ABSTRACT
There have been numerous reports of patients initially misdiagnosed in the 2009 H1N1 influenza and coronavirus disease 2019 (COVID-19) pandemics within the literature. A systematic review was undertaken to collate misdiagnoses during the H1N1 and COVID-19 pandemics and identify which cognitive biases may contribute to this. MEDLINE, Embase, Cochrane and MedRxiv databases were searched for misdiagnoses or cognitive biases resulting in misdiagnosis, occurring during the H1N1 or COVID-19 virus pandemics. Eligible studies were assessed for quality using JBI criteria; primary outcome was the final diagnosis. Sixty-nine studies involving 2551 participants were included. We identified 686 cases of misdiagnosis, categorized as viral respiratory infection, other respiratory infection, non-respiratory infection, and non-infective. Misdiagnoses are listed and relevant investigations are offered. No article described prospective assessment of decision making in the pandemic setting or debiasing diagnostic thinking. Further research is required to understand why misdiagnoses occur and harm arises and how clinicians can be assisted in their decision making in a pandemic context.
ABSTRACT
OBJECTIVES: To compare the performance of chest computed tomography (CT) scan versus reverse transcription polymerase chain reaction (RT-PCR) as the reference standard in the initial diagnostic assessment of coronavirus disease 2019 (COVID-19) patients. DESIGN: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A search of electronic information was conducted using the following databases: MEDLINE, EMBASE, EMCARE, CINAHL and the Cochrane Central Register of Controlled Trials. SETTING: Studies that compared the diagnostic performance within the same patient cohort of chest CT scan versus RT-PCR in COVID-19 suspected patients. PARTICIPANTS: Thirteen non-randomised studies enrolling 4092 patients were identified. MAIN OUTCOME MEASURES: Sensitivity, specificity and accuracy were primary outcome measures. Secondary outcomes included other test performance characteristics and discrepant findings between both investigations. RESULTS: Chest CT had a median sensitivity, specificity and accuracy of 0.91 (range 0.82-0.98), 0.775 (0.25-1.00) and 0.87 (0.68-0.99), respectively, with RT-PCR as the reference. Importantly, early small, China-based studies tended to favour chest CT versus later larger, non-China studies. CONCLUSIONS: A relatively high false positive rate can be expected with chest CT. It is possible it may still be useful to provide circumstantial evidence, however, in some patients with a suspicious clinical presentation of COVID-19 and negative initial Severe Acute Respiratory Syndrome Coronavirus 2 RT-PCR tests, but more evidence is required in this context. In acute cardiorespiratory presentations, negative CT scan and RT-PCR tests is likely to be reassuring.
ABSTRACT
The coronavirus disease 2019 (COVID-19) pandemic is having an enormous impact on public health. Infection with SARS-CoV-2 has become a leading cause of morbidity and mortality in many regions around the world. As many COVID-19 patients are treated with antibiotics, there is concern regarding an associated rise in rates of antimicrobial resistance (AMR). On the other hand, social distancing, isolation and reduced travel may result in decreased spread of AMR. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate on the question of the potential impact of COVID-19 on AMR rates.
ABSTRACT
IntroductionCOVID19 has significantly impacted undergraduate medical education. At Hull York Medical School, the elective period for fifth-year students was cancelled and a seven-week online distance learning course was developed and initiated, focusing on key learning outcomes. Our aim was to incorporate live simulation to add an interactive element to online fifth-year teaching.MethodsWe wrote and recorded immersive 360-degree scenarios tailored to learning outcomes for the week. These focused on the assessment, investigation, and management of an unwell patient. The scenarios were delivered as small group teaching sessions through online meeting software weekly for seven weeks. Clinical teaching fellows guided sessions, encouraging participation, the application of knowledge and progression of clinical reasoning. Quantitative and qualitative feedback was collected after every session and pre/post course evaluation was conducted. A Likert scale from 1 to 5 was used to subjectively assess student’s confidence in the assessment and management of acutely unwell patients.ResultsThe number of students participating in the online simulation course ranged from 127 to 149;84 to 136 completed the surveys each week. 95.8% of students reported virtual simulation as a beneficial form of learning. Of those, 60.4% stated virtual simulations complemented other forms of teaching and 39.6% felt that simulations were more beneficial. Mean confidence rating improved from 3.52 to 4.12 for assessment and 2.89 to 3.68 for management of acutely unwell patients (p-value<0.001). Themes that emerged qualitatively were: 1) Interactive and dynamic nature of the sessions allowed students to feel involved in ward based work, 2) Near-peer teaching made the learning experience more relevant to their future jobs as junior doctors, 3) Students reported that given the current circumstances, the virtual simulations allowed them to put their knowledge into clinical practice.Discussion and ConclusionOnline simulation was a valuable learning resource to final year medical students at the Hull York Medical School during their distance learning block. It improved the student’s confidence in the assessment and management of acutely unwell patients and provided an interactive educational experience that helped prepare them for hospital placements. Delivering simulation in small groups online is a novel teaching method that can be used in line with social distancing measures and can be developed further for both undergraduate and postgraduate education.
Subject(s)
COVID-19 , Community-Acquired Infections , Sepsis , Humans , Organ Dysfunction Scores , SARS-CoV-2ABSTRACT
ObjectivesTo compare the performance of chest computed tomography (CT) scan versus reverse transcription polymerase chain reaction (RT-PCR) in the initial diagnostic assessment of coronavirus disease 2019 (COVID-19) patients. MethodsA systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search of electronic information was conducted to identify studies comparing the diagnostic performance within the same patient cohort of chest CT scan versus RT-PCR in COVID-19 suspected cases. Sensitivity, specificity and accuracy were primary outcome measures. Secondary outcomes included other test performance characteristics, discrepant findings between both investigations and main chest CT findings. Random effects modelling was used for the analyses. ResultsThirteen non-randomised studies enrolling 4092 patients were identified. Accuracy was statistically significantly higher for RT-PCR versus chest CT (Odds Ratio [OR] = 0.22, P = 0.001). Chest CT is also less specific than RT-PCR. Ground-glass opacities and consolidations were the most common chest CT manifestations. Importantly, early small studies tended to favour chest CT versus later larger studies. ConclusionChest CT is inferior to RT-PCR for the initial detection of COVID-19 and has more false positives. It may still be useful in confirming COVID-19, however, in patients with a suspicious clinical presentation, but who have a false-negative SARS-CoV-2 RT-PCR test. Highlights- Chest computed tomography (CT) is less specific in the diagnosis of coronavirus disease 2019 (COVID-19) when compared to reverse transcription polymerase chain reaction (RT-PCR). - The accuracy of RT-PCR is statistically significantly higher than chest CT for COVID-19. - Chest CT, however, can detect false-negative and true-positive RT-PCR cases.
Subject(s)
COVID-19ABSTRACT
BACKGROUND: Assessment of possible infection with SARS-CoV-2, the novel coronavirus responsible for COVID-19 illness, has been a major activity of infection services since the first reports of cases in December 2019. OBJECTIVES: We report a series of 68 patients assessed at a Regional Infection Unit in the UK. METHODS: Between 29 January 2020 and 24 February 2020, demographic, clinical, epidemiological and laboratory data were collected. We compared clinical features between patients not requiring admission for clinical reasons or antimicrobials with those assessed as needing either admission or antimicrobial treatment. RESULTS: Patients assessed were aged from 0 to 76 years; 36/68 were female. Peaks of clinical assessments coincided with updates to the case definition for suspected COVID-19. Microbiological diagnoses included SARS-CoV-2, mycoplasma pneumonia, influenza A, non-SARS/MERS coronaviruses and rhinovirus/enterovirus. Nine of sixty-eight received antimicrobials, 15/68 were admitted, 5 due to inability to self-isolate. Patients requiring admission on clinical grounds or antimicrobials (14/68) were more likely to have fever or raised respiratory rate compared to those not requiring admission or antimicrobials. CONCLUSIONS: The majority of patients had mild illness, which did not require clinical intervention. This finding supports a community testing approach, supported by clinicians able to review more unwell patients. Extensions of the epidemiological criteria for the case definition of suspected COVID-19 lead to increased screening intensity; strategies must be in place to accommodate this in time for forthcoming changes as the epidemic develops.