitted, and of those, who is going to need critical care support and who might be suitable for a more accelerated ambulatory pathway.
It is worth a look, and it elegantly collects and summarises a lot of references in one place, but as it points out, “proposed models are poorly reported, at high risk of bias, and their reported performance is probably optimistic” – so more work to be done.
 
Hot topics that I will keep a watching brief on are (in no particular order):

• Pathophysiology, which is still uncertain.
• Genetic factors, coagulopathy, the role of the ACE2 receptor.  
• Diagnostics including the role of imaging.
• Testing including antigen and antibody tests.
• Potential therapies relevant to us in the ED.

 
It is worth noting that there are a few clinical studies starting up in the UK which you may become involved with in your hospitals if not already. One to highlight is the PRIEST (Pandemic Respiratory Infection Emergency System Triage) study - which was the PAINTED study, but it had to change its name as coronavirus isn’t spelled the same as influenza - this is an observational cohort study collecting data on potential and confirmed COVID-19 patients. It hopes to identify the most accurate method of predicting severe illness among patients who attend the ED with suspected COVID-19.  
 
Another to highlight is the RECOVERY trial, which is a multi-centre RCT of multiple potential treatments for COVID-19, including lopinavir-ritonavir; low-dose dexamethasone; hydroxychloroquine; and azithromycin – more details can be found at https://www.recoverytrial.net.
 
Other non-COVID clinical evidence
 I don’t know about you, but pregnant women who present with breathlessness or pleuritic pain always make me pause for thought before deciding on the best management strategy. This is an area where this is constantly evolving evidence. You may, for example, have seen recent European Society for Cardiology and European Respiratory Society guidelines suggesting that a combination of clinical probability assessment and D-dimer result could rule out PE in pregnancy. You may want to think again if you read Steve Goodacre’s paper in the EMJ (https://emj.bmj.com/content/early/2020/04/09/emermed-2019-209213). This is a secondary analysis of his DiPEP study data, and the conclusions are that some patients with PE would have been missed using this strategy, although the clinical significance of this is not clear. Listen to this man and read his work – he may not inhabit social media, but he is a Jedi.
 
Non-clinical article to read
You might want to take a look at the attached commentary from Chatham House on some of the biases and limitations of the complex modelling that sits at the very heart of our reality currently; https://www.chathamhouse.org/expert/comment/predictions-and-policymaking-complex-modelling-beyond-covid-19
 
And finally..
Thank you for reading to the end. If this has been useful or interesting, let us know. If not, you know how to use the delete button.
Stay safe and sane,
Jason Smith on behalf of the academic team
2020 04 16