22 October

Epidemiology

Smith GD, Blastland M, Munafò M. Covid-19’s known unknowns. BMJ 2020;371:m3979. Full-text: https://www.bmj.com/content/371/bmj.m3979

Do we know exactly what’s going on with SARS-CoV-2 and exactly what to do about it? Over the past months, we have seen strongly contrasting but apparently equally authoritative statements about almost any topic. Stop the nonsense, write Georges Davey-Smith and his colleagues. Acknowledging uncertainty a little more might improve not only the atmosphere of the debate and the science, but also public trust. In any case, the more certain someone is about COVID-19, the less you should trust them.

Immunology

Overbaugh J. Understanding protection from SARS-CoV-2 by studying reinfection. Nat Med 2020, published 22 October. Full-text: https://doi.org/10.1038/s41591-020-1121-z

Can understanding the risk of SARS-CoV-2 reinfection provide an avenue to understanding the path to protection against SARS-CoV-2 for vaccine development? Julie Overbaugh argues that the study of reinfection is critical because if neutralizing antibody responses are robust in people who are re-infected, this would suggest that the vaccine concepts need to be diversified. This could include considering diverse antibody epitopes, both neutralizing and non-neutralizing, and optimizing the effector function of antibodies and enhancing cellular responses.

Diagnostics

Pettengill MA, McAdam AJ. Can We Test Our Way Out of the COVID-19 Pandemic? J Clin Microbiol 2020, published 21 October. Full-text: https://doi.org/10.1128/JCM.02225-20

Frequent, low-cost, universal testing for SARS-CoV-2 infection and quarantining those with a positive result has been suggested as a strategy to address the COVID-19 pandemic. Could such low-sensitivity daily tests (LSDT) help us ‘test our way out’ of the pandemic? The authors don’t think so and don’t mince their words: “Using testing to prevent transmission of SARS-CoV-2 on a large scale is like using the weather report to prevent global warming.” Find out why.

Clinical

Clift AK, Coupland CAC, Keogh RH, Hemingway H, Hippisley-Cox J. COVID-19 Mortality Risk in Down Syndrome: Results From a Cohort Study Of 8 Million Adults. Ann Intern Med. 2020 Oct 21. PubMed: https://pubmed.gov/33085509. Full-text: https://doi.org/10.7326/M20-4986

Persons with Down syndrome seem to be at an increased risk for COVID-19–related hospitalization and death. This is the result of an analysis of individual-level data in a cohort study of 8,26 million adults in the UK. The authors estimate a 4-fold increased risk for COVID-19–related hospitalization and a 10-fold increased risk for COVID-19–related death.

Car J, Koh GCH, Foong PS, Wang J. Video consultations in primary and specialist care during the covid-19 pandemic and beyond. BMJ 2020; 371. Full-text: https://doi.org/10.1136/bmj.m3945

At the start of the pandemic, many GPs and specialists turned to video consultations to reduce patient flow through healthcare facilities and limit infectious exposures. What was your experience? Josip Car and colleagues give you a grand tour of video consultations in the COVID-19 era: how to start, how to prepare patients for the consultation, suggestions for a remote physical examination, and how to switch from a video to a telephone or in-person consultation, depending on technical, patient, or clinical factors. A must-read for GPs.

Treatment

Stone JH, Frigault MJ, Serling-Boyd NJ, et al. Efficacy of Tocilizumab in Patients Hospitalized with Covid-19. N Engl J Med 2020, published 22 October. Full-text: https://doi.org/10.1056/NEJMoa2028836

Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with COVID-19. This is the result of a randomized, double-blind, placebo-controlled trial involving SARS-CoV-2 patients with hyperinflammatory states and at least two of the following signs: fever (body temperature > 38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. John H. Stone and colleagues (for the BACC Bay Tocilizumab Trial Investigators) conclude that their data do not provide support for the concept that early interleukin 6 receptor blockade is an effective treatment strategy in moderately ill patients hospitalized with COVID-19.

Severe COVID

Cates J, Lucero-Obusan C, Dahl RM, et al. Risk for In-Hospital Complications Associated with COVID-19 and Influenza — Veterans Health Administration, United States, October 1, 2018–May 31, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1528–1534. Full-text: http://dx.doi.org/10.15585/mmwr.mm6942e3

COVID-19 is deadlier than influenza. Now, Jordan Cates and colleagues have quantified the difference: hospitalized patients with COVID-19 had a more-than-five-times-higher risk for in-hospital death and increased risk for 17 respiratory and non-respiratory complications than did hospitalized patients with influenza. The risks for sepsis and respiratory, neurologic, and renal complications of COVID-19 were higher among non-Hispanic Black or African American and Hispanic patients than among non-Hispanic White patients.

Pediatrics

Feldstein LR, Rose EB, Horwitz SM. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. N Engl J Med 2020; 383:334-346. Full-text: https://doi.org/10.1056/NEJMoa2021680

SARS-CoV-2-associated multi-system inflammatory syndrome in children (MIS-C) is a life-threatening illness even in previously healthy children and adolescents. This is the result of a study presented by Manish M. Patel, Leora Feldstein and colleagues reporting on 186 children in pediatric health centers across the US. The median age was 8.3 years, and organ-system involvement included the gastrointestinal system in 171 patients (92%), cardiovascular in 149 (80%), hematologic in 142 (76%), mucocutaneous in 137 (74%) and respiratory in 131 (70%). A total of 148 patients (80%) received intensive care, 37 (20%) received mechanical ventilation, 90 (48%) received vasoactive support and 4 (2%) died.

Education

Rubin EJ, Baden LR, Morrissey S. Tocilizumab and Covid-19. Audio interview (32:26). N Engl J Med 2020; 383: e114. Access: https://doi.org/%2010.1056/NEJMe2032051

The editors discuss the results of a new clinical trial of tocilizumab, a monoclonal antibody that blocks the activity of the proinflammatory cytokine interleukin 6.

Society, Prevention

Rosenbaum L. Tribal Truce — How Can We Bridge the Partisan Divide and Conquer Covid? N Engl J Med 2020; 383:1682-1685. Full-text: https://doi.org/10.1056/NEJMms2027985

Interview with Anthony Fauci on empathy, transparency, and global disease outbreaks (podcast).

Top 10: October 22