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

Users Online : 68833

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

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 : September | Volume : 16 | Issue : 9 | Page : OC05 - OC09 Full Version

Comparative Study of Clinical and Radiological Profile and Outcome of COVID-19 Patients with and without Co-morbidities: A Cross-sectional Study


Published: September 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57921.16828
Ummul Baneen, Mohammad Arif, Imrana Masood, Nader Abdul Razak, Zuber Ahmad

1. Assistant Professor, Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India. 2. Senior Resident, Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India. 3. Assistant Professor, Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India. 4. Senior Resident, Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India. 5. Professor, Department of Tuberculosis and Respiratory Diseases, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India.

Correspondence Address :
Dr. Nader Abdul Razak,
Department of Pulmonary Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh-202002, Uttar Pradesh, India.
E-mail: naderrazak@gmail.com

Abstract

Introduction: Coronavirus Disease-2019 (COVID-19) had devastating effects on the healthcare and economic sector worldwide. India stands second in the list of most number of COVID-19 cases. Most of the deaths due to COVID-19 were seen in patients with associated co-morbidities like hypertension, diabetes, chronic kidney disease and obesity. This study would like to examine specific co-morbidities in relation to the COVID-19 disease progression and outcomes.

Aim: To compare the clinicoradiological profile and outcome of COVID-19 in patients with and without co-morbidities (diabetes and hypertension).

Materials and Methods: The present observational, cross-sectional study was conducted at Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh between June 2020 to September 2020, after obtaining Institutional Ethics Committee (IEC) approval. A total of 148 patients with COVID-19 were included in the study. The COVID-19 patients admitted in the hospital were divided into four groups as those having only diabetes, only hypertension, both diabetes and hypertension, and those without any co-morbidities. Those with any other co-morbidity were excluded from the study. The general clinical characteristics, laboratory parameters, disease severity, morbidity and mortality were compared among various groups and the data was analysed. Categorical data were analysed using the Chi-square test.

Results: A total of 148 patients with COVID-19 were included in the study, of which 26 patients were diabetic, 36 were hypertensive, 24 were both hypertensive and diabetic and 62 patients didn’t had any significant co-morbidity. Severe COVID-19 disease was most commonly observed in those with diabetes (n=14) (53.8%). The highest proportion of patients requiring oxygen (84.6%) and Non Invasive Ventilator (NIV) support (46.1%) was also seen among diabetics. The presence of diabetes, severe disease and leukocytosis at presentation increased the risk of mortality. The association of hypertension with COVID-19 does not seem to affect the in-hospital mortality.

Conclusion: COVID-19 in diabetics is associated with both increased risk of severe disease and increased odds of death. In diabetics, those with uncontrolled diabetes were more prone to severe disease and death than those with good glycaemic control. Hypertension, on the other hand, showed no association.

Keywords

Intensive care unit admission, Mechanical ventilation, Non invasive ventilation, Oxygen requirement

The COVID-19, which was first diagnosed in Wuhan, China in December 2019, has now spread to more than 200 countries around the world, and it's unlike any other pandemic that we have seen in almost a century. With all the advancements in the health sector that is witnessed in the last decade or so, that has made almost all the impossible of the medical science possible, this pandemic has brought even the most advanced nations to its knees. India is one of the worst affected countries by the coronavirus. It is third in the list of the total number of patients in a country, behind only the United States and Brazil, and with almost 95000 new cases daily, it is well on track to lead the list (1).

Many of the published studies have identified the presence of co-morbidities, especially diabetes and hypertension, as associated with poor prognosis and clinical outcome. The study conducted by Albitar O et al., among 828 patients of COVID-19 identified that males, advanced age, hypertension, diabetes mellitus patients and patients located in America were the independent risk factors of death among COVID-19 patients. This study reported odds ratio of 12.234 for diabetes and 3.576 for hypertension (2). Holman N et al., did a population based cohort study in 2020 to establish the association of COVID-19 mortality and diabetes mellitus. As per this study, mortality in people with type 1 and type 2 diabetes rose sharply during the initial COVID-19 pandemic in England. Compared with people with an HbA1c of 48-53 mmol/mol (6.5-7.0%), people with an HbA1c of 86 mmol/mol (10.0%) or higher, had significantly higher COVID-19-related deaths (hazard ratio [HR] 2.23 in type 1 diabetes and 1.61 in type 2 diabetes). In addition, in people with type 2 diabetes, COVID-19-related mortality was significantly higher in those with an HbA1c of 59 mmol/mol (7.6%). The mortality rate increased with higher values of HbA1C as it was found that hazard ratio of 1.22 for those with an HbA1c of 59-74 mmol/mol (7.6-8.9%) and 1.36 for 75-85 mmol/mol (9.0-9.9%) (3). Mantovani A et al., did a meta-analysis of 83 observational studies to detect diabetes as a risk factor for COVID-19 severity and mortality. It concluded that pre-existing diabetes (in most cases type 2 diabetes mellitus) significantly increased the rate of COVID-19 associated mortality as well as the risk of incidence of severe/critical illness (4).

India is the diabetes capital of the world. The prevalence of diabetics in India has increased remarkably from 26 million in 1990 to a staggering 65 million in 2016 (5). The same is the case with the prevalence of hypertension in India. According to one study, one in every three adults in India suffers from hypertension (6). Thus, with India leading in both diabetes and hypertension along with COVID-19, it can be a worrisome and dreadful combinationas there are evidences from multiple studies that both diabetes and hypertension pose significant risk to the COVID-19 severity and mortality. The aim of present study was to compare the profile of COVID-19 patients having diabetes and/or hypertension than those without any co-morbidity and see how they are based on clinical profile, disease severity, laboratory parameters, and outcome.

Material and Methods

The present study was an observational, cross-sectional, hospital-based study, done between June 2020 to September 2020 at Jawaharlal Nehru Medical College, Aligarh, which is a tertiary care centre in Uttar Pradesh, India which was a Level-2 COVID Hospital. The Institutional Ethics Committee approved the study (letter no: 94/20/FM/AMU).

Inclusion criteria: All adult patients diagnosed with COVID-19 based on positive Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) of the nasopharyngeal swab and were admitted to the hospital were included in the study after obtaining written informed consent.

Exclusion criteria: Those patients with any other co-morbidity apart from diabetes and hypertension like coronary artery disease, cancer, chronic kidney disease, hypothyroidism, stroke, chronic lung diseases like COPD, bronchial asthma, etc were excluded from the study. Any patients below 18 years were also excluded.

A total of 148 patients of COVID-19 were included in the study. They were divided into four groups, based on whether they were having only diabetes (n=26), only hypertension (n=36), both diabetes and hypertension (n=24), and none of these (n=62). These patients were assessed every day from the day of admission till the day of discharge/ death with necessary clinical and laboratory investigations. All the patients were followed for a minimum of 30 days from the day of presenting to the hospital.

COVID-19 was diagnosed by RT-PCR/Rapid antigen testing and classified according to severity into mild, moderate, and severe based on tachypnoea and/or decreased oxygen saturation as measured by pulse oximetry (7).

Mild cases had a upper respiratory tract symptoms and/or fever without shortness of breath or hypoxia, respiratory rate below 24/min and oxygen saturation (SpO2) ≥ 94%. Moderate cases had respiratory rate between 24 to 30/min and/or oxygen saturation between 90% to ≤93% on room air. Severe cases had their respiratory rate above 30/min and/or oxygen saturation below 90% on room air (7).

The diagnosis of diabetes was based on past history or raised blood glucose levels during admission, according to the American Diabetes Association (ADA) guidelines (8). Systemic hypertension was diagnosed based on the past history of taking antihypertensive medications for a period of more than six months or raised systolic and/or diastolic blood pressure according to American Heart Association (AHA) guidelines (9). Chest X-ray finding was classified as being normal, mild to moderately involved, and extensively involved. Mild to moderate involvement was defined as having basal peripheral shadows and extensive involvement as having approximately more than 50% of the lung involvements bilaterally (10).

Data collection was done using a patient proforma to document clinical data. It included demographic factors like age and sex, symptoms and signs like fever, sore throat, cough, myalgia, dyspnoea, diarrhoea, headache and anosmia. The proforma also noted the presence/ absence of any co-morbidities like diabetes, hypertension, clinical and radiological severity (mentioned above), and outcome in terms of improvement/deterioration/death. Laboratory investigations like Complete Blood Count (CBC), blood urea, serum creatinine, HbA1C, Random Blood Sugar (RBS), D-Dimer and Arterial Blood Gas (ABG) analysis were done for all subjects.

Statistical Analysis

All the data were collected, tabulated, and analysed using Statistical Package for the Social Sciences (SPSS) version 23.0. Continuous data was expressed as median with Interquartile Range (IQR). Non-parametric Kruskal-Wallis test was used to compare the distribution of continuous variables that were not normally distributed. Categorical data were expressed as percentage and were analysed using the Chi-square test. The risk factors associated with mortality were examined with a multivariable binary logistic regression model. The odds ratio was used for evaluating the association between risk factors and mortality. Receiver Operating Characteristic (ROC) Curve was also used to test the regression model predicting mortality. All reported p-values were two tailed, p-value of <0.05 was considered significant.

Results

A total of 148 patients of COVID-19 were included in the study. The mean age of the study subjects was 52.86±15.05 years. The oldest population was in the group with only hypertension while the youngest group was the one without any co-morbidity, the mean age being 61.28±8.3 years and 47.1±18.1 years, respectively. The difference between age among various groups was statistically significant. The majority of the patients were males (63.5%). The most common symptom in present study was fever (95.3%), followed by cough (68.9%) and dyspnoea (63.5%). Those with either diabetes alone or with both diabetes and hypertension had a significantly higher proportion of patients presenting with dyspnoea when compared to the other two groups. The median heart rate and respiratory rate were highest in the diabetes group, with the value being 96.0 and 20.0 respectively. None of the patients were in shock at the time of presentation. The median SpO2 was lowest in the diabetes only group (85%), followed by those with only hypertension (88%). The proportion of patients having the severe disease was highest in the diabetes only group (53.8%), followed by those with only hypertension (50%). The chest X-ray was normal in 38 (25.7%) of the patients whereas extensive involvement was observed in 50 (33.8%) of the patients. About 14 (53.8%) of the patients in the diabetes only group had extensive involvement on chest X-ray (Table/Fig 1).

The baseline laboratory parameters of the study groups have been shown in (Table/Fig 2). A significant difference in distribution was observed in the values of serum creatinine, blood urea nitrogen (BUN), D-dimer, lactate, and pO2 levels among the four groups. The median serum creatinine and BUN levels were highest in patient group with both diabetes and hypertension, probably because such patients have greater risk of developing acute kidney injury. The median D-dimer value was highest in the diabetes group followed by those with both diabetes and hypertension, and the median pO2 was lowest in the diabetes group.

Of the total patients, 62.1% required additional oxygen support was statistically significant (p=0.049). The highest proportion of patients requiring oxygen support were from the diabetes group (84.6%) followed by those having both hypertension and diabetes (66.7%). Patients required oxygen for a median of 7.5 days. There was no significant difference between the groups in their duration of oxygen requirement. (p=0.441) (Table/Fig 3).

Of the total patients, 22.9% required support of NIV in addition to oxygen inhalation. The highest proportion of patients requiring NIV was again among the diabetes only group (46.1%) followed by those having both hypertension and diabetes (33.4%). The difference was statistically significant (p=0.001). The median duration of NIV support was 6.5 days. There was no significant difference in the duration of NIV support between the groups. Invasive ventilation was required in 10.8% of the patients, the maximum proportion again being the diabetes only group (30.7%) (Table/Fig 3).

About 66.2% of the patients were discharged from the isolation ward, 25.6% of the patients had to be shifted to the ICU due to symptoms like dyspnoea and/or oxygen requirement or additional ventilation support. The mortality in the isolation ward stood at 8.1%, whereas the total mortality at the end of 30 days was 16.2%. The highest proportion of patients who died in the isolation ward, as well as the 30-day mortality, was highest in the diabetes only group (30.7%). The mean time to COVID RT-PCR negative conversion was 11.44 days. There was a significant difference between the groups (p=0.015), with the highest time to conversion observed in the diabetes group (Table/Fig 3).

A multivariate binary logistic regression model was applied on 148 patients to examine the risk factors associated with 30 days mortality using the variables shown in (Table/Fig 4). Presence of diabetes, high total leukocytes count at presentation, severe disease at the time of presentation were associated with increased odds of death. The presence of hypertension and raised D-Dimer levels did not increase the odds of death.

(Table/Fig 5) shows the ROC curve constructed for the binary regression model predicting 30 day mortality in COVID-19 patients admitted to the isolation ward. The Area Under Curve (AUC) was 0.840 which means that our logistic regression model has a good diagnostic ability.

Discussion

The impact of the COVID-19 pandemic has been enormous and unprecedented. The total number of cases daily has been mind-boggling and thus, leading to the saturation of the healthcare system and infrastructure. So, it becomes imperative to identify those with increased risk of mortality and morbidity, various factors that can predict these risks early and thus, help us identify these patients so that early intervention can be made and help us with saving as many lives as possible (11).

Many studies have identified older age as a risk factor for mortality in COVID-19 patients (2),(11),(12). The mean age of patients who expired in present study was 56.17±15.006 years while among survivors, it was 52.23±15.032 years. Older patients have a weaker immune system and are also more likely to be having lifestyle diseases which would further put them at a risk. The oldest group in the present study was those with hypertension followed by those having both hypertension and diabetes. Although the difference between the mean age of survivors and non-survivors was not statistically significant in the study, it did increase the odds ratio for mortality in the multivariate regression analysis (OR=1.019). The most likely cause for the age difference being non-significant would be that the centre under consideration was a level 2 referral centre where only sick, old age patients are admitted and very few patients with mild disease were admitted (mostly healthcare workers from the same hospital) which would result in the data being biased since the majority are sick patients.

The presence of diabetes is being constantly documented as a risk factor for mortality among COVID-19 patients in many studies (3),(4),(13),(14). In this study, of those who expired, 14 (58.3%) had diabetes. Diabetes significantly increased the odds of death (OR=5.026).

The data on hypertension as a risk factor in COVID-19 patients is conflicting. In the study done by Li G et al., (14), they did not find hypertension to increase the risk of death among COVID-19 patients while in the study done by Albitar et al., (2) they found hypertension as an independent risk factor for mortality among COVID-19 patients. As perthis study, hypertension did not increase the risk of mortality among COVID-19 patients (OR=0.597).

Also, according to this study, those having both diabetes and hypertension fared better when compared to those having only diabetes indicating that hypertension neither alone nor in diabetics, increased the risk of mortality among COVID-19 patients. As far as these patients being diabetics and faring better when compared to those having only diabetes is considered, the probable reason would be that the former group was having better glycaemic control compared to the latter group (mean HbA1c= 8.6 vs 9.7). In the study done by Holman N et al., (3), they found that diabetics with HbA1c of >7.6% were at significantly higher risk of mortality than those having HbA1c as <7.0%. Therefore, those having well-controlled diabetes are relatively protected than those with poor diabetes control.

A high total leukocyte count at the time of admission was also independently associated with increased odds of death in the present study. Similar results have been found in other studies as well (15). A correlation has been found between high total leukocyte count and high Interleukin-6 levels in some studies, which would indicate higher levels of tissue inflammation, thus explaining increased morbidity and mortality in these patients (16). Thus, in resource-limited settings, an increased total leukocyte count at admission can be taken as a surrogate marker for increased tissue inflammation and IL-6 levels. Also, a superadded bacterial infection, which is a known complication of viral pneumonia, maybe the reason for increased mortality in these patients.

Disease severity at the time of presentation was also an independent risk factor predicting mortality in the present study. Moderate and severe disease increased the odds for death by a factor of 2.083 and 4.000 respectively. Those with severe disease were more prone for post COVID lung fibrosis which may lead to increased morbidity and mortality. In the study done by Ojo AS et al., they found that disease severity, old age, history of smoking and alchoholism, prolonged stay in ICU and the need for mechanical ventilation as predictors of lung fibrosis in COVID-19 patients (17).

The 30-day mortality in the present study was 16.2% (24/148). A higher percentage of mortality seen in this study was probably because the hospital where the study was done catered mostly moderate and severe patients only. An important finding of this particular study was that a significant number of patients (12/24), expired after becoming COVID negative but within 30 days. They were all having severe disease at the time of presentation. Therefore, post-COVID-19 sequelae in those with severe disease and Acute Respiratory Distress Syndrome (ARDS) leading to lung fibrosis is also an important aspect associated with both morbidity and mortality in these patients that cannot be ignored.

Limitation(s)

Echocardiogram and autopsy was not performed in every patient to ascertain the cause of death. A multicentre study with a larger number of subjects would allow for a better co-relation of COVID-19 with co-morbidities and risk factors predicting mortality.

Conclusion

COVID-19 in diabetics results in both increased chances of severe disease and mortality. Those with uncontrolled diabetes fare poorly when compared with those having better glycaemic control. Hypertension did not seem to increase the risk of death among these pateints. Also, disease severity and increased leukocyte count at the time of presentation increased the odds of death among these patients. Furthermore, this study can be used as a source of reference as well as guide to anticipate prognosis and implement better management strategies in patients with co-morbidities in case of newer waves of COVID-19 or even in later pandemics.

References

1.
Coronavirus Disease (COVID-19) Situation Reports. [cited 2020 Sep 26]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.last access date: 2020 Oct 1.
2.
Albitar O, Ballouze R, Ooi JP, Ghadzi SM. Risk factors for mortality among COVID-19 patients. Diabetes Res Clin Pract. 2020;166:108293. [crossref] [PubMed]
3.
Holman N, Knighton P, Kar P, O’Keefe J, Curley M, Weaver A, et al. Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: A population-based cohort study. The Lancet Diabetes & Endocrinology. 2020;8(10):823-33. [crossref]
4.
Mantovani A, Byrne CD, Zheng MH, Targher G. Diabetes as a risk factor for greater COVID-19 severity and in-hospital death: A meta-analysis of observational studies. Nutr Metab Cardiovasc Dis. 2020;30(8):1236-48. [crossref] [PubMed]
5.
Tandon N, Anjana RM, Mohan V, Kaur T, Afshin A, Ong K, et al. The increasing burden of diabetes and variations among the states of India: The Global Burden of Disease Study 1990-2016. The Lancet Global Health. 2018;6(12):e1352-62. [crossref]
6.
Ramakrishnan S, Zachariah G, Gupta K, Rao JS, Mohanan PP, Venugopal K, et al. Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey. Indian Heart J. 2019;71(4):309-13. [crossref] [PubMed]
7.
Clinical guidance for management of adult COVID-19 patients. AIIMS/ ICMR-COVID-19 National Task Force/ Joint Monitoring Group(Dte.GHS) Ministry of Health & Family Welfare, Government of India. Revised on 14/01/2022. Available from: https://www.mohfw.gov.in/pdf/ Clinical Guidancefor ManagementofAdult Covid19Patientsupdatedason17thJanuary2022.pdf.
8.
Diagnosis | American Diabetes Association guidelines [Internet]. [cited 2020 Oct 1]. Available from: https://www.diabetes.org/a1c/diagnosis.
9.
Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International society of hypertension global hypertension practice guidelines. Hypertension. 2020;75(6):1334-57. [crossref] [PubMed]
10.
Monaco CG, Zaottini F, Schiaffino S, Villa A, Della Pepa G, Carbonaro LA, et al. Chest x-ray severity score in COVID-19 patients on emergency department admission: A two-centre study. European Radiology Experimental. 2020;4(1):01-07. [crossref] [PubMed]
11.
DC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)-United States, February 12-March 16, 2020. Morbidity and Mortality Weekly Report. 2020;69(12):343. [crossref] [PubMed]
12.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. The Lancet. 2020;395(10229):1054-62. [crossref]
13.
Abdi A, Jalilian M, Sarbarzeh PA, Vlaisavljevic Z. Diabetes and COVID-19: A systematic review on the current evidences. Diabetes Res Clin Pract. 2020;166:108347. [crossref] [PubMed]
14.
Li G, Deng Q, Feng J, Li F, Xiong N, He Q, et al. Clinical characteristics of diabetic patients with COVID-19. J Diabetes Res. 2020;1652403. [crossref] [PubMed]
15.
Yamada T, Wakabayashi M, Yamaji T, Chopra N, Mikami T, Miyashita H, et al. Value of leukocytosis and elevated C-reactive protein in predicting severe coronavirus 2019(COVID-19): A systematic review and meta-analysis. Clinica Chimica Acta. 2020 ;509:235-43. [crossref] [PubMed]
16.
Zhao K, Li R, Wu X, Zhao Y, Wang T, Zheng Z, et al. Clinical features in 52 patients with COVID-19 who have increased leukocyte count: A retrospective analysis. Eur J Clin Microbiol Infect Dis. 2020;39(12):2279-87. [crossref] [PubMed]
17.
Ojo AS, Balogun SA, Williams OT, Ojo OS. Pulmonary fibrosis in COVID-19 survivors: Predictive factors and risk reduction strategies. Pulm Med. 2020;2020:6175964. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/57921.16828

Date of Submission: May 20, 2022
Date of Peer Review: Jul 05, 2022
Date of Acceptance: Aug 24, 2022
Date of Publishing: Sep 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:
• Plagiarism X-checker: May 24, 2022
• Manual Googling: Aug 22, 2022
• iThenticate Software: Aug 23, 2022 (11%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com