Articles ll patients(n-41)KCUsare (n-13)NolCUcare (n=28)pyalue 7040-30 7.040-80 7040-39 1229%) 1185%) 14 000o se resulting from this virus.Since the c 351 35 41n viraRNA detection rate between and lowe on was no 646 30) 0013 323% 0-027 with unde 0000 and mortality 766 10240 data for a larger erdefine the 25% 215% 0 tion, history.and risk factor 25% 25% urthe 0 0014 18w) 61影 28168 754 a05 do rily rule 65% 38% etbor the Treatments and out ientsinfectedwihzoig-ncov tions in future studies SAR and MERS-CoV were believed t and MERS-oVhas driven the dirch on e dose o ofa SARS-lik in bats with that ability to use ACE as a rep s to be needed to ed deeply in case it bec es a glob th thre and Noantiiralreamcntforcoronavinsinfctionhasbec iniciansntheirietcontacti Combinationoflopinavirandritonavitamo SARS-Co rveillance is essential monitor its future host patients was as with substa benef nd coll n b Articles 504 www.thelancet.com Vol 395 February 15, 2020 suggests that receiving corticosteroids did not have an effect on mortality, but rather delayed viral clearance.27–29 Therefore, corticosteroids should not be routinely given systemically, according to WHO interim guidance.30 Among our cohort of 41 laboratory-confirmed patients with 2019-nCoV infection, corticosteroids were given to very few non-ICU cases, and low-to-moderate dose of corticosteroids were given to less than half of severely ill patients with ARDS. Further evidence is urgently needed to assess whether systematic corticosteroid treatment is beneficial or harmful for patients infected with 2019-nCoV. No antiviral treatment for coronavirus infection has been proven to be effective. In a historical control study,31 the combination of lopinavir and ritonavir among SARS-CoV patients was associated with substantial clinical benefit (fewer adverse clinical outcomes). Arabi and colleagues initiated a placebo-controlled trial of interferon beta-1b, lopinavir, and ritonavir among patients with MERS infection in Saudi Arabia.32 Preclinical evidence showed the potent efficacy of remdesivir (a broad-spectrum antiviral nucleotide prodrug) to treat MERS-CoV and SARS-CoV infections.33,34 As 2019-nCoV is an emerging virus, an effective treatment has not been developed for disease resulting from this virus. Since the combination of lopinavir and ritonavir was already available in the designated hospital, a randomised controlled trial has been initiated quickly to assess the efficacy and safety of combined use of lopinavir and ritonavir in patients hospitalised with 2019-nCoV infection. Our study has some limitations. First, for most of the 41 patients, the diagnosis was confirmed with lower respiratory tract specimens and no paired nasopharyngeal swabs were obtained to investigate the difference in the viral RNA detection rate between upper and lower respiratory tract specimens. Serological detection was not done to look for 2019-nCoV antibody rises in 18 patients with undetectable viral RNA. Second, with the limited number of cases, it is difficult to assess host risk factors for disease severity and mortality with multivariable￾adjusted methods. This is a modest-sized case series of patients admitted to hospital; collection of standardised data for a larger cohort would help to further define the clinical presentation, natural history, and risk factors. Further studies in outpatient, primary care, or community settings are needed to get a full picture of the spectrum of clinical severity. At the same time, finding of statistical tests and p values should be interpreted with caution, and non-significant p values do not necessarily rule out difference between ICU and non-ICU patients. Third, since the causative pathogen has just been identified, kinetics of viral load and antibody titres were not available. Finally, the potential exposure bias in our study might account for why no paediatric or adolescent patients were reported in this cohort. More effort should be made to answer these questions in future studies. Both SARS-CoV and MERS-CoV were believed to originate in bats, and these infections were transmitted directly to humans from market civets and dromedary camels, respectively.35 Extensive research on SARS-CoV and MERS-CoV has driven the discovery of many SARS-like and MERS-like coronaviruses in bats. In 2013, Ge and colleagues36 reported the whole genome sequence of a SARS-like coronavirus in bats with that ability to use human ACE2 as a receptor, thus having replication potentials in human cells.37 2019-nCoV still needs to be studied deeply in case it becomes a global health threat. Reliable quick pathogen tests and feasible differential diagnosis based on clinical description are crucial for clinicians in their first contact with suspected patients. Because of the pandemic potential of 2019-nCoV, careful surveillance is essential to monitor its future host adaption, viral evolution, infectivity, transmissibility, and pathogenicity. Contributors BC and JW had the idea for and designed the study and had full access to all data in the study and take responsibility for the integrity of the All patients (n=41) ICU care (n=13) No ICU care (n=28) p value Duration from illness onset to first admission 7·0 (4·0–8·0) 7·0 (4·0–8·0) 7·0 (4·0–8·5) 0·87 Complications Acute respiratory distress syndrome 12 (29%) 11 (85%) 1 (4%) <0·0001 RNAaemia 6 (15%) 2 (15%) 4 (14%) 0·93 Cycle threshold of RNAaemia 35·1 (34·7–35·1) 35·1 (35·1–35·1) 34·8 (34·1–35·4) 0·35 Acute cardiac injury* 5 (12%) 4 (31%) 1 (4%) 0·017 Acute kidney injury 3 (7%) 3 (23%) 0 0·027 Secondary infection 4 (10%) 4 (31%) 0 0·0014 Shock 3 (7%) 3 (23%) 0 0·027 Treatment Antiviral therapy 38 (93%) 12 (92%) 26 (93%) 0·46 Antibiotic therapy 41 (100%) 13 (100%) 28 (100%) NA Use of corticosteroid 9 (22%) 6 (46%) 3 (11%) 0·013 Continuous renal replacement therapy 3 (7%) 3 (23%) 0 0·027 Oxygen support ·· ·· ·· <0·0001 Nasal cannula 27 (66%) 1 (8%) 26 (93%) ·· Non-invasive ventilation or high-flow nasal cannula 10 (24%) 8 (62%) 2 (7%) ·· Invasive mechanical ventilation 2 (5%) 2 (15%) 0 ·· Invasive mechanical ventilation and ECMO 2 (5%) 2 (15%) 0 ·· Prognosis ·· ·· ·· 0·014 Hospitalisation 7 (17%) 1 (8%) 6 (21%) ·· Discharge 28 (68%) 7 (54%) 21 (75%) ·· Death 6 (15%) 5 (38%) 1 (4%) ·· Data are median (IQR) or n (%). p values are comparing ICU care and no ICU care. 2019-nCoV=2019 novel coronavirus. ICU=intensive care unit. NA=not applicable. ECMO=extracorporeal membrane oxygenation. *Defined as blood levels of hypersensitive troponin I above the 99th percentile upper reference limit (>28 pg/mL) or new abnormalities shown on electrocardiography and echocardiography. Table 3: Treatments and outcomes of patients infected with 2019-nCoV