Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : OC33 - OC37 Full Version

Clinical and Radiological Outcomes of Recovered COVID-19 Patients- An Observational Study during the Early Phase of Pandemic


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48871.15129
Disha Atul Padalkar, Medha Bargaje, Purwa Prakash Doke, Sarosh Gilani, Varad Nadkarni, Sanbanki Pala

1. Assistant Professor, Department of Paediatrics, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India. 2. Professor, Department of Pulmonary Medicine, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India. 3. Associate Professor, Department of Medicine, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India. 4. Intern, Department of Medicine, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India. 5. Postgraduate Student, Department of Medicine, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India. 6. Postgraduate Student, Department of Medicine, Bharati Vidyapeeth (Deemed To Be) University Medical College, Pune, Maharashtra, India.

Correspondence Address :
Purwa Prakash Doke,
Associate Professor, Department of Medicine, Bharati Vidyapeeth (Deemed To Be)
University Medical College, Pune, Maharashtra, India.
E-mail: kavisri1970@gmail.com; purwadoke@gmail.com

Abstract

Introduction: The pandemic caused by the Coronavirus Disease 2019 (COVID-19) has caused huge economic and health crisis. It is reported to have pulmonary sequelae which can overburden the healthcare systems. Survivors needing medical attention in the form of pulmonary rehabilitation should be prioritised.

Aim: To study the impact of COVID-19 infection in terms of the pulmonary and extrapulmonary sequelae.

Materials and Methods: This cross-sectional observational study was carried out at a tertiary hospital in India. Recovered COVID-19 patients who were admitted from April to July 2020 were enrolled. Participants with radiological evidence of pneumonia during hospitalisation were assessed two months post-discharge. They were evaluated for persistent symptomatology, chest radiography, Six-Minute Walk Test (6MWT). The relationship between the outcome parameters with the baseline epidemiology, laboratory and radiology were evaluated by using student t-test, Mann-Whitney U test and multivariate logistic regression analysis.

Results: Thirty participants were recruited. Their mean age was 47.93 years. Males were more than females. Persistent symptoms were reported by 17 (56.66%) and 4 (13.33%) developed pulmonary fibrosis on Chest X-Ray (CXR). Prolonged hospitalisation (mean >20 days) strongly correlated to the fibrosis (p=0.022). A fall in the finger oxygen saturation after the 6MWT was significant (p≤0.001). Higher serum levels of lactate dehydrogenase and D-dimer were associated with a more severe disease (p=0.02 and p≤0.001, respectively).

Conclusion: Convalescent phase of COVID-19 is characterised by persistent symptomatology in half of the recovered patients. Simple and inexpensive CXRs and the 6MWT can be used as the primary investigation to identify post COVID-19 patients requiring pulmonary rehabilitation in resource limited settings.

Keywords

Coronavirus disease 2019, Six-minute walk test, Peak expiratory flow rate, Pulmonary fibrosis

The first cluster of cases of the COVID-19 pandemic was reported on 31st December 2019 in Wuhan, China (1). Researchers from China have shown that the S-protein of the novel coronavirus responsible for COVID-19 is partially homologous to the S-protein of Severe Acute Respiratory Syndrome (SARS) coronavirus (2). A study from China has shown that pulmonary function defects and reduced exercise capacity occurred in SARS survivors (3). There are a number of studies describing the clinical and radiological features in symptomatic COVID-19 patients (4),(5),(6). However, there are very few studies related to the short-term outcomes (7),(8). Hence, it has remained a concern whether similar sequelae exist for COVID-19.

The COVID-19 lung disease can be identified on conventional CXR as well as chest Computed Tomography (CT). Formal cardiopulmonary exercise testing helps in identifying integrative responses of pulmonary, cardiovascular, neuropsychological, and skeletal muscle systems (9). A 6MWT is a functional exercise test (10). Systematic overviews have shown that when used as a functional walk test, it is the investigation of choice for clinical and research purposes. It reflects cardiopulmonary function that requires daily living activities than any other tests (11). As per the guidelines by the American Thoracic Society, a practice test prior to performing it is not mandatory (12).

The authors assessed the epidemiological and clinical profile at the time of COVID-19 infection with the clinical and radiological outcomes at two-month post-discharge. The hospital at which the study was done became a designated COVID-19 centre on the 14th April 2020 in the collaboration with the Pune Municipal Corporation. At the time of submission of this article, the numbers of active and cumulative cases were maximum in the state of Maharashtra (13). Additionally, COVID-19 cases in the rural and urban areas are equal in the state of Maharashtra (14).

Hence, the study was conducted to see the impact of COVID-19 infection in terms of the pulmonary and extrapulmonary sequelae. The findings will help the regional health authorities for policy making decisions. Additionally, it will help the doctors in the follow-up of these patients in rural areas where there is lack of advanced diagnostic tests.

Material and Methods

This cross-sectional observational study was carried out at a tertiary care hospital in Pune, Maharashtra, India. The duration of the study was seven months from may 2020 to november 2020. It was carried out in an 850 bedded tertiary care hospital in Pune, Maharashtra, India. The study began after the institutional Ethical Committee approval (Letter no. BVDUCMC/IEC/11).

Inclusion criteria: Patients >12-year-old with a positive nasopharyngeal Real Time-Polymerase Chain Reaction (RT-PCR) swab for COVID-19 from Government approved centres and atleast one abnormal CXR during their hospital stay were recruited.

Exclusion criteria: Patients who were not reachable telephonically even after three successive attempts.

Study Procedure

The medical records of discharged COVID-19 patients from 14th April to 14th July 2020 were reviewed from the medical records section. Various laboratory investigations like, complete haemogram, inflammatory markers e.g., Lactate Dehydrogenase (LDH), D-dimer, C-Reactive Proteins (CRP) were recorded. Out of these, 82 patients with abnormal CXRs were contacted telephonically after two months of their discharge. Amongst them, six were not reachable and 46 patients denied participation. Hence, total 30 cases were enrolled were enrolled and evaluated at the time of final follow-up.

On the day of the follow-up, the participants were asked simple questions regarding their current health status based on a pre-tested and validated questionnaire in the language best understood by them (Hindi or Marathi). They then underwent a complete clinical examination, CXR, standardised 6MWT and the Peak Expiratory Flow Rate (PEFR) estimation. Among these 30 patients, the 6MWT was not done for two as they were non-ambulatory due to Grade III bed sores and one was denied cardiac fitness due to a co-existent cardiac pacemaker. Therefore, for these three, only PEFR and CXR were done.

CXR protocols: The first abnormal CXR during hospitalisation was considered as baseline. CXRs of all patients were done at the follow-up visit. The on-duty radiologist compared the baseline and follow-up CXRs. To avoid interpersonal variation, they were reviewed by a senior radiologist with over 25 years of experience who was blinded to the study and the clinical data.

Standardised 6MWT protocol: Twenty-seven patients were evaluated by the 6MWT on follow-up visits by graduate doctors undergoing training in pulmonary medicine who were blinded to the clinical data.

PEFR protocol: PEFR were recorded with standardised and calibrated disposable peak flowmeters by the same blinded doctors before the 6MWT. Individual patient reading of PEFR was compared with their Indian reference values (15).

Data Collection

Medical records of the participants were identified. Their basic epidemiological, clinical, laboratory and radiological parameters were noted. As per the clinical management protocol: COVID-19 (version 5, 3rd July 2020) by the Government of India, patients were categorised as mild, moderate or severe disease (16).

The case definitions were as follows: Mild- laboratory confirmed cases without evidence of breathlessness or hypoxia; Moderate- laboratory confirmed cases with pneumonia but no signs of severe disease, i.e., with presence of clinical features of dyspnoea and or hypoxia, fever, cough, including SpO2 of range: 90% to 94% on room air, respiratory rate more or equal to 24/minute; Severe- laboratory confirmed cases with clinical signs of pneumonia plus one of the following: respiratory rate >30 breaths/min, severe respiratory distress, SpO2 <90% on room air.

Statistical Analysis

Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) software version 25.0. The continuous variable results were shown by descriptive statistics and the categorical variables by frequency and percentages. Group comparisons were done using the Chi-square test for categorical variables like severity and outcome categories. The student t-test was used for continuous variables with normal distribution and the Mann-Whitney U test for continuous variables with abnormal distribution. Multivariate logistic regression was applied for analysis of different dependent laboratory parameters with respect to the independent outcome variables. The Spearman’s rho correlation was used to find out the correlation between different continuous laboratory parameters and ordinal variables. Results were shown with 95% confidence. The p-value <0.05 was considered significant.

Results

A total of 30 participants were recruited with a mean age of 47.93 (±10.09) years (minimum 31, maximum 71). Amongst these, 20 (66.66%) were males. Total 22 (73.33%) required oxygen support. Initial symptoms, diseases severity, underlying co-morbidites and need of oxygen delivery devices during hospitalisation were summarised in (Table/Fig 1).

Baseline Radiological and Laboratory Findings

Peak findings on CXR during hospitalisation were noted. Baseline CXR characteristics were encapsulated in (Table/Fig 2). LDH and D-dimer were done in 22 patients as per their disease severity. The mean of LDH was 861.82 (±383.23) IU/L and of D-dimer was 1420.18 (±2511.89) ng/mL. LDH and D-dimer levels had a positive correlation to the severity of disease (Table/Fig 3), (Table/Fig 4). Abnormal value of CRP was not related to development of pulmonary fibrosis (p=0.9).

Clinical and radiological outcome on follow-up: On the follow-up visit, 17 (56.66%) volunteers were suffering from persistent symptom. The most common persistent symptom was dyspnoea on exertion which was present in 8 (26.66%) participants followed by dry cough (16.66%) and generalised weakness (13.33%). Pulmonary fibrosis on CXR was present in 4 (13.33%) in the form of reticulonodular opacities. Amongst the 17 symptomatic volunteers, pulmonary fibrosis was present in three. Additionally, one asymptomatic volunteer also had similar findings. There was no correlation between the symptoms on follow-up and pulmonary fibrosis development. There was no association seen in persistence symptomatology and the epidemiological, haematological and biochemical parameters. In comparison with the volunteers with normal CXRs on follow-up, patients with pulmonary fibrosis had required a longer duration of hospitalisation (p=0.022) as shown in (Table/Fig 5).

Twenty-seven participants performed the 6MWT. Though there were no baseline values of the 6MWT available, there was a clinically significant drop in the SpO2 before (98±1.71) and after (95.89±2.56) the test (p≤0.001). Six patients (22.22%) exhibited ≤95% fall in SpO2 after the 6MWT. Amongst them, five had suffered from severe disease and one from moderate. This fall in SpO2 was not related to the development of pulmonary fibrosis on CXR. Amongst the patients with normal CXR on follow-up, five showed a fall in SpO2 post-test.

Amongst the 27 volunteers, only seven (25.92%) could perform the test satisfactorily. There was no correlation between the distance covered by the participants during the 6MWT and the symptomatology on follow-up. Amongst the patients with normal CXRs on follow-up, 17 had low results for the 6MWD than their expected lower limit. However, the difference in the distance walked by the participants with severe (348.2 m±149.77 m) and non-severe (383.35 m±83.79 m) disease groups was not found to be significant. The PEFR of 15 patients (50%) on follow-up was below the 10% of their expected value (Table/Fig 6).

Discussion

The on-going COVID-19 pandemic has overburdened the healthcare system all over the globe. The recovery rate of COVID-19 in India as on 28th November 2020 is 93.68% (16). It is reported that the survivors of SARS epidemic (2003) had decreased functional capacity on three and six-months follow-up evaluation (17). Meo S et al., reported that the clinical manifestations of COVID-19, SARS and middle earth respiratory coronavirus are almost similar (18). Therefore, it is necessary to follow these patients for their exercise capacity, radiological outcomes and pulmonary function. This is a single centre prospective observational study to know whether similar sequelae occur in COVID-19.

There are very few studies on COVID-19 survivors to look for pulmonary sequelae and exercise capacity (7),(8). In the study from Zhengzhou University, China, patients were evaluated for their Pulmonary Function Test (PFT) and the development of pulmonary fibrosis by CT scans (7). In another study from Sun Yat-sen University, China, patients were followed with PFT, CT scans and 6MWT (8). To the best of our knowledge, this is the first follow-up study from India assessing COVID-19 patients for their daily functional status and pulmonary sequelae.

In this study, it was observed that more than half of the participants suffered from at least one persistent symptom like dry cough, dyspnoea on exertion or fatigue. This finding is similar to a study from Italy where fatigue and dyspnoea were common persistent symptoms on follow-up after six weeks (19). While Zhao Y et al., observed persistence of predominantly gastrointestinal symptoms on follow-up (7).

Due to infection control issues related to patient transport and CT room decontamination, portable CXRs were the baseline radiological investigation in our hospital during the active period of COVID-19 infection. Hence, to compare with the baseline CXRs, the authors evaluated the participants by X-rays. Though it is inferior to CT for diagnosing pulmonary fibrosis, in resource-limited situations, X-ray is the simplest and easily available investigation. All available research on follow-up studies has mainly focussed on CT scan abnormalities. This study is probably the first from India that has centred on X-ray findings of COVID-19 survivors on follow-up. It was observed that pulmonary fibrosis was present in four out of 30 participants after two months. Longer duration of hospitalisation (mean >20 days) is a risk factor for the pulmonary fibrosis development. Similarly, length of ICU stay was a risk factor in a study from Lombardy, Italy on 1300 patients (20). Interestingly, a few participants with normal CXR also had a fall in SpO2 after the 6MWT. There is also another study that has reported impaired lung function test results with normal CT imaging (8). This may signify pathological processes other than fibrosis like microvascular changes in pulmonary circulation interfering with oxygenation. Autopsy findings of COVID-19 patients have vascular microthrombi in diffuse areas of alveolar damage which are associated with endothelial damage (21).

The 6MWT is useful to assess the cardiopulmonary function, muscle strength and nutritional status (12). There is a decrease in the functional activity as authors observed that fall in SpO2 after the 6MWT is significant. However, there was no significant drop in SpO2 in the study from Germany on 33 patients (22). For these controversial findings, more studies with larger sample size are needed. In the previous study from Sun Yat-sen University, there was a difference in the 6MWD in severe and non-severe disease groups (8). Their finding was different from findings in this study. This difference might be due to the timing of follow-up and small sample size. Their study was done in the early convalescent phase in 57 patients while in this study 30 patients after 2 months were followed.

Patients who had a fall in SpO2 after 6MWT and who were unable to walk the expected distance for their age, sex and BMI are candidates for further detailed assessments like PFT and cardiopulmonary stress tests.

Authors compared the values of individual PEFR with the Indian reference values (23). The PEFR of 50% patients was below the expected values. Baseline values of individual PEFR were not available with us to compare. But this shows that some patients may develop pulmonary dysfunction. COVID-19 patients can develop restrictive, obstructive or combined pulmonary dysfunction (8). Though PEFR do not differentiate types of pulmonary dysfunctions, it helps to identify those with abnormalities where detailed PFTs are not available.

Increased levels of serum LDH and D-dimer were associated with the severity of the disease which is consistent with previous studies (24),(25),(26). There was no correlation between the increased D-dimer values during active infection and follow-up CXR abnormalities. This is unlike the findings from the study of Henan Province. This difference is due to the higher sensitivity of CT for diagnosing pulmonary fibrosis than CXR and their larger sample size (7).

Though the 6MWT is not ideal for testing exercise capacity, though it can be easily performed at an outpatient clinic without any sophisticated instruments by a clinician. As it is a subjective test, patients also get insight of their health status. In countries like India, where the healthcare system is already exhausted due to the on-going pandemic, such simple tests can specify individuals who require medical attention post discharge. Advanced imaging modalities like CTs are not available in the rural parts. Majority of the Indian population is from the rural areas, where CXR is cheap and easily available to identify pulmonary pathologies. In a study from Egypt, CXR has been a helpful modality on follow-up assessment (27). The combined use of 6MWT and CXR will guide physicians while managing COVID-19 recovered patients in their follow-up visit. It was found that there were patients with normal CXR but their 6MWT result was unsatisfactory either in the terms of desaturation or unable to walk the expected distance. In such patients, pulmonary rehabilitation is needed subsequently even in the absence of pulmonary pathology on CXR. Therefore, it is important to follow all patients with COVID-19. This is because the asymptomatic ones might also have decreased functional capacity or pulmonary fibrosis. Such individuals may require further investigations and pulmonary rehabilitation.

Limitation(s)

First, the sample size was small. Secondly, there was missing data as LDH and D-dimer were done only in moderate and severe disease. Baseline values of these inflammatory markers were not available.

Conclusion

This study demonstrated that persistent symptoms are experienced by COVID-19 patients even after 2 months. Even in the absence of persistent symptoms on follow-up, some patients were not able to maintain the SpO2 after simple exercises like walking. The 6MWT and CXR can be easily and effectively used as a primary investigation for those who need pulmonary rehabilitation. This approach will short list the patients in need of detailed studies like pulmonary function and cardiopulmonary stress tests, decreasing the unnecessary workload on the healthcare.

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DOI and Others

10.7860/JCDR/2021/48871.15129

Date of Submission: Feb 05, 2021
Date of Peer Review: Mar 12, 2021
Date of Acceptance: May 11, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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