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 : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : LC09 - LC14 Full Version

Clinical Characteristics and Risk Factors for Mortality in COVID-19 Patients: A Retrospective Cohort Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/49881.16335
Rahimeh Khajoei, Nabiollah Heydarpour, Reza Sadeghi, Mohadeseh Balvardi, Hamid Jafari, Sajad Shokohian, Farzad Rahmani

1. Department of Medical Emergencies, Sirjan School of Medical Sciences, Sirjan, Iran. 2. Sirjan Emergency Department, Sirjan School of Medical Sciences, Sirjan, Iran. 3. Department of Public Health, Sirjan School of Medical Sciences, Sirjan, Iran. 4. Department of Public Health, Sirjan School of Medical Sciences, Sirjan, Iran. 5. Department of Medical Emergencies, Sirjan School of Medical Sciences, Sirjan, Iran. 6. Sirjan Emergency Department, Sirjan School of Medical Sciences, Sirjan, Iran. 7. Department of Medicine, Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

Correspondence Address :
Dr. Farzad Rahmani,
Associate Professor of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
E-mail: rahmanif@tbzmed.ac.ir

Abstract

Introduction: Coronavirus Disease in 2019 (COVID-19) is globally a major factor in the mortality of patients. Hence, there is an immediate requirement to recognise the mortality predictors in the COVID-19 patients.

Aim: To identify the clinical features and risk factors for the mortality of adult patients suffering from COVID-19 in Sirjan, Iran.

Materials and Methods: In this retrospective cohort study, all demographic, clinical, laboratory data of COVID-19 patients who were admitted to hospitals of Sirjan city was collected from July to October 2020 and data was analysed in November 2020. In this period, 269 patients with COVID-19 were admitted. The findings based on the considered parameters of patients in the hospital was recorded; Univariable and multivariable logistic regression methods were applied to find the risk factors due to in hospital death.

Results: Out of 269 patients, 39 patients (14.5%) died in the hospital and the rest were discharged. A total of 152 (56.5%) patients had co-morbidity. Hypertension (HTN) was the most common underlying disease 71 (26.4%), followed by Diabetes Mellitus (DM) 55 (20.4%), cardiac disease, and Chronic Obstructive Pulmonary Disorder (COPD). The most common symptom was dyspnea 207 (77%), coughing and fever. The most common findings in the chest Computed Tomography (CT) scan of patients was ground-glass opacity with a frequency of 150 among 188 patients (79.8%) in patients with the abnormal CT scan. Multivariable regression indicated the increased odds of in hospital death associated with COPD (OR=3.20, 95% CI 1.02–10.04; p=0.046), arterial saturation of oxygen ≤93% (OR=5.70, 95% CL 2.42–13.40; p<0.001), and leukocytosis (OR=7.26, 95% CL, 3.02-17.49, p<0.001).

Conclusion: Based on the results of the present study, COPD, arterial saturation of oxygen (≤93%), and leukocytosis were risk factors for the hospital mortality of COVID-19. It might be proper for the initial determination of patients who may need life saving interventions.

Keywords

Coronavirus disease 2019, Hospital mortality, Infectious diseases, Outcome

It has been more than a year since the beginning of COVID-19. This form of viral pneumonia caused by Severe Acute Respiratory Syndrome (SARS-CoV-2) was identified as a pandemic in March 2020 (1). It led to many infections and deaths around the world (2),(3),(4),(5),(5). Globally, since 27th December 2020, 79,232,555 confirmed cases of COVID-19 were observed involving 1,754,493 deaths which were reported to World Health Organisation (WHO); also, 54,693 deaths have occurred to that date because of coronavirus in Iran (5). The outbreak and mortality of COVID-19 in Iran become a considerable public health concern.

Since COVID-19 outbreak, many studies were performed on the clinical and epidemiological characteristics of COVID-19 disease (6),(7). Moreover, many risk factors were determined in terms of severe disease and death from the disease (8),(9). Symptoms of COVID-19 in the patients were different and it might be aymptomatic in nature and/or patients with mild symptoms to patients with bilateral pneumonia and failure in organs, and COVID-19 may result in death at its severe level (10),(11),(12). The symptoms first replicate a respiratory system disorder involving fever, sore throat, dyspnea, and cough. Over time, other symptoms like vomiting, abdominal pain, headache, diarrhoea, loss of taste and smell were added to the clinical features (13),(14),(15).

Moreover, Hypertension (HTN), being the foremost common disease worldwide, was predominant among the hospitalised COVID-19 patients over diverse countries, and a few meta-analysis researches have indicated a positive relationship between HTN and COVID-19 mortality (16),(17),(18),(19),(20),(21). The results of some researches revealed that diabetes increases COVID-19 severity. Furthermore, tabulated descriptive data show that the mortality rate was higher in the patients with previous diagnosis of diabetes (22),(23),(24). In meta-analysis studies, typical Computed Tomography (CT) imaging appearance for COVID-19 patient’s revealed ground-glass opacity (25),(26). Moreover, based on laboratory findings, high C-reactive Protein (CRP), declined albumin, and high Lactate Dehydrogenase (LDH), lymphopenia, and high Erythrocyte Sedimentation Rate (ESR), were reported as the most common laboratory results.

Furthermore, based on risk factors in various research, older age, underlying diseases like HTN, diabetes, cancer, cardiovascular disease are known as the risk factors for severe disease and mortality (27),(28),(29),(30),(31). Risk factors in COVID-19 disease were reported in three other similar viral infections like influenza Influenza Type A virus (H1N1), SARS, and Middle East Respiratory Syndrome (MERS) (32),(33).

To decrease the mortality in COVID-19 patients, it is vital to distinguish the clinical characteristics and risk factors related to this infection. The present study identified the clinical characteristics and risk factors for the mortality of adult patients with COVID-19 in Sirjan, Iran.

Material and Methods

This retrospective cohort study includes all patients suspected of covid-19 who were admitted to Imam Reza and Dr. Gharazi hospitals in Sirjan / Iran between July 20, 2020 and October 22, 2020 and data was analysed in November 2020. The sampling method used was full census. In the study period, 380 suspected patients with COVID-19 who died or discharged were involved, but based on the inclusion and exclusion criteria, 269 patients were assessed. The hospitalisation of these patients was based on WHO protocol (26). The Ethical Research Committee approved this study at Sirjan University of Medical Sciences (IR.SIRUMS.REC.1399.005).

Inclusion criteria: The inclusion criteria were all COVID-19 patients with positive results on Real-Time-Polymerase Chain Reaction test (RT-PCR). A laboratory approved COVID-19 case was defined as a positive result on RT-PCR test for SARS-CoV-2 with presence in nasal and pharyngeal swab specimens.

Exclusion criteria: Patients with unapproved diagnosis,incomplete medical information in the medical records and discharges from hospital against medical advise were excluded from the study.

Study Procedure

The checklist was a standardised data collection form, an adjusted adaptation of WHO/International Serious Intense Respiratory and Rising Disease Consortium case record form for extreme intense respiratory contaminations (3). It incorporates socio-economic and clinical characteristics, research facility discoveries, and imaging highlights. All clinical and research facility information, CT filters, therapeutic history, fundamental co-morbidities, treatment measures (antiviral treatment, corticosteroid treatment, oxygen treatment, mechanical ventilation) and results from the information of patients were enrolled for all patients. Information collection was done by two staff of the medical sciences faculty of Sirjan. Then, it was evaluated by an infectious disease specialist. Patients with incomplete data were excluded from the research. Underlying diseases were recorded based on medical reports and the patient's self-report.

Disease severity was defined based on these criteria as a moderate, severe, and critical illness: Diagnostic criteria for moderate cases involved fever, respiratory symptoms, and pneumonic changes on CT scan. Diagnostic criteria for serious cases were dyspnea with a Respiratory Rate (RR) ≥30 breaths/min, Oxygen Saturation (O2Sat) ≤ 93% at rest, and chest imaging with progression in the lesion of more than 50% within 24-48 hours. Moreover, there were symptomatic criteria for the basic cases of respiratory dyspnea with the requirement for mechanical ventilation, shock, and modified function of other organs which needed hospitalisation within Intensive Care Unit (ICU) (34). Fever was characterised as a temperature at the slightest 37.3°C. Furthermore, hypotension was characterised as blood weight less than 90 mm Hg (35). A Confusion, Uraemia, Respiratory rate, Blood pressure (CURB-65) score was calculated for all patients. CURB-65 scores range from 0 to 4. A score from 0 to 1 indicates a low risk of mortality, whereas a score of 2 or higher is related to higher mortality (36).

Statistical Analysis

Data was entered into SPSS software version 19 (IBM statistics, New York, United States of America). Frequency (percentage) was utilised to explain the qualitative data. To analyse the data between two groups Chi-square or Fisher’s-exact test to assess the risk factors related to in hospital mortality of quiet univariate and multivariate calculated test were utilised. Regarding model overfitting, four variables were chosen due to past research and clinical limitations for univariate logistic tests. In all tests, a significant difference level was set as 0.05.

Results

Demographics and clinical features of the sample are indicated in (Table/Fig 1). Thirty-nine patients (14.5%) died in the hospital, and 230 patients (85.5%) were discharged from the hospital. Near half of the patients were aged more than 50 years. Gender differences were not significant. Among all patients, 152 (56.5%) of patients had an underlying disease. HTN was the most common underlying disease, followed by DM cardiac disease, and COPD. The most common symptoms at the time of admission were dyspnea, coughing, fever, and then myalgia, fatigue, and headache, respectively. The most common finding in the chest CT scan of patients was ground-glass opacity with a frequency of 150 among 188 (79.8%) patients with abnormal CT scan and 22 from 31 (71%) among the patients who died. Twenty-nine (10.8%) patients had lymphocytopenia, and 72 (28.5%) had White Blood Cells (WBC) greater than 103/L. Out of 269 patients, 175 patients (64.9%) had moderate status, 42 (15.7%) had severe, and 52 patients (19.4%) had critical status. A totol of 170 (63.6%) patients had a CURB-65 score of 0 or 1.97 patients (36.3%) had a CURB-65 score of ≥2. All deaths had a CURB-65 score ≥2.

Association between Demographic and Clinical Characteristics and In Hospital Mortality: There was an association between age and mortality in the patients (p<0.001). Moreover, there was an association among the days of hospitalisation in the healing center and mortality in the patients (p=0.001). There was an association between COPD (p=0.001) and carcinoma (p<0.020) with hospital mortality.

Based on the symptoms, there was an association among the indications of hacking (p=0.025), myalgia (p=0.001), fatigue (p=0.002), loss of consciousness (p<0.001), and hospital mortality. There was an association among the RR more than 24 per minute (p<0.001), heart rate more than 125 per minute (p<0.001), O2Sat less than 93% (p<0.001), and blood pressure less than 90 mmHg with hospital mortality (p<0.001). There was an association among laboratory findings of leukocytosis (p<0.001), lymphocytopenia (p=0.001), and death in patients. There was an association between CURB-65 score and mortality in the patients (p <0.001).

Risk factors associated with in hospital mortality: Based on (Table/Fig 2), risk factors are related to in-hospital mortality. In univariable analysis, lymphopenia were associated with hospital mortality. The hospital mortality odds were also higher in the patients with COPD. Moreover, there was an association among the clinical symptom loss of consciousness with hospital mortality. The mortality was higher in the patients with a RR of more than 24 breaths per minute and O2 saturation less than 93%. In the multivariable logistic regression model, we found that COPD (OR=3.20, CI:1.02-10.04), O2Saturation less than 93%, and leukocytosis were associated with the increased odds of mortality.

Discussion

Total 269 patient’s data were evaluated in this retrospective cohort study. Thirty-nine patients died, and the mortality rate was 14.5%. This rate is less than the meta-analysis study by Young L et al., (16.3%) but some studies showed rate more than this study (4.3%) (8),(9),(12),(15).

This retrospective cohort study identified several risk factors for death in the hospitalised COVID-19 patients in Sirjan. COPD, O2 saturation less than 93%, and leukocytosis were associated with the increased odds of the mortality of patients with COVID-19. WHO has determined COPD as the third leading reason of death in low and middle income countries (27). A meta-analysis also found that pre-existing COPD is a risk factor in predicting the adverse consequences in COVID-19 patients (28). Moreover, in a study by Nandy K et al., there was a considerable association between COPD and the occurrence of serious events in COVID-19 patients (29). In the study by Lippi G et al., the mortality rate of COPD patients with COVID-19 was over 60% (30). It is a considerable finding regarding the high prevalence of COPD worldwide. In clinical settings, necessary measures should be taken to advance patient assessment and management with COPD.

An increase in white blood cells was another risk factor that was identified. The results of a meta-analysis study by Yamada T et al., indicated that leukocytosis was associated with severe disease and leukocytosis at admission may predict severe COVID-19 and poor outcomes in these patients (31). Furthermore, in the study of Huang C et al., leukocytosis was determined as one of the risk factors for mortality in the patients with COVID-19 (13).

More than half of the patients had an underlying disease. The results were greater than the findings of another study (32). Based on recent systematic reviews, co-morbidities prevalence in COVID-19 patients was high, and these co-morbidities were associated with increased disease severity (33). In similar studies, HTN was the most prevalent disease (33),(34),(35),(36),(37),(38). There was no association between HTN and mortality in this study. While some research noted that HTN should be considered an independent risk factor for COVID-19 severity, this tip should be considered the high prevalence of HTN in critical patients with COVID-19 may be due to older individuals vulnerability to the infection of SARS-COV-2 which is affected by HTN. There is no epidemiologic evidence to indicate HTN as an independent risk factor to increase intense disease in the patients with COVID-19. Similar to this study, the study by Shibata S also reported that HTN does not constitute as a risk factor for COVID-19 (39).

In a similar research, 20% of all patients had DM, and this condition is determined after HTN as the most prevalent underlying disease (13),(40). Another research found that diabetes was associated with mortality, severity, and acute respiratory distress syndrome in COVID-19 (41). Despite being determined as the second most common underlying disease there was no association between DM and mortality in the patients with COVID-19 in the index research; and it contradicts the results of the meta-analyses that found DM is considerably associated with the mortality in COVID-19 patients (41),(42),(43). Despite this, it is recommended that patients with DM should manage their blood sugar to decrease the risk of infection.

Similar to the present research, cancer was considerably associated with mortality in other studies (27),(44). COVID-19 infected cancer patients encounter with the risk of mechanical ventilation or ICU hospitalisation 3.5 times more than the general population (45).

As in other similar studies, the most prevalent symptoms of disease in the patients were dyspnea followed by coughing, fever, myalgia, and fatigue (13),(33),(38),(46). In addition to common respiratory symptoms, the symptoms of chest pain, headache, diarrhoea, nausea, dizziness, and vomiting were also obvious in some patients. In addition to considering respiratory symptoms in patients, non respiratory symptoms should also be regarded. Other studies showed an association among the symptoms of coughing, myalgia, fatigue, loss of consciousness, and hospital mortality (1),(47),(48). In the present research, 47.2% of all patients and 51.3% of patients with mortality had fever. Fever isn’t a significant clinical symptom to COVID-19 from January 25th, 2020 (49). Similar to this research, the prevalence of ground-glass opacity in chest CT scan was higher than of the other signs of bilateral pulmonary infiltration and consolidation (33),(50). Moreover, these results were consistent with the results of meta-analysis studies by Bao C et al., and Kim H et al., (16),(51).

The mortality rate was greater in the elderly (over 70 years old). Hence, age is determined as a considerable risk factor in COVID-19 patient mortality. In fact, older age is associated with failure in different organs, which exacerbates the risk of being infected (50). More prevalence of cardiovascular diseases, HTN, and DM in older adults is related to decrease immune defense against infections (35),(40),(47). In a meta-analysis study by Starke KR et al., there was a 2.7% increased risk per age year for disease severity. The author also noted that age related diseases are more significant than age itself, and when taking preventive measures, after adjusting for age related factors, the mild impact of age on the severity of disease must be considered (52).

Furthermore, lymphopenia was observed at 38.5% in patients who died, which was significantly higher than patients who were discharged. An important association was observed between lymphocyte counts and mortality. In the research by Zhao Q et al., lymphocyte counts in COVID-19 patients were considerably lower, and in patients with lymphopenia, the risk of developing severe COVID-19 was almost tripled (53).

Inconsistent with the results by Rodriguez-Morales AJ et al., an increase in CRP in the patients was not a considerable finding in laboratory results of COVID-19 patients (33). An increase in CTnI was seen in 20.5% of patients with mortality in the index study. Cardiovascular complications due to COVID-19 have been related to cardiac failure, arrhythmia, cardiac shock, acute myocardial infarction, and myocarditis (54),(55),(56).

In this study, total 23% of all patients, 25.6% of patients with mortality, and 22.6% of discharged patients had a positive history of smoking. Another study found no considerable association between smoking and mortality (32). Nepogodiev D et al., concluded that smoking is not a risk factor for protective factor patients with COVID-19 (47). Smoking is most prevalent among young people and they usually do not have underlying diseases, the lack of an association between smoking and mortality in patients may thus be justified.

Besides, the mortality rate in men was higher than in women; similar to another systemic review (57). The reason for in the higher mortality in men may be due to behaviors which are more common in men. Men are more likely than women to engage in risky behaviors and roles, which are more likely to be present in crowded communities and environments, increasing their risk of infection and death (57). Besides, females have the stronger innate and acquired immunity against viral infections compared to males, which is one reason for less mortality rate in females (58).

Limitation(s)

First, this research was handled as a single center form, and multicenter studies are proposed. Another limitation of the research is that it was retrospective. Moreover, incomplete laboratory data in the present research must be related to retrospective analysis nature, and also some laboratory tests were not handled for patients due to resource constraints. For a limited number of mortality patients due to death in the first hours of hospitalisation in the hospital, some considerable data were not exactly recorded.

Conclusion

The clinical characteristics of COVID-19 patients were assessed, and also the risk factors associated with its mortality were provided. There was an association between cancer, COPD, cough and shortness of breath with hospital mortality. It was found that COPD, O2 saturation less than 93%, and leukocytosis were risk factors for in hospital mortality in patients with COVID-19. These results manage the COVID-19 disease and controlling risk factors associated with mortality from the disease.

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DOI and Others

DOI: 10.7860/JCDR/2022/49881.16335

Date of Submission: Apr 12, 2021
Date of Peer Review: May 13, 2021
Date of Acceptance: Dec 23, 2021
Date of Publishing: May 01, 2022

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

PLAGIARISM CHECKING METHODS:
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• Manual Googling: Sep 02, 2021
• iThenticate Software: Mar 09, 2022 (10%)

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