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

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
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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
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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.
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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
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,
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,
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
(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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : OC48 - OC51 Full Version

Impact of Co-morbidities on Outcome of COVID-19 Patients: An Observational Study among Patients Admitted to Intensive Care Unit

Published: July 1, 2021 | DOI:
Hemant Kumar, Sumeet Dixit, Nikhil Gupta, Preeti Gupta, Manoj Kumar Pandey, Shobhit Shakya, Amiya Kumar Pandey

1. Associate Professor, Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 2. Assistant Professor, Department of Community Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 3. Assistant Professor, Department of General Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 4. Assistant Professor, Department of Ophthalmology, Hind Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 5. Senior Resident, Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 6. Associate Professor, Department of General Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 7. Senior Resident, Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Preeti Gupta,
Faculty Residential Apartments, Dr Ram Manohar Lohia Institute of Medical Sciences, Vibhutikhand, Gomti Nagar, Lucknow, Uttar Pradesh, India.


Introduction: Coronavirus Disease-2019 (COVID-19) has been a major cause of apprehension, morbidity, and mortality in 2020. It had been postulated that associated co-morbid conditions in COVID-19 patients increase the severity of COVID-19 which leads to six times more chances of hospitalisation than patients without co-morbid condition. Mortality is also 12 times higher in such patients.

Aim: To find out the association between co-morbidities and mortalities due to COVID-19 pneumonia.

Materials and Methods: A prospective, observational study was conducted in a tertiary teaching institute of North India which was designated Level 3 (L-3) facility for treatment of COVID-19 patients. All 109 COVID-19 patients confirmed by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR), admitted in Intensive Care Unit (ICU) from 1st July 2020 to 30th November 2020 formed the sample of the study. Data was taken regarding past history, clinical histories and examinations and ICU care and treatments. Based on their final outcome at the end of ICU care, patients were divided into two groups-group 1 (Non-survivor or Expired) and group 2 (Survived) and intergroup differences were studied.

Results: COVID-19 infection was about three times more common in males. Severe category of COVID-19 patients had higher mortality (59.2% of severe category expired during hospital course, 1.7% patients expired in moderate category group). Most common co-morbidities were hypertension (n=51, 46.8%) and diabetes (n=48, 44%). Multivariate analysis showed that co-morbidities in the form of chronic liver disease (OR -0.127 (0.024-0.681, p-value 0.016)) and post tubercular sequel (OR 0.036 (0.003-0.442, p-value 0.009)) were less likely to occur in COVID-19 patients who survived, thus making these co-morbidities significant contributor to the adverse outcomes in COVID-19 patients. More number of co-morbidities in a patient were associated with higher chance of mortality and this trend was significant statistically (p-value <0.001).

Conclusion: Patients with multiple co-morbidities, chronic liver disease and post tubercular sequel were associated with higher mortality in COVID-19 patients.


Chronic liver disease, Coronavirus disease-2019, Mortality, Pneumonia, Severe acute respiratory syndrome coronavirus-2

COVID-19 has been a major cause of morbidity and mortality in 2020. It was first detected in December 2019 as clusters of unexplained pneumonia with similar clinical characteristics in Wuhan, a city in the Hubei Province of China. COVID-19 infection remains asymptomatic in 40-45% patients but these asymptomatic patients can transmit infections to other persons (1). Around 55-60% patients are symptomatic, among them approximately 80% are mild, 15% severe and 5% are critical who have respiratory failure, sepsis, multiorgan failure etc. Case Fatality Rate (CFR) due to COVID-19 is different in different sub-groups. Case fatality in COVID-19 patients increases with increase in severity; it is as high as 50% in critical patients. Mortality is also high in patients who have co-morbidities like diabetes, hypertension, Chronic Kidney Disease (CKD), hypothyroidism etc., (2).

Several theories have been given to explain mechanism of severity and mortality. There is an increase in expression of Angiotensin-Converting Enzyme 2 (ACE-2) receptors on target organs including the cardiovascular system, kidneys, lungs and brain (3) especially in co-morbid conditions. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), which causes COVID-19, attaches to these receptors and downregulate it which leads to vasoconstriction, tissue ischaemia and regulate and renal remodelling. This is also one of reason that patients died with multiorgan failure in COVID-19 (4). Other mechanism of complication is release of pro-inflammatory cytokines especially in immunocompromised individuals like diabetics, CKD patients etc., which increase inflammation in various organs like plaque rupture in coronary artery, Acute Respiratory Distress Syndrome (ARDS) in lungs, generalised hypercoagulability which leads to micro thrombi, ischaemia and tissue necrosis (5). Diabetes is one of most common non communicable disease all over world. Diabetes causes excessive inflammation and also release tissue injury related enzymes which causes excessive morbidity and mortality in COVID-19 (6). Chronic liver diseases like chronic viral hepatitis, liver cirrhosis, non-alcoholic fatty liver disease are not associated with an increased risk of acquiring COVID-19 infection in the absence of immunosuppressive therapy but these patients have high risk to get severe illness from COVID-19 (7). Associated co-morbid conditions increase severity of COVID-19 which leads to six times more chances of hospitalisation than patients without comorbid condition. Mortality is also 12 times higher in such patients (8). Multiple co-morbidities in patients with COVID-19 increases immunosuppression which leads to increased viral replication hence causes severe pneumonia which leads to a higher mortality rate in these patients as compared to patients with no or lesser number of co-morbidities (9).

As prevalence of non-communicable diseases like diabetes, hypertension, cardiac diseases, liver diseases, chronic pulmonary diseases are increasing worldwide so this study was planned to see association of co-morbidities with mortality in COVID-19 patients.

Material and Methods

This prospective, observational study was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences (Dr. RMLIMS), a tertiary teaching institute of Lucknow, Uttar Pradesh, India which was a designated L-3 facility for treatment of COVID-19 patients from 1st July 2020-30th November 2020. Ethical approval was taken from the Institutional Ethics Committee (IEC No.63/20). Informed consent was taken from the patients/family members.

Inclusion criteria: All the patients with moderate to severe COVID-19 pneumonia who were admitted to ICU facility of COVID-19 hospital of the present study, during the study time period were included in the study after obtaining informed consent from patients/family members.

Exclusion criteria: Patients aged <18 years, suffering from other ailments and also non-COVID-19 patients where cause death of patient is different and pregnant females were excluded from the study.

COVID-19 pneumonia was classified according to respiratory rate and oxygen saturation as mild pneumonia (RR <24/min and SpO2 >94%), moderate pneumonia (RR 24-30/min, SpO2 90-94%) and severe pneumonia (RR >30/min, SpO2 <90%) (10). Total 130 patients, who were in the ICU during the study duration, were screened for study but 21 patients were excluded due to unavailability of complete data. A 109 patients were included and analysed in this study. All patients were given appropriate treatment according to ICU protocol. Detailed data was collected including present condition, past history and other relevant clinical history. Detailed data regarding comorbidities were also collected.

Based on their final outcome at the end of ICU care, patients were divided into two groups.

Group 1 (Non-survivor or Expired): This group included those patients who died during hospital stay.

Group 2 (Survived): This group included all those patients who survived during hospital stay and were discharged after recovery.

All demographic, clinical and co-morbidity data were compared between survivor and non-survivor groups.

Statistical Analysis

Discrete data were analysed by cross tables using descriptive method. Univariate and multivariate logistic regression was applied to see the impact of co-morbidities on adverse outcomes in COVID-19 patients. The p-value <0.05 was considered as statistically significant association.


A total of 109 COVID-19 patients admitted in ICU were analysed. Out of 109 patients, 79 survived and were discharged successfully while 30 patients expired during hospital stay. Co-morbidities were analysed in all 109 patients and compared in both groups.

Mean age of patients in survived group and expired group was 56.1 years and 58.9 years, respectively. Higher mortality was seen in elderly as they had more comorbidities and lower immunity. COVID-19 infection was about three times more common in male population as compared to female population. This trend may be because males do outside work more frequently than females hence more chance of exposure. Severe category of COVID-19 patients had higher mortality. Around 59.2% of severe category patients expired during hospital course while only 1.7% patients expired in moderate category group. Most common presenting symptoms were fever, breathlessness and cough. These three symptoms constituted >60% of all COVID-19 patients’ symptoms. Clinical signs like respiratory rate were higher (>30/ min) in expired group as compared to survived group (<30/min). Blood pressure was almost same in both the groups. Oxygen saturation was lower (<90%) in expired group while it was >90% in survived group (Table/Fig 1).

Maximum COVID-19 patients were in the age group of 51-60 years. This is the age group in which people have high mobility along with comorbidities. So, this age group is more vulnerable for severe disease and ICU admission. (Table/Fig 2).

Most common co-morbidity was hypertension (46.8%) in this study. It was there in 60% in expired group while 41.8% in survived group. This difference was not significant (p=0.088). Diabetes was the second most common co-morbidity present in COVID-19 patients. It was present in 45.57% of survived group and in 40% of expired patients group. Other co-morbidities were less common but more frequent in expired group as compared to survived group.

By univariate analysis, among all co-morbidities post tubercular sequel was seen significantly associated (p=0.014) with adverse outcome in COVID-19 patients. On multivariate analysis significant association was observed between chronic liver disease (p=0.016) and post tubercular sequel (p=0.009) with adverse outcome in COVID-19 Patients. (Table/Fig 3).

Number of co-morbidities per patient was higher in expired group. One, two and three or more co-morbidities were present in 20%, 23.33% and 43.33% in expired group respectively while in survived group 32.9%, 31.6% and 8.8% patients had one, two and three or more co-morbidities. Higher number of co-morbidities in a patient were associated with higher chance of mortality and this trend was significant statistically (p-value <0.001). (Table/Fig 4).


Associated co-morbidities play a significant role in severity and mortality of COVID-19 patients. In the present study, a total of 109 patients admitted in ICU were analysed. 79 patients were discharged successfully from ICU and 30 patients expired during the ICU stay. Various comorbidities were analysed in both the groups. Chronic Liver Disease and Post Tubercular sequel were significant in expired group as compared to survived group. In a retrospective cohort study by Harrison SL et al., conducted in 24 centres, they found chronic pulmonary disease and diabetes as most common co-morbidities in COVID-19 patients. Cardiac disease, chronic pulmonary diseases, chronic liver diseases and renal diseases were found as significant co-morbidities, which were associated with mortality. (11). Similar to above findings, this study also suggests post tubercular sequel and chronic liver disease as significant in expired group as compared to survived group. In the present study, cardiac disease was found more in expired group but it was not significant statistically. Docherty AB et al., analysed co-morbidities in 20133 patients in 208 hospitals of United Kingdom. Most common co-morbidities in their study were chronic cardiac disease, uncomplicated diabetes, non-asthmatic chronic pulmonary disease and CKD Chronic cardiac disease, non-asthmatic chronic pulmonary disease, CKD and chronic liver disease were found in patients who expired during hospital course (12). This was partially similar to the present study where it was also found that chronic liver disease and past pulmonary disease were significantly associated with mortality group. Henry BM and Lippi G, did a meta-analysis of four studies with total 1389 COVID-19 patients. A 273 were classified as severe disease. They found that CKD was significantly associated with severity of the disease (13). These findings were in contrast to the findings of this study as in this study coronary artery disease and post tubercular sequel was associated with severity of diseases.

Singh S and Khan A, studied COVID-19 pattern in 250 pre-existing liver disease patients and compared with 2530 COVID-19 patients without pre-existing liver disease. They found that chances of hospitalisation and mortality were higher in pre-existing liver disease cohort as compared to other group (14). These findings support the present study as chronic liver disease was associated with higher mortality in COVID-19 patients. Du RH et al., conducted a prospective cohort study to find out predictors of mortality in COVID-19 patients. They found that pre-existing cardiovascular and cerebrovascular diseases were associated with higher mortality in COVID-19 patients (15). We also found cardiac disease and cerebrovascular diseases more in expired group but this association was not significant statistically.

Mechanism of higher mortality in pre-existing liver disease is not fully explained. Possible mechanism is that there is increased expression of ACE-2 receptors on liver cells and biliary ducts. SARS-CoV-2 virus attaches to these receptors and leads to vasoconstriction in liver micro vessels which leads to further hypoxaemic injury in pre-existing liver disease (16). Pulmonary Tuberculosis causes destruction of lung parenchyma due to several mechanism and most common mechanism is fibrosis and bronchiectasis. SARS-CoV-2 also affects lung parenchyma primarily by attaching to ACE-2 receptors. Cytokine storm further damages lung parenchyma which leads to mortality in post tuberculosis sequel (17).

Mortality in COVID-19 also depends on numbers of co-morbidities present in one individual. In this study, 43.33% patients in expired group had three or more co-morbidities while only 8.8% patients had three or more co-morbidities in survived group. Onder G et al., analysed 355 patients who expired due to COVID-19 in Italy. They found that the mean number of co-morbidities was 2.7. 25.1% had one co-morbidity, 25.6% had two co-morbidities and 48.5% patients had three or more co-morbidities (9). These findings are similar to the present study where we found that percentage of patients who expired with one, two and three co-morbidities were 20%, 23.33% and 43.33% respectively. This trend of multiple co-morbidities was significant statistically in expired group than that of survived group (p-value <0.001).


Firstly the number of enrolled cases with different co-morbidities was small, which might impact the power and precision of the results. Secondly, sample size of the study was small. Thirdly, the duration and degree of control of co-morbidities in pre-covid state was not assessed.


Patients with multiple co-morbidities with COVID-19 require more vigilance as they have higher chance of acquiring severe infection and higher chance of mortality. Among the co-morbidities, patients with chronic liver disease and post tubercular sequel have graver prognosis. There was only 8.8% survival rate of patients with three or more co-morbidities. thus, timely diagnosis, early isolation and intensive monitoring could be critical to reduce the mortality in patints with co-morbidities. A larger sample size study with more details of co-morbidities, their duration and degree of control in pre-covid state, is recommended in future for better precision in the results.


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DOI and Others


Date of Submission: Jan 31, 2021
Date of Peer Review: Apr 20, 2021
Date of Acceptance: May 24, 2021
Date of Publishing: Jul 01, 2021

• 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

• Plagiarism X-checker: Feb 02, 2021
• Manual Googling: May 19, 2021
• iThenticate Software: Jun 19, 2021 (10%)

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