The Baseline Characteristics of Patients with COVID-19 and Impact of Various Risk Factors on the Outcome of Patients Admitted in Tertiary Care Hospital.

Background: The outbreak caused by novel coronavirus was rst reported in Wuhan, China in December 2019 when a new pathogen was discovered from the bronchoalveolar lavage uid of the patient suffering from pneumonia. Globally over 81.47 million conrmed cases and 1.79 million deaths has been reported. The clinical spectrum ranges from mild inuenza-like illness to severe life threatening respiratory disease requiring ventilatory support to death. The purpose of this study was to evaluate the baseline carecteristic of the patients and impact of various risk factors on the outcome of patients admitted in tertiary care hospital. This study included and The years were in and The most prevalent were according to


Introduction
The outbreak caused by novel coronavirus was rst reported in Wuhan, China in December 2019 when a new pathogen was discovered from the bronchoalveolar lavage uid of the patient suffering from pneumonia. 1 The said pathogen had the similar features of the coronavirus family and therefore was classi ed in the subgenus Sarbecovirus, Orthocoronavirinae subfamily. The virus is named as severe acute respiratory distress syndrome coronavirus 2 and the disease caused by it is named as coronavirus disease 2019" (COVID-19). 2 World Health Organization on 11th March 2020 decalared Coronavirus Disease(COVID-19) caused by Coronavirus-2 as pandemic and upto 30th September 2020 at the closure of study globally over 32.7 million con rmed cases and 991000 deaths has been reported. 3,4 The incubation period of Coronavirus disease ranges from 2 to 14 days with clinical spectrum varying from mild in uenza-like illness to severe life threatening respiratory disease requiring ventilatory support to death. It has been reported recently that nearly 14 to 29% hospitalized patients with COVID-19 pneumonia require intensive care support for respiratory support for hypoxic respiratory failure, with acute respiratory distress syndrome (ARDS) developing in 33% of hospitalized patients within 8 days of onset of symptoms. 5,6 The most common symptoms of COVID-19 are cough, fever, and breathlessness. Gastrointestinal symptoms such as diarrhea, nausea or vomiting are also common. 7 It has now been observed that old age and other comorbidities are potential risk factors for the worse outcome of COVD-19 patients. 8 According to preliminary data nearly 30% patients were > 65% years of age and nearly 25% patients had anyone underling medical condition. Among the common medical conditions include diabetes mellitus, hypertension, cardiovascular disease, obesity and chronic pulmonary ,renal disease and the severity of disease at admission. But the impact of each factor has not been asessed leading to variability in management and outcome. 5,9 The purpose of this study was to evaluate the baseline carecteristic of the patients suffering from COVID- 19 and impact of various risk factors on the outcome of patients admitted in a tertiary care hospital.
Materials And Methods 2.1. Subjects: This cross-sectional study included 235 consecutive adults (>18 years age) of either sex admitted at Liaquat University Hospital from April 2020 to September 2020. The patients were included on the basis of diagnosis of COVID-19 con rmed on reverse transcription Polymerase Chain reaction (RT-PCR) test. The approval for study was obtained from University ethical committee.
All patients were admitted in High Dependency Unit (HDU) and shifted to Intensive care Unit (ICU) speci ed for COVID-19 patients based on the following criteria: 10 1. Respiratory rate > 40 breaths/min. 2.6.De nitions: 1.Acute respiratory distress syndrome (ARDS) : was de ned by the Berlin de nition which requires that all of the following criteria be present for diagnosis: 11 Respiratory symptoms must have begun within one week of a known clinical insult, or the patient must have new or worsening symptoms during the past week.
Bilateral opacities must be present on a chest radiograph or computed tomographic (CT) scan not explained by pleural effusions, lobar collapse, lung collapse, or pulmonary nodules.
Oxygenation A moderate to severe impairment of oxygenation must be present, as de ned by the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO 2 /FiO 2 ). The severity of the hypoxemia de nes the severity of the ARDS: Mild ARDS -The PaO 2 / FiO 2 is >200 mmHg, but ≤300 mmHg, on ventilator settings that include positive end-expiratory pressure (PEEP)  The results of above variables were placed in calculator available on the website https://www.mdcalc.com/covid-gram-critical-illness-risk-score.
Based on the results of patients were categorized into low , moderate and high risk group. 8. Outcomes 18,19 Recovery: According to WHO recovery time described as return to baseline health after hospitalization is two weeks.
Prolong stay: who have ongoing shortness of breath, some requiring supplemental oxygen, or with persistent chest pain on exertion, blood clotting problems, poor concentration, gastrointestinal distress, and reduced muscle strength and impaired grasping power after two weeks of hospital admission.

COVID-19-Related Deaths :
The case-fertility is de ned as the proportion of COVID-19 related deaths among patients who were COVID-19 positive on PCR irrespective of pre-existing diseases that may have caused death.

Statistical Analysis
Categorical variables such as age, sex, Gram-Covid risk category,diabetes mellitus, hypertension, renal, pulmonary disease, obesity, outcome of patient were presented as frequency and percentage .
The predictive accuracy of age,sex,severity of illness and comorbidities related to outcome was tested by measuring the area under curves receiver oprating characteristic (AUCROC). Based on ROC, the best cutoff points was chosen. Diagnostic accuracy was evaluated by calculating the sensitivity, speci city, positive predictive value and negative predictive value (PPV,NPV). ROC curve comparison was performed which uses calculation of the area under curve and 95% con dence interval (CIs) by the technique described by Hanley and McNeil. 20 The main end point was to observe the relationship of age, gender, severity of illness and comorbidities with the outcome of patients. We used SPSS (version 22.0) for all analyses. A p < 0.05 was considered as statistically signi cant. This study included 235 consecutive patients admitted in HDU/ ICU from April 2020 to September 2020. There were 187(79.6%) male and 48(20.4 %) female. The age < 65 years were present in 80 (34%) and ≥ 65 155(66%) patients. The most prevalent symptoms were fever ,breathlessness, cough, anorexia, fatigue in all 235(100%) patients.Severity of illness according to Gram-Covid Score showed 18 (7.7%) patients were in low-risk group, 93(39.6%) in moderate risk group and 124 (52.8%) in high risk group. There were no co-morbidity in 121(51.5%), one co-morbidity in 49(20.9%), two co-morbidities in 32 (13.6%), three comorbidities in 18(7.7%) and four co-morbidities in 15 (6.4%) patients.    No: 2 shows the laboratory workup of patients.  AUCROC of number of Co-morbidities with outcome was 0.81(0.75-0.88) with sensitivity of 88% and speci city of 64% negative predictive value of 99% and positive predictive value of 88% (p = 0.010).  incomplete. 29 Wang D and colleagues in a study of 143 patients observed that mortality was14 /143 (11.2 %) in moderate, 23/143 (33.3%) in severe and 68 (67.3% ) in critical cases. 21 Car and colleagues in a study of 143 patients observed that only 13% patients were symptom free after mean 60 days of disease onset. The most common persistent symptoms were fatigue (53 percent), dyspnea (43 percent), joint pain (27 percent), and chest pain (22 percent); none had fever or features concerning for acute illness. 37 Tenforde MW and collogues in a multistate telephonic survey of 292 patients having symptoms of cough, fever, breathlessness and fatigue at the time of testing revealed that 65% patients returned to the baseline health with a median of 7 days(5-12 days). Up to 43% of patients having cough,35% with fatigue and 29% having breathlessness at the time of testing continue to have these symptoms at the > two to three weeks after testing. 18 A strong relationship was observed between the outcome of patient with age,, gram -Covid score risk category and number of comorbidities.
In our study relationship of age with outcome was strong as 6 deaths, 25 prolong stay and 49 recovered were observed in patients < 65 years of age whereas 51deaths,82 prolong stay and 22 recovery in age group > 65 years. AUCROC of age with outcome was 0.65(0.58-0.70) with sensitivity of 90% and speci city of 42%, negative predictive value of 98.7% and positive predictive value of 64% (p = 0.010).
In US epidemiologic study a high mortality ranging from 10%-27% was observed in the age group 85 and above,3%-11% in a age group 65-84 years, 1%-3% in a age group 55-64 years, and < 1% in people younger than 55 years. 38 Harrison S and colleagues in a multicenter study comprising 31461 patients observed the risk of death in patients > 70 years was 1.3 times greater with heart failure, 1.9 times greater with renal disease compared to those without any these conditions. 39 In a cohort of 44000 con rmed cases of COVID  40 According to a Chinese study the mortality of male were 2.8% versus 1.7% for female. 41 The reasons for high mortality in our study might be due to high number of co-morbidities, more severe illness and more age among female patients.
In our study the severity of illness according to Covid Gram-score showed in Low-risk category 0 deaths,3 prolong stay and 15 recovery. Authors' contributions: This work was carried out in collaboration among all authors. Author S. Shaikh designed the study, performed the statistical analysis, wrote the protocol and wrote the rst draft of the manuscript. Authors Fiaza Deedar and Devrajani Tara Chand managed the analyses of the study. Author Devrajani Tara Chand managed the literature searches. All authors read and approved the nal manuscript.