key: cord-0941692-tt1gk8fg authors: Twickler, Theodorus B.; Regieli, Jakub J. title: Introduction: Finding a way in daily clinical practice during COVID‐19 pandemic date: 2020-07-13 journal: Eur J Clin Invest DOI: 10.1111/eci.13329 sha: efe6d0abfa2f9be258d1ab864ea73038d0b770cb doc_id: 941692 cord_uid: tt1gk8fg Since some months, the Covid-19 pandemic changed our world drastically. At the start of the pandemic, in a single week, our medical communities, both in primary care , nursing homes, as in secondary and tertiary facilities have been forced to stop all regular clinical care and to shift towards hospital care that was ultimately restricted to Covid-19 related disease. The clinical presentation of Covid-19 occurred predominantly in the elderly patients (most > 65 years old) displaying a respiratory disability, and in a small proportion among them displayed a respiratory failure, in association with a broad range of pre-existing co-morbidities. Covid-19 had not been taught in university and to prepare ourselves, we aimed to retract data published from especially Chinese studies. Most literature was published without a peer-review procedure (fast track), and most intervention designs existed of small groups and a not blinded/not randomized inclusion. After an extensive week of patients' contact, we experienced various differences (compared to the prior reports) in their first presentation and in their individual course of disease. Since some months, the COVID-19 pandemic changed our world drastically. At the start of the pandemic, in a single week, our medical communities, both in primary care, nursing homes, as in secondary and tertiary facilities, have been forced to stop all regular clinical care and to shift towards hospital care that was ultimately restricted to COVID-19related disease. The clinical presentation of COVID-19 occurred predominantly in the elderly patients (most > 65 years old) displaying a respiratory disability, and in a small proportion, among them displayed a respiratory failure, in association with a broad range of pre-existing co-morbidities. COVID-19 had not been taught in university and to prepare ourselves, and we aimed to retract data published from especially Chinese studies. Most literature was published without a peer review procedure (fast track), and most intervention designs existed of small groups and a not blinded/not randomized inclusion. After an extensive week of patients' contact, we experienced various differences (compared to the prior reports) in their first presentation and in their individual course of disease. Against this background, as active members of the European Society of Clinical Investigation (ESCI), we felt a need to share our experiences, not by repeating or rewriting the existing recently published guidelines (an enormous support in the first clinical orientation). But just by presenting bedside medicine, executed in COVID wards, collected from mostly European community hospitals. Not by presenting dramatic exceptions (case reports), but our daily clinical care and cure. With this special COVID volume, we aim to support our colleagues in their orientation onto a disease that teaches us each day again about the vulnerable human nature. As already mentioned, it is important to notice that no doctor ever learned about this specific clinical picture in medical school and this unknown clinical feature gave a lot of urgency, facilitated by exploding news released and refreshed by social media hourly. It became clear that the epidemiology was characterized by diverse cluster outbreaks that could mostly being related to mass events, like après-skiing (Alpes region/ Italy), march in Madrid, champions league game (Bergamo-Valencia), religious gatherings (Mulhouse France) and carnival (south of Netherlands/Provence Limburg Belgium). Participants from these mass events spread the disease, as a spark. The moment these sparks entered their social circles local outbreaks started, and this repeated fast all over Europe. Such a distribution pattern explains why some European regions were more struck and hurt than others. In a retrospect, one may consider whether pattern recognition could have detected earlier the spread direction of the viremia with less dramatic consequences, like the lockdown. However, due to the absence of overall information about the viral presence within the general population, and only being informed about this in a small selected populations (those who presented with symptomatic disease in clinic) could have hindered the exit strategy among diverse European nations after the total lockdown. Due to this diversity of information, with no guarantee for quality, the exit from total lockdown is an enormous exercise. In line with this, citizens feel less protected by administration and professionals with a subsequent avoidance of looking for help in time of need. Especially, those citizens with a lower health literacy or in a lower economic position are vulnerable today. As a consequence, researchers and clinicians are encountering daily tasks to work on competing risks ever since the beginning of the pandemic. The European Journal of Clinical Investigation (EJCI) at an early stage published a critical review of the potential harms of exaggerated information and nonevidence-based measures by Prof John Ioannidis. 1 The current special edition of the Journal presents patient-oriented experiences and viewpoints straight from clinics across Europe and beyond on this topic. The spirit of the ESCI is cross-discipline: different specialties, one society for both preclinical and clinical health workers, which gives insights and inspiration. This spirit is reflected in this special volume. We will present different actual topics related to COVID-19 with a special focus on daily practice in clinic. We did not intend to rewrite recent guidelines or update them, but more to share clinical experience obtained from daily work with patients suffering from COVID-19 against the background of current clinical guidelines. We start with the recognition of a cardiac involvement which is key from prognostic and therapeutic reasons. The cardiologists (Drs Bert Everaert et al) discuss in their contribution the effect of the cytokine storm, a characteristic of early COVID, and the per acute stress on the mostly "aged" heart. How does this effect outcome, and does it have a therapeutic consequence in the COVID ward? Next, residents in Internal Medicine (Drs Faro Verelst and Michiel Beyens) from Antwerp (B). In the editorial by Beyens et al, they describe their tumbling world as their daily struggles in COVID ward being part of their just started medical training. Pulmonary genetics and histolopathology come together in the 4th article by von der Thusen J et al, which is an indepth perspective contributed by the team of pathologist (Dr Jan von der Thusen) and pulmonologist (Dr Menno van Eerden), both from Rotterdam (NL), with special scientific interest in the development of lung fibroses. They present the history of coronaviruses in relation to lung pathology. What is known of basic mechanisms and what are genetic factors to consider. What may we expect from lung recovery, and should we prepare for specific clinics dealing with lung rehabilitation in the near future? In fact, such specialized rehabilitation made progress fast, and from a more ambulant setting, a specialized team from pulmonary rehabilitation specialists in Hilversum (NL) headed by pulmonologist (Dr Eline bij de Vaate) in article 5 share their innovative and multidomain model of clinical work-up in COVID-19 cases. Given the fact that vascular complications are early hallmarks of the infection, vascular specialists from Genoa (Italy) and Belgium (Dr Federico Carbone et al) have reviewed the latest on lipids and the balance between thrombosis and coagulation in this respect in article 6. The kidney is often involved in COVID-19. From Sao Jose do Rio Preto (Brazil), the nephrologist (Dr Gustavo Betonico) in article 7 discusses the involvement of the "aged" kidney and the approach of acute chronic kidney disease in COVID-19 infection. What should we do preventing an outbreak in the dialysis ward? As an intensivist (again Dr Gustavo Betonico) in a different contribution shares specific bedside strategies in the ICU in article 8. On the other side of the spectrum, family medicine got a totally new orientation towards their patients due to the overwhelming COVID-19 pandemic. In an interesting contribution in article 9, our Italian colleagues (Dr Grattagliano et al) on behalf of the Italian College of Family physicians show their perspectives on the evolution of family medicine. COVID-19 and all related social interactions gave them a different point of view. The endocrinologists (Dr Katrien Clotman et al) in article 10 share their experiences with regard to controlling glycaemia and other endocrine disturbances with a special focus on the clinical work in the COVID ward. The infectiologists from Genua (Italy) (Prof. Matteo Bassetti et al) in article 11 wrote about the cytokine storm that is a principal characteristic of a complicated COVID infection. They delineated molecular pathways associated with this cytokine storm. With their insights, new diagnostic and therapeutic strategies could be developed. The study design that is presented by the group of infectiologists from Utrecht (Dr Jesper Weehuizen et al) in article 12 could tackle the important question what to do with discussion about effectiveness of hydroxychloroquine, that is originally used in the treatment of malaria. The clinical use of this drug is full of controversy. Finally, in article 13, from the perspective of general internal medicine (Dr Di Ciaula et al) from the team of our past ESCI president, prof. Piero Portincasa contributed a view on temporal patterns spreading of the disease in the first European country encountering COVID-19, only 4 months ago. Finally, COVID-19 changed our world forever, and our thinking about creating our own environment (climate warming and global travel) and zoonotic diseases will have a totally different orientation. After reading our contributions, time has evolved and so will be our knowledge. Therefore, the reader is asked not to read this all as a final answer, but more as a moment of consideration in our mission to understand more about the COVID-19 infection in the future. Coronavirus disease 2019: the harms of exaggerated information and non-evidence-based measures None.