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Krishnan A, Kumar R, Amarchand R, Mohan A, Kant R, Agarwal A, Kulshreshtha P, Panda PK, Bhadoria AS, Agarwal N, Biswas B, Nair R, Wig N, Malhotra R, Bhatnagar S, Aggarwal R, Soni KD, Madan N, Trikha A, Tiwari P, Singh AR, Wyawahare M, Gunasekaran V, Sekar D, Misra S, Bhardwaj P, Goel AD, Dutt N, Kumar D, Nagarkar NM, Galhotra A, Jindal A, Raj U, Behera A, Siddiqui S, Kokane A, Joshi R, Pakhare A, Farooque F, Pawan S, Deshmukh P, Solanki R, Rathod B, Dutta V, Mohapatra PR, Panigrahi MK, Barik S, Guleria R. Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study. Am J Trop Med Hyg 2023; 108:727-733. [PMID: 36913920 PMCID: PMC10077017 DOI: 10.4269/ajtmh.22-0705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/12/2023] [Indexed: 03/15/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.
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Affiliation(s)
- Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rakesh Kumar
- Centre for Community Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ritvik Amarchand
- Centre for Community Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | | | | | | | | | | | - Neeraj Agarwal
- Department of Community & Family Medicine, AIIMS, Patna, India
| | - Bijit Biswas
- Department of Community & Family Medicine, AIIMS, Patna, India
| | | | - Naveet Wig
- Department of Medicine, AIIMS, New Delhi, India
| | - Rajesh Malhotra
- Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia, BRAIRCH, AIIMS, New Delhi, India
| | - Richa Aggarwal
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
| | - Kapil Dev Soni
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
| | - Nirupam Madan
- Department of Hospital Administration, AIIMS, New Delhi, India
| | - Anjan Trikha
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | | | - Mukta Wyawahare
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), India
| | | | - Dineshbabu Sekar
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), India
| | | | - Pankaj Bhardwaj
- Department of Community & Family Medicine, AIIMS, Jodhpur, India
| | | | - Naveen Dutt
- Department of Pulmonary Medicine, AIIMS, Jodhpur, India
| | | | | | | | - Atul Jindal
- Department of Paediatrics, AIIMS, Raipur, India
| | - Utsav Raj
- National Tuberculosis Elimination Program, AIIMS, Raipur, India
| | - Ajoy Behera
- Department of Pulmonary Medicine, AIIMS, Raipur, India
| | | | - Arun Kokane
- Department of Community & Family Medicine, AIIMS, Bhopal, India
| | | | - Abhijit Pakhare
- Department of Community & Family Medicine, AIIMS, Bhopal, India
| | - Farhan Farooque
- Department of Community & Family Medicine, AIIMS, Bhopal, India
| | - Sai Pawan
- Department of Medicine, AIIMS, Bhopal, India
| | | | - Ranjan Solanki
- Department of Community & Family Medicine, AIIMS, Nagpur, India
| | | | | | | | | | - Sadananda Barik
- Department of Trauma & Emergency Medicine, AIIMS, Bhubaneswar, India
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Ali SS, Rabbani MA, Moinuddin SSM, Virani S, Farooque F, Salam A, Ahmad A. Maximum tolerable dose of cyclophosphamide and azathioprine in Pakistani patients with primary renal disease. J PAK MED ASSOC 2004; 54:39-42. [PMID: 15058645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE The immunosuppressive regimens, at present, mainly rely on western guidelines that were derived from studies conducted in western populations. No such study exists for South Asian population, which is home to almost two billion people different in both genetics and environment from west. Locally derived thresholds for side effects markedly different from western figures may warrant re-adjustment of current local immunosuppressive regimens that are at present based largely on western guidelines. In order to define optimum dose for Cyclophosphamide (CYC) and Azathioprine (AZA) based immunosuppressive therapy, we conducted this study to find out maximum tolerable doses of azathioprine (AZA) and cyclophosphamide (CYC) beyond which neutropenia and thrombocytepenia are most likely to occur in patients with primary renal pathology. METHOD Patients with systemic vasculitis and idiopathic glomerulonephritis who were on CYC and AZA were identified through review of medical records at a tertiary care hospital in Pakistan (The Aga Khan University Hospital, Karachi). Patients were categorized under three principal diagnosis i.e. systemic lupus erythematosus (SLE), primary (idiopathic) glomerulonephritis (GN) and Wegener's granulomatosis (WG). The Receiver Operating Curve (ROC) was used to calculate the maximum tolerable dose for both CYC and AZA. RESULTS We identified 94 patients aged 6-82 years (median 44.5 years) with primary renal disease (Wegener's granulomatosis n=13, Systemic lupus erythematosis n=62 and idiopathic glomerulonephritis n=19) who received CYC or AZA. Of these 94 patients, 36.2% (n=34) received CYC and 63.8% (n=60) received AZA. The mean dose of CYC was 1.54 +/- 0.50 mg/kg of body weight (range: 0.77-2.93). The mean dose of AZA was 1.64 +/- 0.59 mg/kg of body weight (range: 0.47-2.97). The maximum tolerable doses calculated for CYC and AZA were 1.25 mg/kg and 1.30 mg/kg of body weight respectively. The maximum tolerable dose for CYC and AZA among males could not be calculated, because of insufficient number of patients who developed neutropenia and thrombocytopenia. The maximum tolerable doses for CYC and AZA among females were 1.34 mg/kg and 1.03 mg/kg of body weight respectively. Also we found out that AZA was relatively more likely to cause neutropenia and thrombocytopenia (p=0.07). CONCLUSION We thereby recommend that CYC should be initiated at a dose no more than 1 mg/kg of body weight and AZA at an initial dose of 0.75-1.0 mg/kg of body weight. The dose may be adjusted later on the basis of clinical response and laboratory reports.
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Affiliation(s)
- S S Ali
- Department of Medicine, The Aga Khan University Hospital, Karachi
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