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Comparing between survived and deceased patients with Diabetes Mellitus and COVID-19 in Bangladesh: A cross sectional study from a COVID-19 dedicated hospital

07 Apr 2021-medRxiv (Cold Spring Harbor Laboratory Press)-
TL;DR: In this paper, the clinical features and outcomes of hospitalized patients with COVID-19 and DM in Bangladesh while comparing survivors and deceased were analyzed, and the death rate among all hospitalized patients (with and without DM) was 2.8% compared to 11.3% among diabetic patients.
Abstract: The current coronavirus disease 2019 (COVID-19) outbreak was reported to cause significantly higher mortality and morbidity among patients with diabetes mellitus (DM). Although Bangladesh is amongst the top 10 countries with diabetic people, data on these patients with COVID-19 is scarce from this region. This study aimed to illustrate the clinical features and outcomes of hospitalized patients with COVID-19 and DM in Bangladesh while comparing survivors and deceased. This retrospective cross-sectional study was conducted among RT-PCR confirmed COVID-19 patients with pre-existing Diabetes Mellitus in a specialized COVID-19 hospital in Bangladesh. Data from hospital records were analyzed. Among 921 RT-PCR confirmed COVID-19 admitted during the study period, 231 ([~]25%) patients with pre-existing DM (median age 60 years) were included in the analysis. The death rate among all hospitalized patients (with and without DM) was 2.8% compared to 11.3% among diabetic patients. The median hospital stay was 13 days (IQR 10.5, 17.0) for survivors and five days (IQR 2.0-8.3) for the deceased. The clinical features were not significantly different between survivors and the deceased. However, deceased patients had significantly lower blood oxygen level (85% vs 93%, p <0.001), and higher neutrophil-lymphocyte ratio (7.9 vs 4.5, p 0.003) and serum ferritin (946.0 vs 425.0 ng/ml, p 0.03). Glycemic status was poor in both groups. This study would help identify a subgroup of diabetic patients with COVID-19 who are at higher risk of in-hospital death and improve clinical decision making.

Summary (1 min read)

Jump to: [Introduction][Methods][Results][Discussion] and [Conclusions]

Introduction

  • The ongoing pandemic of coronavirus disease 2019 (COVID-19) is one of the greatest disasters that the world has ever witnessed.
  • While the clinical spectrum of COVID-19 is highly variable, the disease severity and mortality were reported to be significantly higher among patients with comorbidities, particularly diabetes mellitus (DM) [1, 2] .
  • India, Pakistan, and Bangladesh are among the top 10 countries globally by the number of affected people and undiagnosed cases [3] .
  • Moreover, studies comparing survived and diseased patients with DM and COVID-19 are rare in literature, which the authors believe is vital to identify cases requiring urgent clinical attention.
  • This study aimed to address the clinical epidemiology and outcome of COVID-19 patients with DM in Bangladesh, along with a detailed comparison between survived and deceased.

Methods

  • This retrospective cross-sectional observational study was conducted among RT-PCR confirmed COVID-19 patients with pre-existing DM admitted from 1 to 30 June 2020 in a specialized COVID-19 hospital (Kurmitola General Hospital) located in Dhaka, the epicenter of the COVID-19 pandemic in Bangladesh.
  • Patients with known DM and taking antidiabetic agents were considered to have pre-existing DM.
  • The severity of COVID-19 was described by WHO interim guidance [4] .
  • Data were extracted from hospital records using a relevant questionnaire.
  • All information was double-checked before analysis to ensure quality.

Results

  • A total of 921 RT-PCR confirmed COVID-19 patients were admitted to the hospital during the study period.
  • The glycemic status was poor in both survived and deceased patients; median HbA1c was 8.3% and 8.6%, respectively.
  • Interestingly, hospital days were significantly higher among survivors (13 vs 5 days, p <0.001).

Discussion

  • The authors study found that one in four hospitalized patients (235/921) with COVID-19 had preexisting DM.
  • The prevalence showed wide variability in other countries ranging from 5.3% in China to 33% in Europe and nearly 50% in India [1, 6] .
  • Significantly higher NLR and serum ferritin levels among non-survivors compared to survivors were reported in already published studies [10, 11] .
  • While ICU support was indicated in over 30% (72/231) of diabetic patients, more than half of them (43/72) could not be admitted into ICU due to the acute bed crisis (only a ten bedded ICU support in the study hospital).
  • The authors believe this is a unique finding for resource-poor settingsand needs further research.

Conclusions

  • The authors study found deceased patients with DM and COVID-19 had significantly lower oxygen saturation and significantly higher NLR, RBG and serum ferritin levels compared to survived.
  • The authors believe findings from this study will help clinicians to identify a subgroup of diabetic patients with COVID-19 who are at higher risk of in-hospital death; hence, requiring rigorous clinical management.

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1
Comparing between survived and deceased patients with Diabetes Mellitus and COVID-19
in Bangladesh: A cross sectional study from a COVID-19 dedicated hospital
Md. Shahed Morshed
1#
, Abdullah Al Mosabbir
2#
, Mohammad Sorowar Hossain
2
*
# contributed equally
1 Emergency medical officer, Kurmitola general hospital, Dhaka, Bangladesh
2 Department of Emerging and Neglected Diseases, Biomedical Research Foundation, Dhaka,
Bangladesh
Corresponding author:
*Mohammad Sorowar Hossain, PhD, Department of Emerging and Neglected Diseases,
Biomedical Research Foundation, Dhaka, Bangladesh, sorowar.hossain@brfbd.org
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted April 7, 2021. ; https://doi.org/10.1101/2021.04.04.21254884doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

2
Abstract
The current coronavirus disease 2019 (COVID-19) outbreak was reported to cause significantly
higher mortality and morbidity among patients with diabetes mellitus (DM). Although
Bangladesh is amongst the top 10 countries with diabetic people, data on these patients with
COVID-19 is scarce from this region. This study aimed to illustrate the clinical features and
outcomes of hospitalized patients with COVID-19 and DM in Bangladesh while comparing
survivors and deceased.
This retrospective cross-sectional study was conducted among RT-PCR confirmed COVID-19
patients with pre-existing Diabetes Mellitus in a specialized COVID-19 hospital in Bangladesh.
Data from hospital records were analyzed.
Among 921 RT-PCR confirmed COVID-19 admitted during the study period, 231 (~25%)
patients with pre-existing DM (median age 60 years) were included in the analysis. The death
rate among all hospitalized patients (with and without DM) was 2.8% compared to 11.3% among
diabetic patients. The median hospital stay was 13 days (IQR 10.5, 17.0) for survivors and five
days (IQR 2.0-8.3) for the deceased. The clinical features were not significantly different
between survivors and the deceased. However, deceased patients had significantly lower blood
oxygen level (85% vs 93%, p <0.001), and higher neutrophil-lymphocyte ratio (7.9 vs 4.5, p
0.003) and serum ferritin (946.0 vs 425.0 ng/ml, p 0.03). Glycemic status was poor in both
groups.
This study would help identify a subgroup of diabetic patients with COVID-19 who are at higher
risk of in-hospital death and improve clinical decision making.
Keywords: COVID-19, Diabetes Mellitus, Bangladesh, In-hospital mortality
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted April 7, 2021. ; https://doi.org/10.1101/2021.04.04.21254884doi: medRxiv preprint

3
Introduction
The ongoing pandemic of coronavirus disease 2019 (COVID-19) is one of the greatest disasters
that the world has ever witnessed. While the clinical spectrum of COVID-19 is highly variable,
the disease severity and mortality were reported to be significantly higher among patients with
comorbidities, particularly diabetes mellitus (DM) [1,2]. India, Pakistan, and Bangladesh are
among the top 10 countries globally by the number of affected people and undiagnosed cases [3].
Despite diabetes being a major public health concern, there are limited studies on diabetic
patients with COVID-19 from these regions, especially Bangladesh. Moreover, studies
comparing survived and diseased patients with DM and COVID-19 are rare in literature, which
we believe is vital to identify cases requiring urgent clinical attention.This study aimed to
address the clinical epidemiology and outcome of COVID-19 patients with DM in Bangladesh,
along with a detailed comparison between survived and deceased.
Methods
This retrospective cross-sectional observational study was conducted among RT-PCR confirmed
COVID-19 patients with pre-existing DM admitted from 1 to 30 June 2020 in a specialized
COVID-19 hospital (Kurmitola General Hospital) located in Dhaka, the epicenter of the COVID-
19 pandemic in Bangladesh. Patients with known DM and taking antidiabetic agents were
considered to have pre-existing DM. Patients having glycated hemoglobin (HbA1c)
6.5% done
within three months of admission were also included as having pre-existing DM. The severity of
COVID-19 was described by WHO interim guidance [4]. Data were extracted from hospital
records using a relevant questionnaire. All information was double-checked before analysis to
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted April 7, 2021. ; https://doi.org/10.1101/2021.04.04.21254884doi: medRxiv preprint

4
ensure quality. The institutional review board of the Biomedical Research Foundation,
Bangladesh, approved the study protocol (Ref. no: BRF/ERB/2020/003). Data were analyzed by
SPSS 22.0 software.
Results
A total of 921 RT-PCR confirmed COVID-19 patients were admitted to the hospital during the
study period. Of them, 231 (25.0%) patients with pre-existing DM were included in this study.
While the death rate among all hospitalized patients (with and without DM) was only 2.8%
(58/921), it was four times higher (11.3%, 26/231) among patients with DM (Table 1). The
median age of the deceased patients with DM was slightly higher compared to survived (63.5 vs
59 years, p 0.21). The most common comorbidity in both survived and deceased patients were
hypertension (HTN) (59.5% and 73.1%, respectively).The clinical presentations were not
significantly different between survived and deceased except for significantly lower oxygen
saturation among deceased (85% vs 93%, p <0.001). The absolute neutrophil count and
neutrophil-lymphocyte ratio (NLR) of deceased patients with DM were significantly higher than
survived. Besides, serum ferritin was more than two times higher among the deceased (946.0 vs
425.0 ng/ml, p 0.03). The glycemic status was poor in both survived and deceased patients;
median HbA1c was 8.3% and 8.6%, respectively. In addition, random blood glucose (RBG) at
admission was significantly higher among deceased (16.9 vs 14.0 mmol/L, p 0.002). Overall, the
median hospital stay for patients with DM was 12 days (IQR 10.0-16.0). Interestingly, hospital
days were significantly higher among survivors (13 vs 5 days, p <0.001). While intensive care
unit (ICU) support was indicated for 31.2% (72/231) patients with DM, only 12.5% (29/231) of
them got ICU admission (Fig 1).The mortality rate among ICU patients with DM was 46%
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted April 7, 2021. ; https://doi.org/10.1101/2021.04.04.21254884doi: medRxiv preprint

5
(12/29). Among antidiabetic agents used, a significantly higher proportion of deceased patients
required insulin than survived (Table S1).
Discussion
Our study found that one in four hospitalized patients (235/921) with COVID-19 had pre-
existing DM. One study from the southern region of Bangladesh reported a slightly lower
prevalence (19.8%) of DM among hospitalized patients [5]. The prevalence showed wide
variability in other countries ranging from 5.3% in China to 33% in Europe and nearly 50% in
India [1,6]. This could be due to regional variation of healthcare policy and perception of
diabetic patients towards COVID-19. In this study, the mortality rate among hospitalized patients
with DM was more than 11%. However, the overall case fatality rate in Bangladesh is only 1.5%
[7]. This trend largely agrees with other studies, althoughthe death rate was comparatively higher
in our study [1,6,8]. While we are not certain about the cause of this observation, we found that
some parameters were significantly different between two groups. While both deceased and
survived patients with DM had poor glycemic control, deceased patients had significantly higher
RBG.The association between poorly controlled blood glucose and higher mortality in patients
with DM and COVID-19 has been reported in many studies
1,9
. Additionally, median NLR and
serum ferritin levels were almost double among deceased compared to survived. Highly elevated
NLR and serum ferritin essentially indicate excessive inflammation leading to cytokine storm
and multiple organ damage in patients with COVID-19. Significantly higher NLR and serum
ferritin levels among non-survivors compared to survivors were reported in already published
studies [10,11].
All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprintthis version posted April 7, 2021. ; https://doi.org/10.1101/2021.04.04.21254884doi: medRxiv preprint

Citations
More filters
Journal ArticleDOI
TL;DR: There is high rate of mortality in neurological patients with COVID-19 who have variable neurological diagnosis including stroke, autoimmune disease and cerebral infections and co-existent diabetes further increases the rates of mortality.
Abstract: Background: The presentation of corona virus disease 2019 (COVID-19) may include neurological features and patients with neurological disorders may develop concomitant COVID-19 during pandemic. Hyperglycemia leads to higher propensity to COVID-19 infection with higher disease severity. Objective: To assess the neurological diagnoses, glycemic status and outcome in patients hospitalized primarily for neurological problems and subsequently diagnosed as COVID-19. Methods: This retrospective cohort study was conducted in National Institute of Neurosciences (NINS) & Hospital, Dhaka, Bangladesh. Patients admitted to adult Neurology ward during April to November 2020 primarily for neurological problems and diagnosed as confirmed COVID-19 (with positive RT-PCR test for COVID-19) were included. The hospital records were reviewed and recorded in a checklist. Outcome of patients referred to COVID-19 dedicated hospitals was obtained over telephone. Results: The study included 85 patients with COVID-19 [median age 60 years (IQR: 45-65); 63.5% male]. Acute ischemic stroke was the most common neurological diagnosis (32.9%), followed by acute hemorrhagic stroke and subarachnoid hemorrhage (22.4% and 15.3% respectively). Other neurological diagnoses were meningoencephalitis (7.1%), Guillain Barre Syndrome (4.7%), Myasthania Gravis (1.2%), brain abscess (1.2%) and intracranial space occupying lesion (1.2%). Fourteen percent patients had no definite neurological diagnosis, they were admitted for delirium. History of diabetes was present in 18% patients. The mortality was 27% and the proportion of mortality was significantly higher in patients known to have DM in comparison to those who were not (p=0.012). The mean age and proportion of male sex was significantly higher among those who expired. Conclusion: There is high rate of mortality in neurological patients with COVID-19 who have variable neurological diagnosis including stroke, autoimmune disease and cerebral infections. Co-existent diabetes further increases the rate of mortality. Journal of National Institute of Neurosciences Bangladesh, July 2021, Vol. 7, No. 2, pp. 97-102
References
More filters
Journal ArticleDOI
07 Apr 2020-JAMA
TL;DR: Hospitalised COVID-19 patients are frequently elderly subjects with co-morbidities receiving polypharmacy, all of which are known risk factors for d
Abstract: Background: Hospitalised COVID-19 patients are frequently elderly subjects with co-morbidities receiving polypharmacy, all of which are known risk factors for d

14,343 citations

Journal ArticleDOI
TL;DR: The results of this nationwide analysis in England show that type 1 and type 2 diabetes were both independently associated with a significant death with COVID-19, and the effects were attenuated to ORs of 2·86 (2·58–3·18) for type 1 diabetes and 1·80 (1·75–1·86) fortype 2 diabetes when also adjusted for previous hospital admissions with coronary heart disease, cerebrovascular disease, or heart failure.

662 citations

Journal ArticleDOI
TL;DR: The aim of this study was to determine the role of ferritin in COVID‐19, a pandemic coronavirus disease that has rapidly developed into aPandemic.
Abstract: OBJECTIVE: The coronavirus disease 2019 (COVID-19) has rapidly developed into a pandemic. Increased levels of ferritin due to cytokine storm and secondary hemophagocytic lymphohistiocytosis were found in severe COVID-19 patients. Therefore, the aim of this study was to determine the role of ferritin in COVID-19. METHODS: Studies investigating ferritin in COVID-19 were collected from PubMed, EMBASE, CNKI, SinoMed, and WANFANG. A meta-analysis was performed to compare the ferritin level between different patient groups: non-survivors versus survivors; more severe versus less severe; with comorbidity versus without comorbidity; ICU versus non-ICU; with mechanical ventilation versus without mechanical ventilation. RESULTS: A total of 52 records involving 10 614 COVID-19-confirmed patients between December 25, 2019, and June 1, 2020, were included in this meta-analysis, and 18 studies were included in the qualitative synthesis. The ferritin level was significantly increased in severe patients compared with the level in non-severe patients [WMD 397.77 (95% CI 306.51-489.02), P < .001]. Non-survivors had a significantly higher ferritin level compared with the one in survivors [WMD 677.17 (95% CI 391.01-963.33), P < .001]. Patients with one or more comorbidities including diabetes, thrombotic complication, and cancer had significantly higher levels of ferritin than those without (P < .01). Severe acute liver injury was significantly associated with high levels of ferritin, and its level was associated with intensive supportive care, including ICU transfer and mechanical ventilation. CONCLUSIONS: Ferritin was associated with poor prognosis and could predict the worsening of COVID-19 patients.

223 citations

Journal ArticleDOI
TL;DR: The worldwide experience of the COVID-19 pandemic offers the possibility to not only prepare better for future disasters but also transform diabetes care beyond the CO VID-19 era.
Abstract: The COVID-19 pandemic has added an enormous toll to the existing challenge of diabetes care world-wide. A large proportion of patients with COVID-19 requiring hospitalization and/or succumbing to the disease have had diabetes and other chronic conditions as underlying risk factors. In particular, individuals belonging to racial/ethnic minorities in the U.S. and other countries have been significantly and disproportionately impacted. Multiple and complex socioeconomic factors have long played a role in increasing the risk for diabetes and now for COVID-19. Since the pandemic began, the global healthcare community has accumulated invaluable clinical experience on providing diabetes care in the setting of COVID-19. In addition, understanding of the pathophysiological mechanisms that link these two diseases is being developed. The current clinical management of diabetes is a work in progress, requiring a shift in patient-provider interaction beyond the walls of clinics and hospitals: the use of tele-medicine when feasible, innovative patient education programs, strategies to ensure medication and glucose testing availability and affordability, as well as numerous ideas on how to improve meal plans and physical activity. Notably, this worldwide experience offers us the possibility to not only prepare better for future disasters but also transform diabetes care beyond the COVID-19 era.

97 citations

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Frequently Asked Questions (6)
Q1. What are the contributions in "Comparing between survived and deceased patients with diabetes mellitus and covid-19 in bangladesh: a cross sectional study from a covid-19 dedicated hospital" ?

Comparing between survived and deceased patients with Diabetes Mellitus and COVID-19 in Bangladesh: A cross sectional study from a COVID-19 dedicated hospital Md. Shahed Morshed, Abdullah Al Mosabbir, Mohammad Sorowar Hossain * # contributed equally 1 Emergency medical officer, Kurmitola general hospital, Dhaka, Bangladesh 2 Department of Emerging and Neglected Diseases, Biomedical Research Foundation, Dhaka, Bangladesh 

The authors believe this is a unique finding for resource-poor settingsand needs further research. 

Patients having glycated hemoglobin (HbA1c) ≥6.5% done within three months of admission were also included as having pre-existing DM. 

While ICU support was indicated in over 30% (72/231) of diabetic patients, more than half of them (43/72) could not be admitted into ICU due to the acute bed crisis (only a ten bedded ICU support in the study hospital). 

While intensive care unit (ICU) support was indicated for 31.2% (72/231) patients with DM, only 12.5% (29/231) of them got ICU admission (Fig 1). 

The authors believe findings from this study will help clinicians to identify a subgroup of diabetic patients with COVID-19 who are at higher risk of in-hospital death; hence, requiring rigorous clinical management.