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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
Images in Medicine
Full Version
Prevalence of Anaemia and its Association with Severity of COVID-19 among Hospitalised Patients: A Cross-sectional Study
Correspondence Address :
Dr. Anirban Ghosh,
Flat 2A, Fountain Exotica, 432, Mahamayatala, Kolkata-700103, West Bengal, India.
E-mail: ani.medico@gmail.com
Introduction: Coronavirus Disease-2019 (COVID-19) emerged as a global pandemic and was associated with various haematologic abnormalities. There are very few studies from India regarding the association between anaemia and disease severity of COVID-19.
Aim: To check the prevalence of anaemia and its association with the severity of the disease among hospitalised COVID-19 patients.
Materials and Methods: This was a cross-sectional study involving 203 patients admitted to the general ward and Intensive Care Unit (ICU) of a tertiary care hospital in eastern India. Complete blood count at admission along with other relevant clinical and laboratory parameters were noted. Haematological parameters of the patients were described and then correlated with disease severity and death. Spearman’s correlation and Chi-square test were used to determine the associations.
Results: Out of 203 patients with COVID-19, 145 (71.4%) had anaemia. The study included 107 males (52.7%) and 96 females (47.3%), of which 77 (80%) females had anaemia compared to 68 (63.5%) males. Co-morbidities were present in 73 patients. Haemoglobin levels were significantly negatively correlated with disease severity (p<0.001). This was even true for patients without any other co-morbidities (p<0.05). Haemoglobin was also negatively correlated with deaths in this study (p<0.05).
Conclusion: The prevalence of anaemia in admitted patients with COVID-19 was very high, and low haemoglobin levels were associated with more severe disease and death. Therefore, low haemoglobin levels in COVID-19 may be considered a risk factor for more severe disease and death.
Blood count, Co-morbidity, Coronavirus, Death, Severe
COVID-19 has emerged as a global pandemic with over 628 million cases and 6.5 million deaths officially recorded as of November 2022 (1). India has also had to bear a major impact with more than 44 million cases and 0.5 million deaths till date (2).
Haematologic abnormalities in the form of reduced lymphocytes and an increased neutrophil-to-lymphocyte ratio, have been extensively studied and linked to disease severity (3),(4),(5). A Chinese study in 2021 described an association between anaemia and COVID-19 (6). However, the association between haemoglobin levels of patients and their outcome has been less frequently described in the Indian context (7). There is inadequate data with respect to this association in Indian patients across all classes of severities, ranging from mild to severe COVID-19. Haemoglobin level as a risk factor for severe disease has not been studied adequately in the Indian context. The Indian study that has been found on this subject has shown increased severity of disease associated with low haemoglobin levels but it has included only patients from ICUs (7). So, naturally that study included patients only with severe disease but not the vast majority of the patients with mild or moderate disease who were managed in general wards. This current study included patients from both general wards and ICU so that the subjects belong to all classes of severities and also included those with and without co-morbidities. This present study aimed to analyse the prevalence of anaemia on admission in hospitalised patients of COVID-19 and the association of haemoglobin levels with the severity of COVID-19 and death.
This cross-sectional study was conducted on the hospitalised patients admitted between March 2021 and October 2021 in ESI-PGIMSR and ESIC Medical College and Hospital, Joka, Kolkata, West Bengal, India. Ethical clearance was taken from the Institutional Ethics Committee (IEC) for the study {No. 412(Dean Joka)/IEC (Joka)/2022}.
Inclusion criteria: All hospitalised patients who were tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus infection by Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test or Rapid Antigen Test (RAT) were included in the study.
Exclusion criteria: Patients who had incomplete data (inadequate documentation of clinical parameters) to determine severity and incomplete investigation reports of complete blood count and patients who left hospital against medical advice were excluded from the study. The number of total exclusions were 36.
Procedure: After satisfying the inclusion and exclusion criteria, a total of 203 patients were included in the study. The clinical notes indicating the severity of COVID-19 (mild/moderate/severe) were studied and noted. The classification was based on the official COVID-19 management protocols issued by the Ministry of Health and Family Welfare, Government of India (8). Mild cases had no shortness of breath or hypoxia, moderate cases had dyspnoea and/or hypoxia (oxygen saturation 90-93% on room air), respiratory rate of more or equal to 24/minutes. Severe cases had features of pneumonitis along with either of Oxygen saturation <90%, respiratory rate >30 and severe respiratory distress. The data studied were the clinical findings including the age, pulse rate, blood pressure, sensorium, respiratory rate and oxygen saturation along with the presence of any co-morbidity.
Laboratory data on complete blood count in the form of haemoglobin, neutrophil, lymphocyte and neutrophil:lymphocyte ratio was studied. Clinical outcomes were also noted in the form of death or discharge. The random capillary blood glucose, serum urea, creatinine and C-reactive protein on admission were noted. World Health Organisation (WHO) recommendations were followed for diagnosis and severity assessment of anaemia (9). Anaemia is defined as haemoglobin <13 and 12 g/dL, respectively for adult males and non pregnant adult women respectively. The cut-off level is 11 g/dL for pregnant women. Anaemia is further classified into severe (<8 g/dL for men and non pregnant women, <7 g/dL for pregnant women), moderate (8 < Hb < 11 g/dL for adult men and non pregnant women, 7-10 g/dL for pregnant women) and mild (Hb=11-13 g/dL for adult men, 11-12 g/dL for adult non pregnant female and 10-11 g/dL for pregnant women).
Statistical Analysis
The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 18.0. Descriptive statistics in the form of mean, median, range and standard deviation of the parameters were studied. Spearman correlation was done between the haemoglobin levels and the severity of COVID-19. Correlation between COVID-19 deaths and haematological parameters were also assessed. Chi-square test was done to see the association between severity of anaemia and severity of COVID-19. A p-value <0.05 was considered to be statistically significant.
The total number of patients recruited in the study were 203 with 107 males (52.7%) and 96 females (47.3%). The mean±SD age was found to be 55.7±15.34 years (range 18-88 years). The mean±SD haemoglobin level was 11.14±2.17 g/dL (range 4.3-16.6 g/dL). Anaemia was found in 145 patients (71.4%), 77 out of 96 (80%) female patients had anaemia, whereas 68 out of 107 (63.5%) male patients had anaemia. Anaemia was significantly associated with female sex (Chi-square value 6.88, p-value <0.01). Mild anaemia was found in 51 patients, moderate in 79 patients and severe was found in 15 patients (Table/Fig 1). (Table/Fig 2) shows the descriptive statistics of the demographic, clinical and laboratory parameters of the patients.
The number of patients categorised as having mild, moderate and severe disease were 89 (43.8%), 38 (18.7%) and 76 (37.4%), respectively. The number of deaths was 41 (20.2%). (Table/Fig 3) shows a glimpse of co-morbidities found in the patients. The most common co-morbidities were hypertension 66 (32.5%) and Diabetes Mellitus 49 (24.1%). Eight of the included patients were pregnant out of which one had an abortion and four underwent caesarean section at term.
Significant positive association was found between the severity of anaemia and the severity of disease (Chi-square value: 19.68, p-value <0.005) (Table/Fig 4).
The analysis of data revealed that there was significant negative correlation between haemoglobin values and severity of COVID-19. (Spearman’s rho-0.306, p-value <0.001). This was found to be true even in the 130 patients without any other co-morbidities (Spearman rho: -0.3, p-value <0.05). Haemoglobin level was also found to have mild negative correlation with death (Spearman rho: -0.154, p-value <0.05). The severity was found to have positive correlation with total leukocyte count (Spearman rho: 0.267, p-value <0.01), Neutrophil count (Spearman rho: 0.375, p-value <0.001), neutrophil:lymphocyte ratio (Spearman’s rho: 0.384, p-value <0.001). There was positive correlation between death and neutrophil:lymphocyte ratio (Spearman rho: 0.342, p-value <0.001). (Table/Fig 5) shows the associations of severity of COVID-19 and death with different laboratory parameters.
This cross-sectional data from a tertiary care government hospital in eastern India shows that anaemia is highly prevalent with presence in 71.4% of patients admitted with COVID-19. Female sex had higher prevalence of anaemia than males. Other studies from India and abroad have shown high prevalence of in COVID-19 patients [6,7,10-12]. A study by Jha M et al., on 784 COVID-19 patients from India in 2022 showed anaemia prevalence of 44% (6). Studies by: i) Chen C et al., from China in 2021 with 137 patients showed prevalence of 44.5%; ii) Oh SM et al., from USA in 2021 with 4356 patients showed prevalence of 43.3%; iii) Bergamaschi G et al., from Italy in 2021 with 206 patients showed prevalence of 61%; and iv) Faghih Dinevari M et al., from Iran in 2021 with 1274 patients showed prevalence of 48.3% [7,10-12]. So, anaemia can be considered as a common manifestation of COVID-19. Lower haemoglobin levels were found to be associated with increased severity of infections and also death. Haemoglobin level was found to be significantly associated with severity of disease even in patients who didn’t have any other comorbidities suggesting that low haemoglobin levels can be considered as an independent risk factor for more severe disease. Among the co-morbidities, other than hypertension 66 (32.5%) and diabetes mellitus 49 (24.1%), renal impairment 24 (11.8%) in the form of AKI and CKD were found to be the most common associations.
Studies on anaemia in COVID-19 are few especially from India. One study published recently from western part of India has shown the association of anaemia with death in patients admitted in ICUs (6). This study showed significant correlation between anaemia and disease severity and suggested that anaemia can be included as an independent risk factor for prognostication of COVID-19 but as stated earlier this study involved patients admitted only in the ICU and but didn’t include patients from general wards. Another study from USA has also shown that anaemia on admission predicts mortality in COVID-19 patients. It showed that anaemia was independently associated with increased odds of all-cause mortality in hospitalised COVID-19 patients. Also, moderate-severe anaemia (Hb <11 g/dL) was found to be an independent risk factor for severe COVID-19 outcomes (10). One study from Italy has however shown that though anaemia has been found to be a common manifestation of COVID-19, but it isn’t associated with increased mortality (11).
A study from Iran evaluated the effects of anaemia on COVID-19 and was found to be associated with poorer outcomes including increased mortality (12). To the best of our knowledge, present study was probably the first study from India evaluating the haemoglobin levels in COVID-19 disease encompassing patients from all grades of severity and admitted in both ICU and general wards.
Hypothetically, anaemia in COVID-19 has been attributed to a number of factors. The major theories are: i) Interaction of SARS-nCov-2 with Haemoglobin by CD 147, CD 26 and some other receptors resulting in a haemoglobinopathy; ii) Hepcidin mimetic action of viral element with ferroportin blockage (13). Haemoglobin denaturation and iron metabolism dysregulation are considered in some studies as resulting in anaemia in COVID-19 (13).
Limitation(s)
More number of patients could have presented a better analysis of the associations. There was no control group for comparison with patients who were negative for COVID-19. Some conditions like chronic kidney disease, thalassaemia and gastrointestinal bleeding would themselves contribute to the anaemia and increased severity of COVID-19. Co-morbid conditions like obstructive airway disease, diabetes mellitus, ischaemic heart disease themselves may increase the severity of the disease. Also, the haemoglobin level was taken at the time of admission of the patients, so records of past or future haemoglobin estimations indicating any dynamic change could not be evaluated from this study. So, a retrospective cohort or case-control study with larger sample size may provide more information on the causal relationships between risk factors and severity of COVID-19.
This study describes the high prevalence of anaemia in COVID-19 in hospitalised patients due to all causes and also attempts to have a glimpse of its association with the severity and outcome. Low haemoglobin, high leukocyte count and high neutrophil:lymphocyte ratio have been found to be associated with increased severity and mortality. Therefore, low haemoglobin levels in COVID-19 may be considered as a risk factor for more severe disease and death. Hence, in a developing country like India with limited resources, a simple baseline blood test like a complete blood count can be used to predict and prevent poorer outcomes in the disease process.
Authors are grateful to all the doctors and staffs of the Medical Record Department of our institute for their cooperation in collection of the data.
DOI: 10.7860/JCDR/2023/63141.18006
Date of Submission: Jan 28, 2023
Date of Peer Review: Mar 01, 2023
Date of Acceptance: Apr 27, 2023
Date of Publishing: May 01, 2023
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? No
• For any images presented appropriate consent has been obtained from the subjects. No
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