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Introduction: Effective triage of COVID-19 patients, especially in resource-limited settings, requires cost-effective and readily available markers. The present study looks at the prognostic role of three such laboratory parameters, absolute lymphocyte count (ALC), absolute neutrophil count (ANC), and neutrophil-to-lymphocyte ratio (NLR). Methodology: A retrospective cohort study was done including 328 COVID-19 reverse transcriptase-polymerase chain reaction-confirmed hospitalized patients aged 18 and above in a tertiary center in northern India. Baseline demographic, clinical, and laboratory parameters were collected on the day of admission. Statistical analysis included descriptive statistics, sensitivity-specificity analysis for optimum cutoffs, multiple logistic regression, and Cox proportional hazards regression. Results: The median age of the patients was 45 with 266 (81.1%) males and 62 (18.9%) females. A total of 109 (33.2%) patients were affected with moderate to severe disease. Forty-nine (14.9%) patients had fatal outcomes. Median ALC was lower in patients with moderate to severe disease compared to mild disease (895 vs. 1554.2) and in nonsurvivors compared to survivors (732.0 vs. 1423.9). Median ANC (5182.8 vs. 3057.6) and NLR (5.38 vs. 2.03) were significantly raised in patients with moderate to severe disease as against mild disease and in nonsurvivors(ANC 7040.25 vs. 3448.5, NLR 10.05 vs. 2.35). ALC <1273, ANC >3907, and NLR >2.74 showed considerable sensitivity and specificity for disease severity at admission. ALC and ANC were significantly associated with the odds of moderate to severe disease at admission in the multivariable logistic regression analysis. ALC <1183, ANC >4612, and NLR >3.76 had good sensitivity and specificity as predictors of mortality and emerged as independent risk factors for mortality in the multivariable Cox proportional hazards regression. Conclusion: ALC, ANC, and NLR are relatively cost-effective and readily available routine investigations obtained as a part of complete blood count. These indices show good prognostic significance. Their utility in clinical algorithms can better guide management of patients.
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BACKGROUND: Patients with type 1 diabetes mellitus (DM) require intensive monitoring, which was adversely affected during coronavirus disease 2019 (COVID-19) restrictions. METHODS: We evaluated the management of type 1 DM and the role of telephonic consultation and follow-up in 46 patients (10 on insulin pump) with type 1 DM at our centre from 1 February 2020 to 31 January 2021. Patients were telephonically counselled fortnightly. Web-based diabetes education sessions for the patients and parents were conducted. Finally, change in HbA1c during the period of the study, frequency of severe hypoglycaemia, hospital admissions for hyperglycaemic emergencies and degree of satisfaction with care rendered by the treating team were assessed by ratings scored by the patients. RESULTS: Five episodes of severe hypoglycaemia were noted in three patients. Two patients had diabetic ketoacidosis. Patients on insulin pump showed a mean baseline HbA1c of 7.8%. Nine of these patients (90%) showed an improvement in Hba1c during the study period compared to 64.3% of patients on conventional regimen. There were no episodes of severe hypoglycaemia or hospitalization with DKA noted in these patients. Only two patients had COVID-19 disease with mild manifestations. Overall satisfaction levels with therapy were high. CONCLUSION: This study illustrates the role played by teleconsultation and video conferencing during the period of the COVID-19 pandemic in ensuring optimal healthcare delivery to patients with type 1 DM. Some of these methods can be used even after the pandemic to improve patient convenience and reduce the out-patient burden on the hospitals.
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BACKGROUND: The rapid spread of the coronavirus disease 2019 (COVID-19) with high mortality rate necessitates disease characterization and accurate prognostication for prompt clinical decision-making. The aim of this study is to study clinical characteristics and predictors of mortality in hospitalized patients with COVID-19 in India. METHODS: Retrospective cohort study was conducted in a tertiary care hospital in northern India. All consecutive confirmed hospitalized COVID-19 cases aged 15 years and older from 13 Apr till 31 Aug 2020 are included. Primary end point was 30-day mortality. RESULTS: Of 1622 patients ,1536 cases were valid. Median age was 36 years, 88.3% were men and 58.1% were symptomatic. Fever (37.6%) was commonest presenting symptom. Dyspnea was reported by 15.4%. Primary hypertension (8.5%) was commonest comorbidity, followed by diabetes mellitus (6.7%). Mild, moderate, and severe hypoxemia were seen in 3.4%, 4.3%, and 0.8% respectively. Logistic regression showed greater odds of moderate/severe disease in patients with dyspnea, hypertension, Chronic Kidney Disease (CKD), and malignancy. Seventy six patients died (4.9%). In adjusted Cox proportional hazards model for mortality, patients with dyspnea (hazard ratio [HR]: 14.449 [5.043-41.402]), altered sensorium (HR: 2.762 [1.142-6.683]), Diabetes Mellitus (HR: 1.734 [1.001-3.009]), malignancy (HR:10.443 [4.396-24.805]) and Chronic Liver Disease (CLD) (HR: 14.432 [2.321-89.715]) had higher risk. Rising respiratory rate (HR: 1.098 [1.048-1.150]), falling oxygen saturation (HR: 1.057 per unit change 95% CI: 1.028-1.085) were significant predictors. CONCLUSION: Analysis suggests that age, dyspnea, and malignancy were associated with both severe disease and mortality. Diabetes Mellitus and Chronic Liver Disease were associated with increased the risk of fatal outcome. Simple clinical parameters such as respiratory rate and oxygen saturation are strong predictors and with other risk factors at admission can be effectively used to triage patients.
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Introduction: Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have multisystemic involvement with hyperinflammation being a cardinal feature and deranged iron metabolism having a possible role. In this premise, we studied the prognostic value of two markers of iron metabolismferritin and hemoglobin. Methodology: A retrospective-cohort study was carried out in a tertiary hospital in northern India involving 210 hospitalized COVID-19 patients aged 15-andabove. Analysis was done for clinical profile, comorbidities and basic laboratory indices including ferritin-hemoglobin ratio (FHR) with primary end-point being in-hospital all-cause mortality. Results: Median serum ferritin levels (640.00ng/mL vs 220.00ng/mL) were significantly higher among non-survivors as against survivors while median hemoglobin levels were significantly lower (12.12g/dL vs 13.73g/dL). Serum ferritin levels >400ng/mL (Sn 80%, Sp 70%) predicted mortality with high sensitivity and specificity. Notably, serum ferritin levels >400ng/mL (HR 11.075 [1.481-82.801]) and anemia, defined as a hemoglobin of <12g/dL for females and < 13g/dL for males and were significantly associated with the risk of mortality in a univariable Cox-proportional hazards regression. The median FHR was significantly higher among non-survivors compared to survivors (56.98 vs 17.17). FHR>31 (Sn 85% Sp 71.6%) was highly sensitive and specific for predicting mortality. The multivariable analysis indicated that FHR >31 remained an independent risk factor for mortality (HR 12.293 [3.147-48.028]). Conclusion: Ferritin-hemoglobin ratio (FHR), which encompasses into a single index, the effects of both elevated levels of ferritin and the severity of anemia, seems to perform particularly well as a prognostic marker and emerged as an independent risk factor for mortality in COVID-19 patients. Hyperferritinemia and anemia, both, are inexorably interlinked in addition to having a role, directly or indirectly in the disease pathophysiology. Ferritin and hemoglobin, hence should be seen as two sides of the same coin rather than as two discrete entities. © 2021 Journal of Association of Physicians of India. All rights reserved.
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BACKGROUND: Efficacy of vaccines studied in clinical trial settings are likely to be different from their effectiveness in a real-world scenario. Indian Armed Forces launched its vaccine drive against COVID-19 on 16 Jan 2021. This study evaluated the effect of vaccination on mortality amongst hospitalized COVID patients. METHODS: A cross sectional study was done on all admitted moderate to severe COVID-19 patients at a designated COVID hospital in New Delhi. The primary outcome assessed the association of being fully vaccinated with mortality. Unadjusted odds ratios (OR) (with 95% CI) was performed for each predictor. Logistic regression was used for multivariable analysis and adjusted odds ratios obtained. RESULTS: The 1168 patients included in the study had a male preponderance with a mean age of 54.6 (± 17.51) years. A total of 266 (23%) patients were partially vaccinated with COVISHIELD® and 184 (16%) were fully vaccinated. Overall, 518 (44.3%) patients had comorbidities and 332 (28.4%) died. Among those fully vaccinated, there was 12.5% (23/184) mortality while it was 31.45 % (309/984) among the unvaccinated (OR 0.3, 95% CI 0.2 to 0.5, p<0.0001). In a logistic regression model, complete vaccination status and younger age were found to be associated with survival. CONCLUSIONS: Vaccination with two doses of COVISHIELD® was associated with lower odds of mortality among hospitalized patients with moderate to severe COVID.
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Diabetes mellitus (DM) was noted as the commonest comorbidity in the coronavirus disease 2019 (COVID-19) which contributed to worse prognosis in these patients. In some cases, we also noted new-onset DM detected during hospitalization for symptomatic COVID disease. We describe three such cases, where the patients presented with severe symptomatic hyperglycemia and ketoacidosis in two and hyperosmolality in one of them. Antibody to GAD-65 was negative and varying degrees of C-peptide secretion was noted after recovery in them. There was no clinical or biochemical evidence of exocrine pancreatic involvement noted during acute presentation or after the recovery. This interesting phenomenon of coexisting DM in symptomatic COVID-19 requires further studies to differentiate between coincidence or causation.