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Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control and has worked in both pediatric and adult acute care facilities.

Clinical Manifestations and Outcomes for COVID-19 Patients

With each passing week we learn more about SARS-CoV-2 and the disease, COVID-19. From epidemiology to treatment modalities, this is very much a learn-as-we-go situation. As more cases are identified in the United States though, it is important to understand the clinical characteristics of COVID-19 to help guide better testing and response. 
A new article in the journal Clinical Infectious Diseases discusses this very topic, focusing on refractory pneumonia patients. Studying 155 patients with confirmed COVID-19, a retrospective study was performed via a single center, the Zhongnan Hospital of Wuhan University. From January 1st through February 5th, cases were identified and then divided into general and refractory COVID-19 groups based upon clinical efficacy following hospital admission. 
Assessing the differences between these 2 patient populations, the authors note that “compared with general COVID-19 patients (45.2%), refractory patients had an older age, male sex, more underlying comorbidities, lower incidence of fever, higher levels of maximum temperature among fever cases, higher incidence of breath shortness and anorexia, severer disease assessment on admission, high levels of neutrophil, aspartate aminotransferase (AST), lactate dehydrogenase (LDH) and C-reactive protein, lower levels of platelets and albumin, and higher incidence of bilateral pneumonia and pleural effusion (P<0.05).”

Moreover, those refractory patients tended to receive oxygen, mechanical ventilation, expectorant, and adjunctive treatments like corticosteroids and antiviral drugs. This difference was found to be statistically significant. 
The authors indicated that following adjustment, those with refractory COVID-19 were more likely to have “manifestations of anorexia” and fever on admission. Interestingly, the study team noted that roughly 50% of the studied COVID-19 patients failed to reach clinical and radiological remission of the disease within 10 days following admission and overall, those afebrile men with anorexia experienced poor efficacy of medical interventions.
These findings are particularly relevant as more cases are identified in the United States and rapid clinical decisions must be made.

More analyses of COVID-19 clusters and cases are critical for clinical responses around the world. The recent publication of the characteristics and outcomes of 21 patients with COVID-19 in Washington state also sheds light on how patients might manifest the disease and respond to treatment. 

In this particular review of cases, the authors studied patients admitted to the intensive care unit at Evergreen Hospital in Washington. The mean age was 70 years and 52% of those studied patients were male. In total, 86% had identified comorbidities, with the most common being chronic kidney disease and congestive heart failure. The patients initially presented more frequently with shortness of breath (76%) and just over half had a fever. The mean onset of symptoms prior to hospitalization landing at 3.5 days and 81% of patients were admitted to the intensive care unit within a day of admission.

The authors note that “an abnormal chest radiograph was observed in 20 patients (95%) at admission. The most common findings on initial radiograph were bilateral reticular nodular opacities (11 patients [52%]) and ground-glass opacities (10 [48%]). By 72 hours, 18 patients (86%) had bilateral reticular nodular opacities and 14 (67%) had evidence of ground-glass opacities.” Sadly, mortality in this patient population was 67% with only 9.5% having been discharged at the time of March 17th.

These analyses shed insight into patient presentation and clinical course during the treatment process for COVID-19. It is critical to continue publishing and providing this information to help guide clinical care of these patients as the pandemic continues. 
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