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1.
Ann Transl Med ; 10(10): 545, 2022 May.
Article in English | MEDLINE | ID: covidwho-1887397

ABSTRACT

Background: The coronavirus disease 2019 (COVID-19) has forced accelerated optimization of Emergency Department (ED) process, and simulation tools offer an alternative approach to strategic assessment and selection. Methods: Field research and case analysis methods were used to obtain the treatment process and medical records information from the ED of a general hospital. Minitab was used for analysis of the measurement system, and Arena was applied for simulation modelling. We established a framework for the triage protocol of ordinary and quarantined patients, analysed bottlenecks in the treatment time of the hospital's ED, and proposed an optimised management strategy. Results: The computed tomography (CT) pre-scheduling strategy simulation results demonstrated that longer CT room preparation times for quarantined people before their arrival (Tp) resulted in reduced CT scan and waiting times for quarantined patients, but these times were longer for ordinary patients. The nucleic acid priority strategy simulation results demonstrated that when the average daily number of ordinary patients (λc) was relatively stable, the hospital could guide ordinary patients to perform nucleic acid testing first followed by CT testing. However, when λc fluctuated greatly, the hospital could appropriately reduce the proportion of preferential nucleic acid testing. Furthermore, when λc was overloaded, the nucleic acid priority strategy showed no advantages. The joint analysis results demonstrated that the optimal strategy selection was significantly affected by the severity of the epidemic. The nucleic acid detection sample size optimisation strategy demonstrated that optimizing the sample size of each batch according to the number of patients could effectively reduce the waiting times for nucleic acid testing (Tn). Conclusions: Simulation tools are an alternative method for strategic evaluation and selection that do not require external factors.

2.
Bioinformatics ; 2022 May 31.
Article in English | MEDLINE | ID: covidwho-1873852

ABSTRACT

: Mutation is the key for a variant of concern (VOC) to overcome selective pressures, but this process is still unclear. Understanding the association of the mutational process with VOCs is an unmet need. Here we developed VOC-alarm, a method to predict VOCs and their caused COVID surges, using mutations of about 5.7 million SARS-CoV-2 complete sequences. We found that VOCs rely on lineage-level entropy value of mutation numbers to compete with other variants, suggestive of the importance of population-level mutations in the virus' evolution. Thus, we hypothesized that VOCs are a result of a mutational process across the globe. Analyzing the mutations from January 2020-December 2021, we simulated the mutational process by estimating the pace of evolution, and thus divided the time period, January 2020-March 2022, into eight stages. We predicted Alpha, Delta, Delta Plus (AY.4.2) and Omicron (B.1.1.529) by their mutational entropy values in the stages I, III, V, and VII with accelerated paces, respectively. In late November 2021, VOC-alarm alerted that Omicron strongly competed with Delta and Delta plus to become a highly transmissible variant. Using simulated data, VOC-alarm also predicted that Omicron could lead to another COVID surge from January 2022-March 2022. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

3.
Front Psychol ; 13: 776986, 2022.
Article in English | MEDLINE | ID: covidwho-1834523

ABSTRACT

From an integrative approach of parable interpretation that combines ethical, evolutionary, historical, and psychological perspectives, the current research empirically examined the purely theorized assumption elucidating the behaviors of the priest, Levite, and Samaritan in the good Samaritan parable (Luke 10:25-37) by the regulatory focus theory. In one experiment conducted during the COVID-19 outbreak, 93 Polish participants were randomly assigned to a simulated vignette of the good Samaritan parable where either the prevention or promotion regulatory focus was manipulated. The results confirmed a certain favorable tendency to offer quasi-realistic help in both the regulatory focus conditions. The finding highlights a dynamic association in goal pursuit motivation and prosocial behavior in a pandemic context regarding the good Samaritan parable. The current study is among rare empirical research which reflects a challenge people respond to offer help in simulated scenarios as original as the good Samaritan parable.

4.
Int J Gen Med ; 15: 2957-2962, 2022.
Article in English | MEDLINE | ID: covidwho-1753258

ABSTRACT

Background: The aim of this study was to analyse changes in influenza detection rates of the influenza seasons 2017/2018, 2018/2019, 2019/2020, and 2020/2021 and the changes in personal awareness of protection during the COVID-19 pandemic. Methods: This retrospective study included patients tested for influenza virus A and B from November 2017 to March 2021 at the Affiliated People's Hospital of Ningbo University (Ningbo, China). Influenza virus A and B tested by direct RT-PCR. A small group of 100 regular participants in influenza virus detection were surveyed on the use of protective measures in four different influenza seasons. Results: There were 14,902, 14,762, 25,070, and 1107 tests of influenza virus A and B in the four influenza periods, for total positive rates of 32.45%, 35.77%, 29.40%, and 0.54%, respectively. In the two periods of four influenza seasons, from November to January, the total number of influenza samples was 8530, 4980, 22,925, 868; from February to March, the number of tests was 6372, 9782, 2145, 239. Total number of tests and positive rate decreased significantly from February/March onwards of the 2019/2020 season, coinciding with the beginning of COVID-19. The proportion of people taking protective measures also increased during the 2019/20 and 2020/21 flu seasons. Conclusion: The influenza virus has a high incidence in this area. The diagnosis rate of influenza decreased after the start of the COVID-19 pandemic. The COVID-19 pandemic had an important impact on the detection rates for influenza virus.

5.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-325266

ABSTRACT

Background: Hospitalized patients with Coronavirus Disease 2019 (COVID-19) pneumonia showed a severve loss of muscle mass and strength over admission. Therefore, early physical interventions might be conducive to prevent disability and fasten recovery. Methods: : We designed a prospective, randomized controlled trial to identify the effectiveness and safety of pulmonary rehabilitation based on muscle exercise in COVID-19 patients. The study was conducted between February 7 th and March 31 st 2020 in Union Hospital. Patients were randomly assigned to the pulmonary rehabilitation exercise group or the control group. Primary outcome was improvement of activity of daily living (ADL). Secondary outcome was changes of muscle strength assessed by manual muscle test (MMT) and arterial blood gas analysis. Length of hospital staying (LOS) and adverse events related to physical activity were also observed. Results: : A total of sixty patients were in analysis, and thirty patients were in PR group. Patients had a mean age of 54.43±10.57 years. A statistically and clinically significant increase in ADL was observed in PR group (75.00 [66.25,90.00] to 100.00 [100.00,100.00], p<0.001). We also found that the improvement of ADL was related to younger age and higher PaO 2 (p<0.01). Both groups had MMT improvement and there was no statistical difference between groups. There was a significant increase in PaO 2 (80.23±6.49 vs. 90.47±7.82, respectively, p<0.001) between two groups before discharge. There was no statically significant difference in LOS between study group and control group (p=0.62). None of these patients had severe complications during the study. Conclusions: : The protocal of pulmonary rehabilitation based on muscle training exercise was feasible in COVID-19 patients and it might accelerate recovery in ADL as compared with the spontaneous recovery in the control group. Clinical Trial Registration: ChiCTR, ChiCTR2000032457. Registered 29 April 2020- Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=52925.

6.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-313412

ABSTRACT

Coronavirus Disease 2019 (COVID-19) has become a serious global epidemic in the past few months and caused huge loss to human society worldwide. For such a large-scale epidemic, early detection and isolation of potential virus carriers is essential to curb the spread of the epidemic. Recent studies have shown that one important feature of COVID-19 is the abnormal respiratory status caused by viral infections. During the epidemic, many people tend to wear masks to reduce the risk of getting sick. Therefore, in this paper, we propose a portable non-contact method to screen the health condition of people wearing masks through analysis of the respiratory characteristics. The device mainly consists of a FLIR one thermal camera and an Android phone. This may help identify those potential patients of COVID-19 under practical scenarios such as pre-inspection in schools and hospitals. In this work, we perform the health screening through the combination of the RGB and thermal videos obtained from the dual-mode camera and deep learning architecture.We first accomplish a respiratory data capture technique for people wearing masks by using face recognition. Then, a bidirectional GRU neural network with attention mechanism is applied to the respiratory data to obtain the health screening result. The results of validation experiments show that our model can identify the health status on respiratory with the accuracy of 83.7\% on the real-world dataset. The abnormal respiratory data and part of normal respiratory data are collected from Ruijin Hospital Affiliated to The Shanghai Jiao Tong University Medical School. Other normal respiratory data are obtained from healthy people around our researchers. This work demonstrates that the proposed portable and intelligent health screening device can be used as a pre-scan method for respiratory infections, which may help fight the current COVID-19 epidemic.

7.
AJR Am J Roentgenol ; 215(1): 121-126, 2020 07.
Article in English | MEDLINE | ID: covidwho-1211773

ABSTRACT

OBJECTIVE. Confronting the new coronavirus infection known as coronavirus disease 2019 (COVID-19) is challenging and requires excluding patients with suspected COVID-19 who actually have other diseases. The purpose of this study was to assess the clinical features and CT manifestations of COVID-19 by comparing patients with COVID-19 pneumonia with patients with non-COVID-19 pneumonia who presented at a fever observation department in Shanghai, China. MATERIALS AND METHODS. Patients were retrospectively enrolled in the study from January 19 through February 6, 2020. All patients underwent real-time reverse transcription-polymerase chain reaction (RT-PCR) testing. RESULTS. Eleven patients had RT-PCR test results that were positive for severe acute respiratory syndrome coronavirus 2, whereas 22 patients had negative results. No statistical difference in clinical features was observed (p > 0.05), with the exception of leukocyte and platelet counts (p < 0.05). The mean (± SD) interval between onset of symptoms and admission to the fever observation department was 4.40 ± 2.00 and 5.52 ± 4.00 days for patients with positive and negative RT-PCR test results, respectively. The frequency of opacifications in patients with positive results and patients with negative results, respectively, was as follows: ground-glass opacities (GGOs), 100.0% versus 90.9%; mixed GGO, 63.6% versus 72.7%; and consolidation, 54.5% versus 77.3%. In patients with positive RT-PCR results, GGOs were the most commonly observed opacification (seen in 100.0% of patients) and were predominantly located in the peripheral zone (100.0% of patients), compared with patients with negative results (31.8%) (p = 0.05). The median number of affected lung lobes and segments was higher in patients with positive RT-PCR results than in those with negative RT-PCR results (five vs 3.5 affected lobes and 15 vs nine affected segments; p < 0.05). Although the air bronchogram reticular pattern was more frequently seen in patients with positive results, centrilobular nodules were less frequently seen in patients with positive results. CONCLUSION. At the point during the COVID-19 outbreak when this study was performed, imaging patterns of multifocal, peripheral, pure GGO, mixed GGO, or consolidation with slight predominance in the lower lung and findings of more extensive GGO than consolidation on chest CT scans obtained during the first week of illness were considered findings highly suspicious of COVID-19.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/diagnostic imaging , Disease Outbreaks , Lung/diagnostic imaging , Pneumonia, Viral/complications , Pneumonia, Viral/diagnostic imaging , Adult , Aged , COVID-19 , China , Coronavirus Infections/epidemiology , Female , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/epidemiology , Retrospective Studies , SARS-CoV-2 , Tomography, X-Ray Computed
8.
Ieee Sensors Journal ; 20(22):13674-13681, 2020.
Article | Web of Science | ID: covidwho-907569

ABSTRACT

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronaviruses 2 (SARS-CoV-2) has become a serious global pandemic in the past few months and caused huge loss to human society worldwide. For such a large-scale pandemic, early detection and isolation of potential virus carriers is essential to curb the spread of the pandemic. Recent studies have shown that one important feature of COVID-19 is the abnormal respiratory status caused by viral infections. During the pandemic, many people tend to wear masks to reduce the risk of getting sick. Therefore, in this paper, we propose a portable non-contact method to screen the health conditions of people wearing masks through analysis of the respiratory characteristics from RGB-infrared sensors. We first accomplish a respiratory data capture technique for people wearing masks by using face recognition. Then, a bidirectional GRU neural network with an attention mechanism is applied to the respiratory data to obtain the health screening result. The results of validation experiments show that our model can identify the health status of respiratory with 83.69% accuracy, 90.23% sensitivity and 76.31% specificity on the real-world dataset. This work demonstrates that the proposed RGB-infrared sensors on portable device can be used as a pre-scan method for respiratory infections, which provides a theoretical basis to encourage controlled clinical trials and thus helps fight the current COVID-19 pandemic. The demo videos of the proposed system are available at: https://doi.org/10.6084/m9.figshare.12028032.

9.
Int Immunopharmacol ; 89(Pt B): 107089, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-844966

ABSTRACT

AIM: To evaluate the nucleic acid and antibody test results of patients with Coronavirus Disease 2019 (COVID-19) in China. METHODS: All patients with laboratory-confirmed SARS-CoV-2 infection from Jan to Apr 2020were retrospectively analyzed. Clinical characteristics and laboratory test results were obtained from electronic medical records. Patients were divided into three groups based on antibody production, and compared for laboratory test results. RESULTS: Of 73 patients aged11-82 years, 12 (16.4%), 28 (38.4%), 25 (34.2%) and 8 (11.0%)were ≤ 30, 31-50, 51-70,and ≥ 71 years old, respectively. Thirty-four (46.6%) patients were male. Most individuals had mild symptoms, and no patient died during treatment. All patients were tested positive for SARS-CoV-2 in sputum and nasopharyngeal samples, and 40 (54.8%) were also tested positive in stool. Nine(12.3%) patients were re-positivefor SARS-CoV-2, as assessed by Reverse Transcription-Polymerase Chain Reaction (RT-PCR) after discharge. Sixty-five (89.0%) patients had IgM or IgG antibodies against SARS-CoV-2.Among the four age groups, there was no difference in IgG antibody production (P = 0.664).CD3, CD4, CD8 and CD19 cell counts between the antibody producing and non-producing groups showed no significant differences (all P > 0.05).The antibodies disappeared within two months in four patients. Lymphocyte count, C-reactive protein, IL-6, lactate dehydrogenase, alanine aminotransferase, creatinine and D-Dimer levels were similar in the three groups (all P > 0.05). CONCLUSIONS: Patients after recovery from COVID-19 can be tested positive for SARS-CoV-2.Some patients may produce antibodies only for a short time, or even no antibodies at all.


Subject(s)
Antibodies, Viral/analysis , COVID-19 Nucleic Acid Testing , COVID-19 Serological Testing , COVID-19/diagnosis , SARS-CoV-2 , Adolescent , Adult , Aged , Aged, 80 and over , Child , Female , Humans , Male , Middle Aged , Retrospective Studies , Young Adult
10.
SSRN; 2020.
Preprint | SSRN | ID: ppcovidwho-499

ABSTRACT

Background: To study the clinical features and CT manifestations of patients with confirmed 2019-nCoV pneumonia and compare between patients with and without 20

11.
Transl Lung Cancer Res ; 9(4): 1516-1527, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-782600

ABSTRACT

BACKGROUND: Radiological manifestations of coronavirus disease 2019 (COVID-19) featured ground-glass opacities (GGOs), especially in the early stage, which might create confusion in differential diagnosis with early lung cancer. We aimed to specify the radiological characteristics of COVID-19 and early lung cancer and to unveil the discrepancy between them. METHODS: One hundred and fifty-seven COVID-19 patients and 374 early lung cancer patients from four hospitals in China were retrospectively enrolled. Epidemiological, clinical, radiological, and pathological characteristics were compared between the two groups using propensity score-matched (PSM) analysis. RESULTS: COVID-19 patients had more distinct symptoms, tended to be younger (P<0.0001), male (P<0.0001), and had a higher body mass index (P=0.014). After 1:1 PSM, 121 matched pairs were identified. Regarding radiological characteristics, patients with a single lesion accounted for 17% in COVID-19 and 89% in lung cancer (P<0.0001). Most lesions were peripherally found in both groups. Lesions in COVID-19 involved more lobes (median 3.5 vs. 1; P<0.0001) and segments (median 6 vs. 1; P<0.0001) and tended to have multiple types (67%) with patchy form (54%). Early lung cancer was more likely to have a single type (92%) with oval form (66%). Also, COVID-19 and early lung cancer either had some distinctive features on computed tomography (CT) images. CONCLUSIONS: Both COVID-19 and early lung cancers showed GGOs, with similar but independent features. The imaging characteristics should be fully understood and combined with epidemiological history, pathogen detection, laboratory tests, short-term CT reexamination, and pathological results to aid differential diagnosis.

12.
Ann Transl Med ; 8(14): 878, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-721676

ABSTRACT

BACKGROUND: The 2019 coronavirus disease (COVID-19) has become a global pandemic. To date, although many studies have reported on the computed tomography (CT) manifestations of COVID-19, the vascular enlargement sign (VES) of COVID-19 has not been deeply examined, with the few available studies reporting an inconsistent prevalence. We thus performed a systematic review and meta-analysis based on the best available studies to estimate the prevalence and identify the underlying differential diagnostic value of VES. METHODS: We searched nine English and Chinese language databases up to April 23, 2020. Studies that evaluated CT features of COVID-19 patients and reported VES, with or without comparison with other pneumonia were included. The methodologic quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Meta-analyses with random effects models were performed to calculate the aggregate prevalence and pooled odds ratios (ORs) of VES. We also conducted meta-regression and subgroup analyses to analyze heterogeneity. RESULTS: VES findings from a total of 1969 patients were summarized and pooled across 22 studies. Our analysis demonstrated that the prevalence of VES among COVID-19 patients was 69.37% [95% confidence interval (CI): 57.40-79.20%]. Compared with non-COVID-19 patients, VES manifestation was more frequently observed in confirmed COVID-19 patients (OR =6.43, 95% CI: 3.39-12.22). Studies that explicitly defined distribution of VES in the lesion area demonstrated a significantly higher prevalence (P=0.03). Subgroup analyses also revealed a relatively higher VES rate in studies with a sample size larger than 50, but the difference was not statistically significant. No significant difference in VES rates was found between different countries (China/Italy), regions (Hubei/outside Hubei), average age groups (over/less than 50-year-old), or slice thicknesses of CT scan. Extensive heterogeneity was identified across most estimates (I2>80%). Some of the variations (R2=19.73%) could be explained by VES distribution, and sample size. No significant publication bias was seen (P=0.29). CONCLUSIONS: VES on thoracic CT was found in almost two-thirds of COVID-19 patients, and was more prevalent compared with that of the non-COVID-19 patients, supporting a promising role for VES in identifying pneumonia caused by coronavirus.

13.
Ann Transl Med ; 8(12): 749, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-639128

ABSTRACT

BACKGROUND: Since the outbreak of COVID-19 in January, 2020, the fever of unknown origin (FUO) emergency department has become the first station for disease prevention and identification in hospitals. Establishing a standardized FUO emergency department within a short period of time has become the key to preventing and controlling COVID-19 in densely populated Chinese cities. METHODS: Based on the lean management model, the research group established a process of less-link visits, which sees reduced contact between patients and physicians during diagnosis and treatment, and zero-contact consultation through lean workflow and value stream analysis. Three steps were implemented to improve the operations of the FUO emergency department: the rapid establishment of an isolation zone, the refinement of duty and protection configuration, and the use of Internet and technology to establish a full-process follow-up consultation system. RESULTS: (I) Tests related to COVID-19 screening are all completed in the FUO emergency department; (II) 12 new isolated observation rooms have been built; (III) hospital visiting time, waiting time for consultation, and the time from pre-examination to virus screening has been shortened from 18 to 8 hours, from 2 hours to 10 minutes, and from 34 to 3 hours, respectively; (IV) the transfer distance has been shortened from 450 to 20 m, and the observation time has been shortened from 72 to 26 hours. The median waiting time for image examination has been reduced from 40 to 3 minutes, and the moving distance has been shortened from 800 to 10 m; (V) the diagnosis and treatment process is facilitated by 5G, achieving zero contact between doctors and patients. CONCLUSIONS: Through the implantation of information technology, the local transformation of the site, the rational allocation of medical teams and the planned distribution of protective equipment, in a short period of time, individual medical institutions can set up a safe FUO emergency department to provide 24-hour screening and detention services. Establishing an FUO emergency department with lean management and realizing the management approach of combining daily operation with prevention and control could help China and other countries to handle the outbreak of fulminant infectious diseases.

14.
Front Med (Lausanne) ; 7: 321, 2020.
Article in English | MEDLINE | ID: covidwho-633920

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China, in December 2019 and quickly spread throughout China and the rest of the world. Many mathematical models have been developed to understand and predict the infectiousness of COVID-19. We aim to summarize these models to inform efforts to manage the current outbreak. Methods: We searched PubMed, Web of science, EMBASE, bioRxiv, medRxiv, arXiv, Preprints, and National Knowledge Infrastructure (Chinese database) for relevant studies published between 1 December 2019 and 21 February 2020. References were screened for additional publications. Crucial indicators were extracted and analysed. We also built a mathematical model for the evolution of the epidemic in Wuhan that synthesised extracted indicators. Results: Fifty-two articles involving 75 mathematical or statistical models were included in our systematic review. The overall median basic reproduction number (R0) was 3.77 [interquartile range (IQR) 2.78-5.13], which dropped to a controlled reproduction number (Rc) of 1.88 (IQR 1.41-2.24) after city lockdown. The median incubation and infectious periods were 5.90 (IQR 4.78-6.25) and 9.94 (IQR 3.93-13.50) days, respectively. The median case-fatality rate (CFR) was 2.9% (IQR 2.3-5.4%). Our mathematical model showed that, in Wuhan, the peak time of infection is likely to be March 2020 with a median size of 98,333 infected cases (range 55,225-188,284). The earliest elimination of ongoing transmission is likely to be achieved around 7 May 2020. Conclusions: Our analysis found a sustained Rc and prolonged incubation/ infectious periods, suggesting COVID-19 is highly infectious. Although interventions in China have been effective in controlling secondary transmission, sustained global efforts are needed to contain an emerging pandemic. Alternative interventions can be explored using modelling studies to better inform policymaking as the outbreak continues.

15.
J Infect ; 80(6): 656-665, 2020 06.
Article in English | MEDLINE | ID: covidwho-47365

ABSTRACT

OBJECTIVE: To better inform efforts to treat and control the current outbreak with a comprehensive characterization of COVID-19. METHODS: We searched PubMed, EMBASE, Web of Science, and CNKI (Chinese Database) for studies published as of March 2, 2020, and we searched references of identified articles. Studies were reviewed for methodological quality. A random-effects model was used to pool results. Heterogeneity was assessed using I2. Publication bias was assessed using Egger's test. RESULTS: 43 studies involving 3600 patients were included. Among COVID-19 patients, fever (83.3% [95% CI 78.4-87.7]), cough (60.3% [54.2-66.3]), and fatigue (38.0% [29.8-46.5]) were the most common clinical symptoms. The most common laboratory abnormalities were elevated C-reactive protein (68.6% [58.2-78.2]), decreased lymphocyte count (57.4% [44.8-69.5]) and increased lactate dehydrogenase (51.6% [31.4-71.6]). Ground-glass opacities (80.0% [67.3-90.4]) and bilateral pneumonia (73.2% [63.4-82.1]) were the most frequently reported findings on computed tomography. The overall estimated proportion of severe cases and case-fatality rate (CFR) was 25.6% (17.4-34.9) and 3.6% (1.1-7.2), respectively. CFR and laboratory abnormalities were higher in severe cases, patients from Wuhan, and older patients, but CFR did not differ by gender. CONCLUSIONS: The majority of COVID-19 cases are symptomatic with a moderate CFR. Patients living in Wuhan, older patients, and those with medical comorbidities tend to have more severe clinical symptoms and higher CFR.


Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , COVID-19 , China/epidemiology , Coronavirus Infections/blood , Coronavirus Infections/diagnostic imaging , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/blood , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/mortality , Risk Factors
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