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

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On Sep 2018

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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.
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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.
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Aug 2018

Dr. Rajendra Kumar Ghritlaharey

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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.
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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.
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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 : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : UC22 - UC26 Full Version

Factors Associated with Mortality among COVID-19 Patients Admitted in an Intensive Care Unit at a Tertiary Care Setting: A Retrospective Study from Mizoram, India

Published: January 1, 2022 | DOI:
Lalnunmawii Sailo, Lalnundiki, Saidingpuii Sailo, Micky Zodinpuia, Ganesh Shanmugasundaram Anusuya, Israel Lalramthara, Zoengmawia

1. Associate Professor, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India. 2. Assistant Professor, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India. 3. Assistant Professor, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India. 4. Associate Professor, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India. 5. Associate Professor, Department of Community Medicine, Zoram Medical College, Falkawn, Mizoram, India. 6. Senior Resident, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India. 7. Senior Resident, Department of Anaesthesiology and Intensive Care, Zoram Medical College, Falkawn, Mizoram, India.

Correspondence Address :
Dr. Ganesh Shanmugasundaram Anusuya,
Associate Professor, Department of Community Medicine, Zoram Medical College,
State Referral Hospital, Falkawn-796005, Mizoram, India.


Introduction: Characteristics of Coronavirus Disease-2019 (COVID-19) patients from different tertiary centres in India are beginning to be enumerated with limited data on critically ill patients admitted in Intensive Care Units (ICU), with low SpO2 levels.

Aim: To describe clinical profile and identify the factors associated with mortality among COVID-19 positive patients admitted in ICU at a tertiary care setting in Mizoram, India.

Materials and Methods: A retrospective study was conducted in Zoram Medical College, Mizoram, India, among 55 confirmed COVID-19 patients admitted in ICU between March 2020 and March 2021. All the patients admitted in ICU during the period was included in the study. Demographic data, symptoms, co-morbidity, investigations, ventilation required, treatment given, duration of ICU stay, and outcomes were recorded from case sheets. The primary outcome was inpatient mortality. Secondary outcomes included length of ICU stays, SpO2 levels, need for oxygen support. The p-value was set at <0.05 analysed using coGuide software.

Results: The mean age was 56.47±15.24 years, and 38 (69.1%) participants were males. Most of 45 (81.8%) participants survived, and 10 (18.2%) patients died in ICU. The mean length of ICU stay was 7 (4 to 13) days in the survival group and 13 (7.5 to 17) for non survivors. The mean SpO2 levels at the time of admission were 95% (90 to 97) in survivors and 80% (72.25 to 95.50) among non survivors. Following admission to ICU, 16 (29.1%) patients required intubation, High Flow Nasal Cannula (HFNC) was given to 2 (3.6%), and oxygen support (non rebreather mask) was required in all 55 (100%) patients. Pharmacological treatment included empiric antibiotics in 51 (92.73%), antiviral in 30 (54.55%), steroids in 45 (81.8%), Ivermectin in 21 (38.2%), and low molecular weight heparin in 36 (65.5%) patients. Binary logistic regression analysis found low SpO2 levels at the time of admission (CI:0.85-0.97, p-value=0.008), hypotension (p-value <0.001), tachycardia (p-value=0.001), use of remdesivir (odds ratio 14.82, 95% CI:1.72 to 127.52), use of tocilizumab (odds ratio 14.33, 95% CI: 2.14 to 95.85) and use of meropenem (odds ratio 8.00, 95% CI: 1.51 to 42.45) were significantly associated with in-hospital mortality.

Conclusion: Oxygen saturation below 90%, hypotension, and tachycardia, at the time of admission in ICU were considered as predictors of in-hospital ICU mortality in COVID-19 patients. The reason for low mortality among patients admitted in ICU can be attributed to early admission to ICU and care when SpO2 reading has reached 94%.


Coronavirus disease-2019, Critical care, Hypotension, Oxygen saturation, Tachycardia

In 2019, more than 13 million people were diagnosed with Coronavirus Disease-2019 (COVID-19) worldwide, since it was first identified in China (1). Almost one-third of the hospitalised patients with COVID-19 are admitted to the Intensive Care Units (ICU) (2). The agent causing Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV 2) is COVID-19 and the disease is responsible for the largest pandemic since the Spanish flu pandemic in the early twentieth century. Optimised support is the most important factor in the patient’s prognosis, as there is no specific antiviral treatment (3).

The first COVID-19 case in India was reported in January 2020, and gradually the incidence of disease increased extensively by May. By mid-October 2020, India has emerged as the second most affected country globally after the United States of America (USA) with 7.3 million cases and a mortality rate of 1.7% (4). The infection in India is widely prevalent with predominant asymptomatic individuals. Lack of adequate health resources has caused complications to set in, thus increasing the admission of COVID-19 patients to ICU (5).

Patients with COVID-19 usually present with fever, myalgia, non productive cough, and progressive shortness of breath. In moderate to severe cases, signs of organ dysfunction, such as Acute Respiratory Distress Syndrome (ARDS), acute kidney injury, pulmonary oedema, myocarditis, septic shock, and deaths, can occur (6). Based on the clinical symptoms and laboratory test results, patients are categorised as mild, moderate, severe, and critical. Mild/moderate cases include most of the affected patients (81%). Although, severe and critical ones comprise only 14% and 5% of infected subjects, they require hospitalisation. Almost 20% of hospitalised patients need ICU. The mortality rate of ICU admitted COVID-19 patients are reported to be relatively high. Nearly, 61.5% die due to many different reasons (7).

A previous single-center retrospective study among proven COVID-19 pneumonia admitted to Dubai hospital, United Arab Emirates, by Nadeem R et al., reported that survivors spent more days in the ICU and the hospital than non survivors {median 18 (6.5-29.5) vs. 11 (4-18), p-value 0.003} (8). Another retrospective study among COVID-19 ICU patients by Anudeep A et al., in India concluded that patients treated with antivirals had a better outcome (9). The mean length of ICU stay was 9.2±3.7 days, and the mortality rate was 38%.

Current evidence-based literature was conducted only on epidemiological characteristics, clinical profile, and preventive measures of COVID-19. However, studies on clinical profiles and outcomes of critically ill COVID-19 patients admitted to ICU in India are very limited.

Coronavirus disease-2019 fatality rates might be significantly different, prompting researchers to seek more information about the characteristics and treatments of COVID-19 patients in ICUs. An in-depth analysis of related data may help develop more effective treatment protocols for future severe patients. Here we described clinical characteristics, treatments, and outcomes of confirmed COVID-19 patients admitted to the ICU of a tertiary hospital.

During the period from March 2020 to March 2021, Mizoram has recorded the least COVID-19 deaths in whole of India. Hence, it is of utmost importance to study the clinical profile and reasons for low mortality among COVID-19 patients admitted in ICU.


1. To determine the clinical profile of acutely ill COVID-19 positive patients admitted in an ICU at a tertiary care setting.
2. To identify factors associated with mortality among COVID-19 patients admitted in ICU.

Material and Methods

A retrospective study was conducted in the Department of Anaesthesiology and Intensive Care of Zoram Medical College, Mizoram, India. The study was conducted for a period of one year, from March 2020 to March 2021. Institutional Ethics Committee approval was obtained from the Institutional Ethical Committee board of concerned tertiary care setting (No.F.20016/1/18-ZMC/IEC). As the data was collected retrospectively, patient’s consent form was not needed. COVID-19 positive patients were the source population, and patients admitted in the COVID-19 ICU were selected as the study population.

Sample size calculation: The proportion of ICU admission in COVID-19 patients was assumed as 58% as per the study by Grasselli G et al., (10). Absolute precision was 15% and 95% confidence level. The formula was used for sample size as per the study by Daniel WW (11).

N = Z2p(1-P) / d2

Where, n=sample size

Z=statistic for a level of confidence level=1.960

P=Expected prevalence/proportion of outcome=0.58


As per the calculation mentioned above, the required sample size was 42. Considering non participation rate of about 20%, eight subjects were added. With this, the final sample size was 50. Total 55 samples were considered in the final study. A convenient sampling technique was used.

Inclusion criteria

• COVID-19 positive patients age ≥18 years of both genders.
• COVID-19 Reverse Transcription Polymerase Chain Reaction (RT-PCR) positive and Rapid Antigen Test (RAT) positive.
• High-Resolution Computed Tomography (HRCT) chest which was suggestive of COVID-19.
• Acutely ill COVID-19 patients admitted in ICU.

Exclusion criteria

Non COVID-19 patients admitted with respiratory problems were excluded from the study.

Data Collection

Case sheets of COVID-19 patients admitted to the ICU between March 2020 to March 2021 from the medical records division were used to collect data. Demographic data, symptoms on presentation, vitals on presentation, co-morbidities, investigations, ventilation required, treatment given, complications, procedures, duration of hospital stay and course of ICU stay, and outcomes were recorded. Baseline Electrocardiogram (ECG), COVID-19 RT-PCR, HRCT-Chest, and Computed Tomography (CT) severity, {COVID-19 Reporting and Data System (CO-RADS) for use in the standardised assessment of pulmonary involvement of COVID-19 on unenhanced chest CT images} were done in all the cases. All laboratory tests, including RT-PCR for confirming COVID-19, were performed at the concerned tertiary care setting (12).

Pharmacological treatment included empiric antibiotics, antiviral, steroids, Ivermectin, and low molecular weight heparin in COVID-19 patients. The therapy was followed as per pharmaco immunomodulatory therapy in COVID 19 and the treatment protocol followed in COVID-19 Dexamethasone (CoDEX) randomised clinical trial in Brazil (13),(14).

Study variables: The primary outcome was inpatient mortality. Secondary outcomes included length of ICU stays, SpO2 levels, need for oxygen support.
Statistical Analysis

Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency, and proportion for categorical variables. For normally distributed quantitative parameters, the mean values were compared between study groups using an independent sample t-test (2 groups), and non normally distributed parameters were compared between study groups using the Mann-Whitney U test. Wilcoxon rank test was used to compare SpO2 between admission and discharge. Uni variate binary logistic regression analysis was performed to test the association between the explanatory variables and outcome variables. An unadjusted Odds ratio along with 95% Confidence Interval (CI) was presented. p-value <0.05 was considered statistically significant. IBM Statistical Package for the Social Sciences (SPSS) was used for statistical analysis version 26 (IBM Corp., Armonk, NY, USA) (15).


The study included 55 COVID-19 positive patients, with a mean age of 56.47±15.24 years (ranging 25-93 years), and included 38 (69.1%) males. Upon presentation, 19 (34.5%) had a high fever, and 41 (74.5%) participants had low SpO2 levels. Out of 55 patients, 45 (81.8%) survived, and 10 (18.2%) patients died in ICU (Table/Fig 1).

Following admission to ICU, 16 (29.1%) patients required Intubation, HFNC was given to 2 (3.6%), and oxygen support (non rebreather mask) was required in all 55 (100%) patients. Pharmacological treatment included empiric antibiotics in 51 (92.73%), antiviral in 30 (54.55%), steroids in 45 (81.8%), Ivermectin in 21 (38.2%), and low molecular weight heparin in 36 (65.5%) patients (Table/Fig 2).

Overall inpatient mortality was 10 (18.2%) in the present study. The median length of ICU stay was 7 (4 to 13) days for survivors and 13 (7.5 to 17) for non survivors. The median SpO2 levels on admission were 95% (90 to 97) in survivors and 80% (72.25 to 95.50) among non survivors. Binary logistic regression analysis found low SpO2 levels at the time of admission (CI:0.85-0.97, p-value 0.008), hypotension (p-value <0.001), tachycardia (p-value 0.001), use of remdesivir (odds ratio 14.82, 95% CI:1.72 to 127.52), use of tocilizumab (odds ratio 14.33, 95% CI:2.14 to 95.85) and use of meropenem (odds ratio 8.00, 95% CI:1.51 to 42.45) were significantly associated with in-hospital mortality (Table/Fig 3),(Table/Fig 4).


According to the author’s knowledge, this is the first study from their tertiary care centre that reported the clinical profile of COVID-19 positive patients admitted in the ICU.

The mean age was 56.47±15.24 years in this study, and 38 (69.1%) participants were males. The finding can be compared to a single-center, retrospective, observational study by Yang X et al., in China, where the mean age was 59 years, 27 (52%) were older than 60 years, and 35 (67%) patients were men out of 52 (16). The present study observed that non survivors 63.9±17.86 years were more senior than survivors 54.82±14.29 years. Based on previous studies, evidence suggests that older male patients are the most susceptible to COVID-19, which present study data supports (17).

Following admission to ICU, 51 (92.73%) received antibiotic treatment, 45 (81.8%) received steroids, 30 (54.55%) received antiviral, 16 (29.1%) patients required Intubation, and all 55 patients support of oxygen needed (non rebreather mask). These findings were following retrospective manual medical record review by Argenzian MG et al., in New York, where overall, 64.9% (552/850) of patients required in-hospital antibiotic treatment, 543 (63.9%) out of 850 patients received hydroxychloroquine, 222 (94.1%) out of 236 of patients received vasopressors, 220 (93.2%) were intubated at least once, and 174/236 (73.7%) required supplemental oxygen (18).

The majority of 45 (81.8 %) survived, and 10 (18.2%) patients died in ICU. The median length of ICU stay was 7 (4 to 13) days in the survival group and 13 (7.5 to 17) days for non survivors. This finding was similar to a cross-sectional study by Kokoszka-Bargiel I et al., in Poland, where 27 out of 32 patients completed their ICU stay during the observation period (19). The mean ICU stay was 12.7 (9.7) days (1 h to 41.4 days). ICU mortality was 67%. Hospital mortality and those disqualified were 70% and 79%, respectively. The present study’s survival rate was 80%, similar to a recent study by Weiss P, where the survival rate was nearly 70% (20).

During stay in ICU, the COVID-19 patients had high fever 19 (34.5%), bradycardia 16 (29.1%), drowsiness 5 (9.1%), atrial fibrillation 3 (5.5%), and 41 (74.5%) participants had low SpO2. The majority of 28 (50.9%) participants had diabetes, and 14 (25.5%) were hypertensive. These findings can be related to a retrospective study by Aggarwal S et al., in the United States where out of 42, fever was reported by 15 (94%) patients, 9 (56.3%) had a history of hypertension, 3 (19%) had a history of coronary artery disease, 3 (19%) had a history of congestive heart failure, and 2 (13%) had a history of stroke, 5 (31%) patients were tachycardic, 6 (38%) patients were hypoxemic, and none of the patients were hypotensive (21).

In the present study, the mean SpO2 levels on admission were 91.82±8.21% which increased to 98.29±2.80% during discharge among patients who survived. The median SpO2 levels on admission were 95% (90 to 97) in survivors and 80% (72.25 to 95.50) among non survivors. The finding was following a retrospective cohort study by Mejía F et al., in Peru, where oxygen saturation (SaO2) on admission was generally low with a median of 87% (IQR: 77-92) and (28.46%), patients were admitted with oxygen saturation (SaO2) below 80% (22). The oxygen saturation (SaO2) levels on admission was less in deceased patients than discharged patients (78% vs. 91%, p-value <0.001). The findings suggest that a maximum of patients were hospitalised too late after developing significant hypoxaemia, resulting in higher mortality. The challenging context of the “silent hypoxaemia” that many COVID-19 patients experience early in the disease should be recognised faster in the community setting for timely management of patients (23).

As previously studied in children (24), the importance of hypoxaemia as a predictor of mortality includes other lower respiratory infections elsewhere COVID-19. Timely detection of hypoxaemia, strategies such as use of pulse oximeters to monitor for hypoxaemia, is needed. These pulse oximeters are now relatively inexpensive and widely available in primary and community care facilities (25).

Exploratory analysis showed that for settings where pulse oximeter use in the community would not be feasible, measuring tachypnoea could be an alternative predictive factor on mortality, which is also inexpensive and straight forward (26). As this is a matter of concern involving the public’s health, more hospital beds and increased availability of supplemental oxygen should be upgraded to meet the expected increase in demand for the early care of hypoxaemia. Patients with alarm signs should be quickly identified and transferred to the hospital with the help of a robust call centre and ambulance system.

Patient characteristics across different regions are required to enable better clinical awareness and allocation of medical resources. There is paucity in literature describing the clinical features of ICU hospitalised patients infected with COVID-19, especially outside of major metropolitan areas. The present study will encourage other hospitals to publish their experiences, not only from significant university hospitals but also from smaller and middle-sized community institutions. The main strength is that population and setting are both representatives of care for COVID-19 patients. The data added evidence to existing literature and can help in timely management of COVID-19 patients at a referral centre.


As the study was the retrospective study, results should be interpreted cautiously. It was a single-centre study, and the findings cannot be generalised to the overall population. Further, extensive prospective multicentric studies are needed to support the present study’s findings to provide insights into this ongoing pandemic globally.


In conclusion, the mortality of critically ill patients with COVID-19 is high. The survival time of the non survivors was likely to be within two weeks after ICU admission. The median SpO2 levels on admission were more in survivors compared to non survivors. Identifying risk factors associated with non survivors could help in risk-stratification and in-time management of COVID-19 positive patients. The key to successful management of COVID-19 patients is to admit the patients in ICU when SpO2 reading reaches the level of 94% and start early treatment.


The authors would like to acknowledge all the Doctors, staff, and paramedical staff of Zoram Medical College, Mizoram, for their tireless service done in times of this COVID-19 Pandemic.


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DOI and Others

DOI: 10.7860/JCDR/2022/52500.15860

Date of Submission: Sep 23, 2021
Date of Peer Review: Oct 21, 2021
Date of Acceptance: Dec 03, 2021
Date of Publishing: Jan 01, 2022

• 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? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Sep 27, 2021
• Manual Googling: Dec 01, 2021
• iThenticate Software: Dec 27, 2021 (24%)

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