Diabetes as a predictive factor for severe form and high mortality risk of COVID-19: Retrospective cohort study of 188 cases

Introduction Since the appearance of the first case of the SARS CoV 2 infection, several studies have been conducted to identify the predictive factors of mortality in patients with COVID-19. According to previous reports, diabetes seems to be associated with severe clinical forms of the new coronavirus (SARS CoV 2). Our study aimed to identify the epidemiological, clinical, radiological and prognostic profile of diabetic patients with COVID-19. Methods This retrospective study included diabetic patients diagnosed with COVID-19 and admitted to the Resuscitation Department of our university hospital center From Mars 1st 2020, to December 31st, 2020. Results and discussion In this study, we collected the data of 600 patients admitted to the Anesthesia and Resuscitation Department of the Mohammed VI University Hospital of Oujda, a group of 188 (31.3%) had diabetes. The median age of our patients was 67 [25–75]. Were noted in the majority, of patients 69.6% with diabetes have developed a severe or critical injuries in the Chest CT Scan. Furthermore, we found that the mortality rate in this category of patients was higher 65/188 (34.60%) compared to non-diabetic patients, 130/412 (31.60%) (34.60%vs 31.60%; p: 0.464). Conclusion Based on the results of this retrospective study, we concluded that diabetes is predictive factor for the need of an intensive care as well as a high risk of mortality related to COVID-19. Practically speaking, diabetic patients should be monitored more closely and need an aggressive preventive management protocols in order to prevent severe forms of the disease and a drastic evolution. More research is direly needed to identify patients of a higher risk of developing severe forms of COVID-19.


Introduction
As of December 2019, the COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was initially identified in Wuhan, China and has rapidly become a global pandemic [1,2].
Several studies have shown that diabetes is associated with severe forms and complications of COVID-19: such as acute respiratory distress syndrome (ARDS), admission to the intensive care unit (ICU), use of mechanical ventilation, as well as a high mortality rate.
This chronic condition increases the risk of disabling and life-threatening complications from micro-and macro-vascular diseases [3]. Which is important to understand the special aspects of COVID-19 infection in people with this underlying comorbidity [4]. This study was conducted for the purpose of identifying the epidemiological, clinical, radiological and prognostic profile of diabetic patients with COVID-19 managed at the Anesthesia and Resuscitation Department of Mohammed VI University Hospital of Oujda -Morocco.

Objectives
The objective of this 10-months long retrospective study was to determine whether diabetes is a predictive factor for the occurrence of severe forms and high rate mortality related to COVID-19 in our department.

Type of study
We conducted a retrospective cohort study, mono-centric, of diabetic patients with SARS CoV 2 pneumonia hospitalized in the Anesthesia and Resuscitation Department of the Mohammed VI University Hospital of Oujda during a ten months period, from March the 1st to December the 31st, 2020.

Inclusion criteria
Among the 600 patients gathered, a 188 had diabetes in this study were hospitalized, and diagnosed according to the World Health Organization (WHO) provisional guidelines.
Cases infected with SARS-CoV-2 were confirmed by reverse transcription-polymerase chain reaction (RT-PCR) testing of throat and nose samples or Chest CT Scan typically for COVID-19 during the study period spread over 10 months, between March 2020 and December 2020 were included in the study.

Data collection
Patient's baseline characteristics were noted in the time of admission (day zero) such as medical history, degree of pulmonary involvement, type of oxygen supplementation as well as the outcome.
The term "death due to COVID-19" according to WHO: "is a death resulting from a clinically compatible disease, in a probable or confirmed case of COVID-19, in the absence of any other obvious cause of death unrelated to the coronavirus disease" this definition was used in this work.

Statistical analysis
Statistical analysis was conducted using the SPSS version 25.0. to determine the most powerful factors, such as demographic data, including age and gender, and underlying diseases affecting the mortality outcome among COVID-19 patients with diabetes, and with other comorbidities [5].

Ethical approval and consent
This study does not require a formal ethical committee approval. Access to the data was authorized and approved by the head of Department.
Given the retrospective design of this study, the requirement of patient consent is lifted. Data anonymity was respected in accordance with national and international guidelines.
Our study was registered in Research Registry under the number: 7171.
This work has been reported in line with the STROCSS criteria [11].

Results
Six hundred (600) cases were admitted to our department, among them a 188 (31.3%) diabetic patients were included after fulfilling inclusion criteria.

Complications and outcome
Among the 188 diabetic patients included in our study, 65 out of 188 (34.6%) died.
Furthermore, in our study we found that the evolution of diabetic patients hospitalized in the Anesthesia and Resuscitation Department of the Mohammed VI University Hospital of Oujda was characterized by the occurrence of multiple complications (represented in • Myocarditis: 9 (4.8%)

Discussion
COVID-19 is a global health crisis, challenging the preparedness of health systems' all over the world as well as the ability to cope with and sustain a pandemic response [3]. It has been clinically observed that diabetes was associated with an increased risk of developing severe forms of COVID-19 such as ARDS (acute respiratory distress syndrome) and increased mortality risk.
Many studies conducted during the recent crisis, reported that diabetes plays a critical role in the outcome of SARS-CoV-2 pneumonia. According to a Chinese data on more than 70,000 cases, the overall mortality linked to COVID-19 was 2.3% versus 7.3% in diabetic patients [6]. In the study of Guo et al. [7], diabetic patients died much more often than non-diabetic patients (10.8% versus 3.6%).
In some other studies, it has been pointed that the COVID-19 mortality risk in pre-existing diabetes is 5-fold higher compared to individuals with normal glucose levels, while this is 10-fold higher in newly diagnosed patients [8].
In Italy, 35% of the deceased patients were diabetic, compared to 20% of the general population in this age group: therefore; diabetics are overrepresented among the deceased patients; 70% are men with average age of 80 years old [9].
In our group, 67 (35.6%) diabetic patients had critical injuries between 75 and 100% in the Chest CT, performed during their hospitalization.
In addition, in this series of cases, we concluded that diabetic patients developed several complications characterized mainly by the occurrence of acute renal failure with a percentage of 45.2%, Ischemic accidents with a rate of 22.9%, septic shock found in 20.7% of our patients, and Thrombocytopenia in 17% of cases.
Furthermore, in a study conducted by Li et al., diabetes constitutes the highest percentage in terms of admission to the ICU and require more frequently mechanical ventilation [10].
These results are similar to those of our study, All our patients required oxygen supplementation where 49 (26.1%) benefited from oxygenation by non-invasive ventilation (NIV) and 59 (31.4%) of diabetes patients were intubated.

Conclusion
While diabetes does not appear to increase the incidence of COVID-19 infection, once infected, diabetic patients have an increased risk of developing severe forms of the disease thus requiring special attention.
From our study, we can conclude that diabetic patients developed more severe pulmonary lesions, requiring the use of non-invasive ventilation or intubation with a higher mortality rate than nondiabetic patients.
Practically speaking, diabetic patients should be monitored more closely and need an aggressive preventive management protocols in order to prevent severe forms of the disease and a drastic evolution.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Funding
This research did not receive any form of funding

Ethical approval
Research studies involving patients require ethical approval. Please state whether approval has been given, name the relevant ethics committee and the state the reference number for their judgement.
This study does not require a formal ethical committee approval.

Consent
Given the retrospective design of this study, the requirement of patient consent is lifted. Data anonymity was respected in accordance with national and international guidelines.

Guarantor
The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Sara BERRAJAA.   Table 4 The most common complications.