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 : August | Volume : 16 | Issue : 8 | Page : DC33 - DC38 Full Version

Clinical Features and Predisposing Factors Influencing the Outcome of COVID-19 in First and Second Wave at Nanded, Maharashtra- A Retrospective Study


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56227.16730
Supriya Madhavrao Emekar, Sanjaykumar Rajaram More, Rohit Sinha, Raghavendra Swamy

1. Associate Professor, Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Vishnupuri, Nanded, Maharashtra, India. 2. Professor and Head, Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Vishnupuri, Nanded, Maharashtra, India. 3. Assistant Professor, Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Vishnupuri, Nanded, Maharashtra, India. 4. Junior Resident, Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Vishnupuri, Nanded, Maharashtra, India.

Correspondence Address :
Dr. Raghavendra Swamy,
Junior Resident, Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Vishnupuri, Nanded-431606, Maharashtra, India.
E-mail: raghavendraswamyrn@yahoo.com

Abstract

Introduction: It is crucial to determine possible factors associated with exacerbation of the disease due to the alarming global spread, morbidity and mortality associated with Coronavirus Disease-2019 (COVID-19). It is important to determine the co-morbidities associated with this disease which will help in better treatment of patients in time and to make amendments to management policy.

Aim: To compare the clinical features, and predisposing factors (socio-demographic factors and co-morbidities) influencing the outcome in COVID-19 infected patients admitted in a tertiary care centre in the first and second wave of COVID-19 pandemic.

Materials and Methods: The retrospective study was conducted at the Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India. The data was collected from the electronic resource which was maintained by the institute Integrated Disease Surveillance Program (IDSP) health record reporting database for the duration of June 2020 to August 2021. This data included patient’s demographic details (age, sex, address, contact number), other details (history of close contacts, international travel) clinical history, different types of symptoms (ICMR patient category), co-morbidities, number of patients requiring ICU admission, type of sample, the outcome in terms of death and discharge, cause of death. The analysis was done for the complete data and then for two separate durations of the first and second wave which were compared later with Chi-square test (Bivariate analysis).

Results: A total of 8841 patients were involved and the majority of patients in the study were between the age group of 30-75 years, there was a predominance of males in first and second waves with 6514 (73.7%) and 5795 (58.6%) respectively. The paediatric patients had a mortality rate of 100% (n=7) found in the second wave. Fever (39%) and dyspnea (22%) were found as the commonest presentation in both waves. Gastrointestinal manifestations were observed relatively more in the second wave. The serious patients on ventilator were found to have (>91%) the highest mortality. It appeared that the highest attributable risk to severity and mortality (eight to ten times increased) was due to hypertension, diabetes and other co-morbidities. Pregnancy did not predisposed to be as a risk factor.

Conclusion: Prompt management and preventive care are needed for patients with co-morbidities to avoid the exacerbation of COVID-19 as well as drug cross interactions.

Keywords

Co-morbidities, Coronavirus disease-2019, Disease severity, Pandemic

As COVID-19 continues to spread, it is still unclear who exactly this virus would impact critically. As of 12th February 2022, a total of 1,02,348 COVID-19 patients with 2691 deaths were recorded having 2.62% case fatality rate in Nanded district, Maharashtra, India (1).

Given the alarming global spread, morbidity and mortality associated with COVID-19, it is crucial to determine possible factors associated with the exacerbation of the disease (2). It is also important to note that due to differences in demographic and genetic features of various populations, the generalisability of previous reported pathophysiological parameters from all over the world may be limited (3). It has been demonstrated that the careful and precise consideration of patient’s medical history and underlying conditions plays a huge role in the proper management of COVID-19 which could make practitioners alert to the possibility of poor prognosis (2).

The importance of determining the serious risk factors (co-morbidities) of virus mortality would further make improvements in management policy and enhance the patient’s treatment outcome. In specific, such data may contribute to the early identification of most at risk subjects for mortality in an emergency condition, accurately monitoring the patients and making treatment decisions and discharge accordingly (4),(5). It is also important to consolidate the information to develop an antiviral strategy for susceptible and weak people (6).

Hence the authors decided to study the demographics, clinical features, association with co-morbidities, and outcomes of the sequentially hospitalised COVID-19 patients at a tertiary care centre.

Study Objectives

• To compare the socio-demographic factors, clinical features, co-morbidities and outcomes in COVID-19 infected patients admitted to a tertiary care centre in the first and second waves of COVID-19 pandemic.
• To study the effect of associated co-morbidities among the hospitalised COVID-19 patients in terms of prevalence and outcome by comparing those with no co-morbidity.

Material and Methods

The present retrospective study was conducted at Dr. Shankarrao Chavan Government Medical College, district Nanded, Maharashtra, India, serving approximately 40 lakh population. The data was collected from the electronic resource which was maintained by the institute (IDSP health record reporting database). The duration of data collected for the complete study was from June 2020 to August 2021. The duration of the first and second waves were considered as (12th June 2020 to 31st January 2021) and (1st February 2021 to 31st August 2021). The ethical approval has been waived by the Institutional Ethical Committee in the view of retrospective nature of the study and anonymously collected data.

Inclusion criteria: All consecutive hospitalised patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections by a positive result on Real Time Polymerase Chain Reaction (RT-PCR) testing of a nasopharyngeal and or pharyngeal swab.

Exclusion criteria: Suspected patients without confirmation of a positive result were excluded from the study.

Study Procedure

The sample collection, transport, testing procedure and interpretation guidelines for COVID-19 RT-PCR were strictly followed as given by the Indian Council of Medical Research (ICMR) (7). Nucleic acid extraction followed by Real Time Quantitative Reverse Transcription PCR (qRT-PCR) assays was done to determine the genetic markers of SARS-CoV-2 using the ICMR approved kits supplied to us as government supplies regularly. The RNA Extraction Kits-

a) Manual spin column based- GeneS2ME, MetaDesign.
b) Automated- Mag RNA, Kingfisher Flex. qRT-PCR Kit-Diagsure nCOV-19, COVIDsure Trivitron, Meril COVID-19 one step RT-PCR, Quantiplus Multiplex.

Authors have defined the patient’s severity as moderate (patients requiring admission to covid ward), severe (patients requiring oxygen therapy in the form of Non Invasive Ventilation (NIV)/High Flow Nasal Cannula (HFNC) or intubation/ventilator management, as per definition of updated triage criteria used for clinical management for the COVID-19 patients (8). Data collected included patient demographic information, co-morbidities and presenting symptoms, and outcomes (discharge and death).

Statistical Analysis

The analysis was done for the complete data and then for two separate durations of the first and second wave which were compared later with Chi-square test (bivariate analysis). The data obtained was entered in Microsoft excel 2010. The frequencies and the percentage were calculated. Bivariate analysis (Chi-square test) was used to know the statistical association among the study variables. This was done using the statistical software Epi Info version 7 application. The p-value <0.05 was considered as statistically significance.

Results

Among the total patients 8841, the first and second waves comprised 3362 and 5479 patients respectively.

First wave: The commonly affected age group is 46-60 years (n=1043) followed by 61-75 years (n=861) with mortality rates of 14.66% and 24.39% respectively. Among the total number of 3408 COVID-19 positive patients, the numbers of male and female were found as 2226 and 1182 respectively. The male to female ratio was 1.9:1. The ratio of co-morbidities found more in males than females. The mortality rate among patients with and without co-morbidity was (383/1202) 31.86% and (112/2160) 5.18% respectively.

Second wave: The commonly affected age group was 46-60 years (n=1571) followed by 61-75 years (n=1221) with mortality rates of 18.2% and 37.91`% respectively. The mortality rate in second wave was found higher in the younger population when compared to first wave. Among the total number of 6013 COVID-19 positive patients, the male to female ratio was 1.8:1. The co-morbidities were found more in the male population. The mortality rate among the patient with and without co-morbidity was (927/2318) 39.99% and (98/3161) 3.1% respectively. The overall mortality rate was higher in second wave.

The details were shown in (Table/Fig 1). Authors did not find the data related to the outcome from 46 and 534 patients from first wave and second wave respectively, hence they were excluded from further analysis.

Various parameters in first and second waves in COVID-19 patients associated with co-morbidity: The number of patients with co-morbidities patients was higher (2318/5479) 42.3% in second wave than in first wave (1202/3362) 35.7%. When compared to first wave, the co-morbidity and mortality rate were observed higher in the younger population in second wave. The worse outcome was noted among co-morbid elderly patients with co-morbidities in second wave. The details are mentioned in (Table/Fig 2).

The distribution of rural/urban population, outcome (in a patient with or without co-morbidity and different types of severity) in first and second waves: The urban population was having more co-morbid patients 59.4% and 61.99% in the first and second wave respectively. There was no statistical association noted for location. The mortality rate was 24.39% and 26.17% in the age group 61-75 years and >75 years for the first wave while it was 37.91% and 19.92% respectively in the second wave. The overall mortality was 14.72% and 18.7% in first and second waves respectively. The relation between the outcomes (overall) among the patients with different age groups and co-morbidities was also found to be statistically significant in both waves.

Authors found the patients who were admitted and on oxygen support had better outcomes as 66.48% and 77.89% in terms of discharge in the first and second wave respectively. The discharge rate was 6.22% and 8.34% in the patients who required ventilator support which did not show any statistical association. In the present study, the death rate was 93.78% and 91.66% among the patients who required ventilator support in first and second waves respectively. The details are shown in (Table/Fig 3).

The outcome and associated co-morbidities among the COVID-19 patients in first and second waves: Hypertension (HTN) and Diabetes Mellitus (DM) with or without other co-morbidities 42.18% patients was the commonest co-morbidity associated with the mortality in the first wave while HTN and DM as co-morbidity 51.26% in the second wave. The patients who had the DM and HTN with or without co-morbidity were having 10-11 times the risk of mortality than those with no Co-morbidities. The pregnancy didn’t appear to have an association with increased mortality. The other details are mentioned in (Table/Fig 4).

Clinical presentations/symptoms found in first and second waves: The most common symptom of presentation in both waves was fever and breathlessness followed by cough and body ache. The number of asymptomatic patients was 320 (9.51%) and 940 (17.15%) in the first and second wave respectively. Breathlessness was frequently seen in the first wave. Other non respiratory symptoms such as diarrhea, abdominal pain, body ache etc were observed commonly in the second wave. (Table/Fig 5) shows the details.

Mortality risk depending on disease severity: The risk of mortlity increased 122 times (100%) when the disease was severe. The COVID-19 patients associated with two co-morbidities (hypertension and diabetes mellitus) have eleven times risk of mortality when compared to those with no co-morbidity. The other details are shown in (Table/Fig 6).

Discussion

The present study mentioned in detail the characteristics and outcomes of sequentially hospitalised patients with confirmed COVID-19. As this is an ongoing pandemic, the different genetic makeup of SARS-CoV-2 and predisposing risk factors in various waves might have a different impacts on the prognosis of patients. Hence when the comparison between various parameter in the first and second wave was done where authors found the commonly affected age group was 46-60 years followed by 61-75 years (elder) in both the waves. A study by Salari A et al., (3) found the same. In the present study the mortality rate was observed as 31-52% and 19-38% in the elderly with and without associated co-morbidities respectively. In the current study, (2867/3362) 85.27% and (4454/5479) 81.29% of patients have been discharged (overall discharge rate among all patients) from the hospital in the first and second wave respectively. The rate of discharge of COVID-19 patients from the hospital was (819/1202) 68.13% and (1391/2318) 60% respectively in those with associated co-morbidity in first and second waves. Alamdari NM et al., (2) found the same. In the present study, no mortality was seen in the age group 0-15 years (as no child got admitted) in the first wave but the mortality was (7/7) 100% in the second wave. There were no deaths in patients with age (less than 18 years) (9). In the current study, the overall mortality rate in the age group 16-60 years as (665/5662) 11.74%. While it was 7.5% in one study (9). The current study, concludes that the male to female ratio was 1.9:1. Similar male preponderance was seen in studies (10),(11).

According to the present study, the mortality rate among the patient with co-morbidities any significantly increased (31.86% and 40%) than those without co-morbidity (5.18% and 3.1%) in first and second waves respectively. A higher incidence of severe and fatal COVID-19 is observed with increasing age (12) and is partly attributed to pre-existing co-morbid conditions (13). Co-morbidities contributed to acute disease prognosis and increased risk of severe symptoms. Around 70% of patients who require ICU care have been observed to have co-morbidities (6).

Disease severity: In the present study, authors calculates the number of patients on ventilation were (877/3520) 24.91% while their mortality as (808/877) 92.13%. It had been recorded for patients on mechanical ventilation as 12.2% and a mortality rate of 21% among the hospitalised patients (9). In the present study when compared, the overall mortality was found similar but the serious patients on ventilation were found in half number of cases. This could be because of the less number of COVID-19 patients under study in the developed countries (9).

The current study, findings showed that the patients requiring O2 (severe disease) has worse outcomes in first wave 33.52% than in second wave 24.11%. It was found that mortality was 2% among the patients who were not on ventilation (9). This could be because of the better healthcare facility in a developed countries.

In the current study, the risk of mortality increased 122 times (100%) when the disease was severe with complications (patients on mechanical ventilation). Similarly, the high mortality rates (24.5%) were observed in a study (9) and case series (14).

Co-morbidity: In the current study, HTN/DM with or without other co-morbidities was the commonest co-morbidities associated with 10-11 times the risk of mortality than those with no co-morbidities. The prevalence of HTN+DM and HTN, was observed as (612/3520) 17.38% and (731/3520) 20.76% respectively in the present study. This is very similar to the range 15-30% as found in a study (15). A systematic review, it had shown an increase in severity and almost 2.5 fold increase in mortality in COVID-19 patients with hypertension (16).

The prevalence of diabetes was observed as (758/3520) 21.53% in the present study. This was similar to the different studies (9),(15),(17). Where the prevalence of diabetes among hospitalised patients with COVID-19 fluctuates in the range of 10 to 34% and even more. Several studies conducted in China and Italy have shown a more severe course of SARS-CoV-2 infection, requiring transfer to the Intensive Care Unit (ICU) and mechanical ventilation in patients with diabetes (18). A study by Zhu L et al., (19) showed significant high mortality as three times than non diabetic individuals. The change in immune profile and its consequences are thought to make diabetic patients more susceptible to infections (20). The situation is complicated by the need to use glucocorticoids, which leads to an increase in the dose of hypoglycemic drugs. Diabetes is associated with a maladaptive inflammatory response leading to a worsening of the viral infection course and the possibility of bacterial complications (20). The SARS-CoV-2 viruses show more susceptibility to the presence of excess ACE2, and the chances of infection and contracting the disease increase too (21),(22). SARS-CoV-2 was found to have damaged the lungs, kidney, heart, and the endocrine part of the pancreas due to the presence of Angiotensin Converting Enzyme 2 (ACE2) receptor. This was directly related to fatality (18). The results in the review by Ng WH et al., (23). Also indicated a significant 94% increased hazard of Mortality due to Covid-19 in patients with diabetes and 2.1 times increased risk in Patients with HTN. It is similar to the current study even though not to that extent. The COVID-19 is associated with increased clot strength, platelet fibrinogen, elevated D-dimer levels, and hyperfibrinogenemia (24). Hence, the association of severe outcomes in patients with hypertension and diabetes may be partially explained by the increased incidence of thrombotic complications as these co-morbid patients already have elevated risk of thrombotic events (25),(26). and also due to the induction of cytokine storm leading to hyperinflation (a hallmark of severe SARS-CoV-2 infection) (27).

In the current study there was a 10 times increase in risk of death in COVID-19 patients with associated co-morbdities as HTN and DM and any other (including CKD). Similar observations were made in one review (10). This could be because SARS-CoV-2 may have kidney tropism (28) and the renal cells express ACE2 receptors 100 times more than the lungs (29). Chronic renal diseases usually exist with other co-morbidities such as diabetes, a cardiovascular illness, which are, as already stated, further risk factors for critical COVID-19 (30).

In the present study, the prevalence of cardiovascular disease and respiratory illness as (12/3520) 0.35%. The prevalence was observed in a range of 2.5-16% in various studies (15),(31) and 0.95% in one study (32). The lower prevalence may be due to a very less number of such patients. The authors from the present study found the associated cardiac and respiratory diseases were found to have 5.5 and 4 times increased risk of death in COVID-19 patients respectively while the risk is increased to 8 times when the patient had both the co-morbidities. A similar finding was noted in one study (33). The reason could be explained as increased susceptibility, and severity in patients with cardiovascular conditions (34).

The patients in the present study associated with the malignancy and immunocompromised statuses were at 8-9 times increased risk of death. It is seen that an Odds Ratio (OR) of 1.63 (95% CI, 1.01-2.00) showed an increase in COVID-19 related mortality in cancer patients in one review (23). Malignancy was observed in (24/3520) 0.68% of patients in present study. The different studies (35),(36) also found the percentage of COVID-19 patients with malignancy as 0.9% and 7.2% respectively with increase in severity and death rate (37). The risk is increased because of the unavailability of continued treatment due to workload and saturation of the health system (38). Immunocompromised status was observed in (32/3520) 0.90% of patients in the present study. The immunosuppressive medication affects cell mediated and humoral immunity, resulting in more severe infection in these patients (39). The coronavirus uses the host’s innate immunity to mount a deregulated and excessive immune response, which is usually the cause of the severity of the disease (40). Hence further studies are needed to determine the attributable risk with severity.

In the current study, pregnancy (a physiological condition) did not appear to be a risk factor for the increased mortality. The potential adverse effects on pregnancy during the COVID-19 pandemic have often shown varying results, therefore preventive measures are needed (6). Authors observed the minimal risk with connective tissue disorders, leprosy, chronic medical disease may predispose these people to infections and disease complications (31).

Clinical presentation: In the present study authors observed fever (71.49%) as the most commonest symptom among the COVID-19 patients in the second wave. A study by Richardson S et al., (9). (30.7%) patients were febrile and (27.8%) received supplemental oxygen. Symptoms such as cough, sore throat, fever, and body ache were present in 81% of patients (6) which is similar to the present study. This may be because authors have included hospitalised patients. Similarly, shortness of breath (86.5%) and fever (83.7%) were the most common symptoms in major referral centres in Iran (2). The present study shows the commonest symptoms in the first wave were fever (62.52%) and breathlessness (58.12%) but Gasmi A et al., (6) found 14% patients with dyspnea as findings in his review. Similarly, 46% of patients experienced severe symptoms in one study (3). Symptoms such as vomiting, diarrhoea and abdominal pain were seen vomiting, diarrhea, and abdominal pain in 0.81%, 1.58% and 1.7% of patients respectively whereas the same were seen in 32%, 27.2%, and 18.7% of all patients in one study (2). The gastrointestinal manifestations were found at 20% (3).

Limitation(s)

The increased incidence of associated co-morbidity was noted in the present study due to the referral nature of the hospital. The authors did not calculate the risk associated with all the co-morbidity separately.

Conclusion

The maximum numbers of patients were of the age group 30-75 years with male predominance in both waves. The number of pediatric patients and their mortality were more in the second wave. Asymptomatic patients were more commonly seen in the second wave. The symptoms like fever and dyspnea being the commonest presentation in both waves and pre-existing co-morbidities played an important in the management of patients. Gastrointestinal manifestations were observed relatively more in the second wave. The serious patients on ventilator were found to have (>91%) the highest mortality. It appears that the highest attributable risk to severity and mortality was due to hypertension, diabetes and other co-morbidities. This was followed by malignancy, immunodeficiency, and both cardiac illness and respiratory illness. Pregnancy did not appear as a risk. The prompt management, immunomodulatory and preventive measures need to get followed strictly for these patients.

Acknowledgement

The authors are thankful for the kind support from doctors and paramedical staff of Medicine and ENT Department.

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DOI and Others

DOI: 10.7860/JCDR/2022/56227.16730

Date of Submission: Mar 09, 2022
Date of Peer Review: Apr 05, 2022
Date of Acceptance: May 14, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

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