key: cord-0983503-5txhcr7h authors: Siso-Almirall, A.; Kostov, B.; Mas-Heredia, M.; Vilanova-Rotllan, S.; Sequeira-Aymar, E.; Sans-Corrales, M.; Sant-Arderiu, E.; Cayuelas-Redondo, L.; Martinez-Perez, A.; Garcia Plana, N.; Anguita-Guimet, A.; Benavent-Areu, J. title: PROGNOSTIC FACTORS IN SPANISH COVID-19 PATIENTS: A CASE SERIES FROM BARCELONA date: 2020-06-20 journal: nan DOI: 10.1101/2020.06.18.20134510 sha: aa07998578858378a00acdce600e76312034627e doc_id: 983503 cord_uid: 5txhcr7h Background In addition to the lack of COVID-19 diagnostic tests for the whole Spanish population, the current strategy is to identify the disease early to limit contagion in the community. Aim To determine clinical factors of a poor prognosis in patients with COVID-19 infection. Design and Setting Descriptive, observational, retrospective study in three primary healthcare centres with an assigned population of 100,000. Method Examination of the medical records of patients with COVID-19 infections confirmed by polymerase chain reaction. Results We included 322 patients (mean age 56.7 years, 50% female, 115 (35.7%) aged [≥] 65 years). The best predictors of ICU admission or death were greater age, male sex (OR=2.99; 95%CI=1.55 to 6.01), fever (OR=2.18; 95%CI=1.06 to 4.80), dyspnoea (OR=2.22; 95%CI=1.14 to 4.24), low oxygen saturation (OR=2.94; 95%CI=1.34 to 6.42), auscultatory alterations (OR=2.21; 95%CI=1.00 to 5.29), heart disease (OR=4.37; 95%CI=1.68 to 11.13), autoimmune disease (OR=4.03; 95%CI=1.41 to 11.10), diabetes (OR=4.00; 95%CI=1.89 to 8.36), hypertension (OR=3.92; 95%CI=2.07 to 7.53), bilateral pulmonary infiltrates (OR=3.56; 95%CI=1.70 to 7.96), elevated lactate-dehydrogenase (OR=3.02; 95%CI=1.30 to 7.68), elevated C-reactive protein (OR=2.94; 95%CI=1.47 to 5.97), elevated D-dimer (OR=2.66; 95%CI=1.15 to 6.51) and low platelet count (OR=2.41; 95%CI=1.12 to 5.14). Myalgia or artralgia (OR=0.28; 95%CI=0.10 to 0.66), dysgeusia (OR=0.28; 95%CI=0.05 to 0.92) and anosmia (OR=0.23; 95%CI=0.04 to 0.75) were protective factors. Conclusion Determining the clinical, biological and radiological characteristics of patients with suspected COVID-19 infection will be key to early treatment and isolation and the tracing of contacts. The best predictors of ICU admission and death were age, male sex (OR = 2.99; 95%CI = 1.55 to 6.01), dyspnoea (OR = 2.22; 95%CI = 1.14 to 4.24), fever (OR = 2.18; 95%CI = 1.06 to 4.80), auscultatory alterations (OR = 2.21; 95%CI = 1.00 to 5.29) and low oxygen saturation (OR = 2.94; 95%CI = 1.34 to 6.42). However, myalgia or arthralgia (OR = 0.28; 95%CI = 0.10 to 0.66), dysgeusia (OR = 0.28; 95%CI = 0.05 to 0.92) and anosmia (OR = 0.23; 95%CI = 0.04 to 0.75) were significant protective factors against ICU admission and death (Fig 1) . Comorbidities were presented by 212 (65. 8%) patients: the most common were hypertension in 109 (33.9%), diabetes mellitus in 46 (14.3%), and obesity in 46 (14.3%) ( Table 2 ). The most important predisposing factors for ICU admission and death were heart disease (OR = 4.37; 95%CI = 1.68 to 11.13), autoimmune disease (OR = 4.03; 95%CI = 1.41 to 11.10), diabetes (OR = 4.00; 95%CI = 1.89 to 8.36) and hypertension (OR = 3.92; 95%CI = 2.07 to 7.53) (Fig 1) . Chills (OR = 4.80; 95%CI = 1.52 to 20.07), fever (OR = 4.20; 95%CI = 2.47 to 7.27), dyspnoea (OR = 3.37; 95%CI = 1.91 to 6.08), depression (OR = 9.08; 95%CI = 2.08 to 82.91), heart disease (OR = 6.10; 95%CI = 1.99 to 25.04) and chronic obstructive pulmonary disease (OR = 6.02; 95%CI = 1.67 to 32.89) are the best predictors of hospitalization (Fig 2) . Chest X-ray was necessary in 227 patients (70.5%) and showed lobar pulmonary infiltrates in 35 (15.4%), bilateral pulmonary infiltrates in 129 (56.8%) and an interstitial pattern in 48 (21.1%) ( Table 3) . Chest CT was required in 28 patients and pulmonary ultrasound in 10 (3.1%). Biologically, 171 (81.4%) of 210 patients had lymphopenia (< 1,000 mm3). Likewise, 60.8% had a lactate dehydrogenase (LDH) > 250 U/ml and liver test alterations were common: elevated AST/GOT in 41.4% and ALT/GPT in 32.4%. In 86 (52.1%) of 165 cases D-dimer was elevated (> 500g/L). The most important factors of a poor prognosis were bilateral pulmonary infiltrates (OR = 3.56; 95%CI = 1.70 to 7.96), elevated lactate-dehydrogenase (OR = 3.02; 95%CI = 1.30 to 7.68), elevated C-reactive protein (OR = 2.94; 95%CI = 1.47 to 5.97), elevated Ddimer (OR = 2.66; 95%CI = 1.15 to 6.51) and low platelet count (OR = 2.41; 95%CI = 1.12 to 5.14) (Fig 1) . Treatment included hydroxychloroquine in 162 (50.3%) patients, azithromycin in 149 (46.3%), lopinavir/ritonavir in 132 (40.7%), glucocorticoids in 34 (10.6%) and tocilizumab in 27 (8.4%), among others ( Table 4 ). 49.1% of patients required hospitalization. The mean hospital stay was 9.4 (SD 5.8) days. Phone follow up was made in 277 (86.0%) non-hospitalized and discharged patients, 57 (17.7%) patients were monitored at home. 161 (77.8%) of the 207 patients of working age sought work disability due to COVID-19. The ICU admission rate was 13.0%. The evolution included adult respiratory distress syndrome in 37 (11.5%) patients, severe renal failure in 8 (2.5%), pulmonary thromboembolism in 4 (1.2%) and sepsis in 3 (0.9%) patients. Occupational contact with persons with confirmed or suspected COVID-19 infection was reported by 71 (22.0%) patients, while 51 (15.8%) reported that contact occurred in the family setting. Occupational contact was a protective factor against hospitalization (OR = 0.23; 95%CI = 0.12 to 0.42), ICU admission or death (OR = 0.05; 95%CI = 0.00 to 0.31). The mortality rate to date was 5.6%. This study summarizes the clinical, biological and radiological characteristics, evolution and prognostic factors of patients with COVID-19 disease. To date, we are aware of only one published Spanish study [10] , which reported on ICU admissions in a region where the epidemic was reported early. Although there have been two systematic 1 0 professionals, who felt undersupplied. Secondly, many cases were health professionals from primary healthcare or the reference hospital who reside in the same area where they work. In all reported series, bilateral pneumonia was the most common radiological finding, was present in more than half the cases [19] and was a factor of a poor prognosis and mortality. In contrast, an interstitial radiological pattern did not confer an increased risk of mortality. The Wuhan study reported a CAT scan use of 88.7%, compared with 8.7% in Barcelona. In contrast, chest X-rays were carried out in 59.1% and 70.5%, respectively: the availability of diagnostic means was higher in China. A recent international consensus states that radiological assessment is not necessary in asymptomatic patients or those with mild disease but is required in patients with moderate or severe disease, regardless of whether a definite diagnosis of COVID-19 has been made [20] . In addition, simple chest radiology [20] is preferable in a resourceconstrained environment with difficulties in accessing CAT scans [20] . The possible use of pulmonary ultrasound for the point-of-care diagnosis of COVID-19 pneumonia has not been sufficiently analysed but might be an efficient alternative due to its portability and reliability [21] . In fact, the regional Catalan government has recently acquired 90 ultrasound machines to enable family physicians to make doctors can make point-ofcare (home or nursing home) diagnoses of pneumonia [22] . Biologically, lymphopenia and increased CRP, LDH and D-dimer were usually constant and similar in all series and, together with a low platelet count were associated with an increased risk of mortality. A differential variable in our series is a greater number of alterations in liver tests, which was present in 30-40% of patients, data similar to the USA and Italian cohorts, but different from the Chinese cohort, where it was 22% [7] . We also found hypokalaemia in 20.5% of patients, a factor not reported in other studies. 1 1 We found a hospitalization rate of 48.7%, compared with 20-31% in the USA and 93.6% in China, and an ICU admission rate of 13%, which was similar to the Chinese (15%), USA (5-11.5%) and German (10%) results. While the protocols of action and admission are similar and depend on the level of clinical involvement, the therapeutic protocols differ between hospitals, cities, and countries. There remain many unknowns in the treatment of COVID-19. The only truth is that we do not have a vaccine, an etiological treatment or a treatment with sufficient scientific evidence to generalize its use. Currently, the systematic review of antiretroviral treatments has not offered conclusive results [23] and despite possibly encouraging in vitro results for hydroxychloroquine, COVID-19 infections are currently intractable [24, 25] . The mortality rate in our study was 5.6%, compared with 10.2% in New York (21% in hospitalized patients), 1.4% in China, 3.1% in Germany and 6.8% in Italy. Different information and recording systems, the availability of diagnostic tests, and above all, the organization of national health systems may have contributed to the differences observed. The study had some limitations due to the observational, retrospective design. However, it is sufficiently representative of the population with confirmed COVID-19 to permit better identification of the factors of a poor prognosis of the disease from a clinical perspective. Three months after the declaration of the pandemic, there is not a sufficiently reliable, available and generalizable diagnostic test that can analyse the seroprevalence of COVID-19, even in the most industrialized countries. Given this lack, determining the clinical, biological and radiological characteristics of probable cases of COVID-19 infection will be key to the initiation of early treatment and isolation, and for contact tracing, especially in primary healthcare. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The study was approved by the Ethics Committee of the Hospital Clinic of Barcelona (HCB/2020/0525). The authors have declared no competing interests. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 20, 2020. . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 20, 2020. . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 20, 2020. . (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 20, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 20, 2020. . World Health Organization. Pneumonia of unknown cause -China First Case of 2019 Novel Coronavirus in the United States Situación del COVID-19 en España Clinical Characteristics of Coronavirus Disease 2019 in China Utility of hyposmia and hypogeusia for the diagnosis of COVID-19 Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) -United States The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice The role of imaging in 2019 novel coronavirus pneumonia (COVID-19) The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society The authors wish to thank David Buss for his editorial assistance.