Discussion
We present the first UK clinical data of 71 cases of COVID-19 patients admitted to one clinical centre. The majority of patients (70 patients) were white British and one patient was Asian. Our cohort of patients of mean (SD) age of 70.7 (16.6) years, with 75% are ≥65 years, appears older than the published Chinese cohort {median age was only 46.0 years and the proportion of older patients (> 60 years) was 44.1%}, we had slightly more men (58% v 51.6%) but the comorbidities were similar. 8 Around 10% of our patients presented with gastrointestinal symptoms such as diarrhoea compared to only 3.8% in a Chinese study. 9 Although in another Chinese study by Wang et al, 10% of patients initially presented with nausea and diarrhoea 1-2 days before the onset of fever and dyspnoea.4 Laboratory systemic abnormalities particularly lymphopenia and elevated CRP and chest imaging findings are consistent with previously published literature. 10 The majority of our patients (55%) had normal chest x-ray in comparison to only around 18% in a Chinese report. 9 Our case fatality rate of 14% was similar to 8% for those aged 70-79 and 14.8% for those ≥80 years that was reported from China. 8 Also, previously, older age has been reported as an important independent predictor of mortality in SARS and MERS. 11, 12 Older people are more susceptible to infection likely due to associated comorbidities and attenuation of the innate immunity.13 The ageing immune system is characterized by a low grade and chronic systemic inflammatory state or “InflammAgeing” and is associated with an increased susceptibility to infection.14 One important finding in this case series, which has not been reported yet in the literature, is the emergence of frailty as a detrimental significant factor for poor outcome in patients with COVID-19. Frailty is a syndrome that is characterised by multisystem dysregulation that leads to reduced physiologic reserve and increased risk of adverse health outcomes. Dysregulation in the innate and adaptive immunity also leads to chronic inflammation, with increase in inflammatory markers, and increased susceptibility to severe infections. Increased inflammatory markers have been shown in patients with viral pneumonia. 13 Although frailty was not formally assessed in the COVID-19 studies, the fact that old age is associated with comorbidities and was associated with an increased risk of COVID-19 infection and worse outcomes may suggest underlying frailty was common in these old patients. The strength of this case series is its prospective design which allowed follow up of cases as well as the use of electronic record which allowed accurate documentation of results. However, this study has few limitations which include first, the small number included so far and the incomplete conclusion of outcomes of the patients who are still under treatment in hospital however, this series is in a continuous follow up and successive publications will follow as more information are gathered. Second, we were not able to record the incubation period for the current infection as this was not clearly re-called by the patients. Third, we are not able to report efficacy of any specific antiviral therapy as per our hospital protocol, this has not been used.