Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 33246

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : TC19 - TC23 Full Version

Prediction of Clinical Requirement of Tocilizumab Injection in COVID-19 Patients with High Chest CT Severity Score- A Retrospective Analysis


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/47309.15148
Megha Maulik Sheth, Yashpal Rana, Dinesh Patel, Anshul Ghai, Samir Pate, Milin Garachh, Pinkesh Shah, Krutika Patel

1. Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 2. Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 3. Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 4. Resident, Department of Radiology, B.J.Medical College, Ahmedabad, Gujarat, India. 5. Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 6. Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 7. Intensivist, Department of Critical Care, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India. 8. Research Associate, Department of Research, U.N.Mehta Institute of Cardiology and Research Centre, Ahmedaba

Correspondence Address :
Yashpal Rana,
Consultant Radiologist, Department of Radiology, U.N.Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India.
E-mail: yashpal_my2@yahoo.co.in

Abstract

Introduction: The ongoing Coronavirus Disease 2019 (COVID-19) pandemic has spread rapidly across the globe. Tocilizumab is a recombinant monoclonal antibody to Interleukin-6 (IL-6) receptor. An increasing number of studies across the world is reporting the use of tocilizumab in treating COVID-19 patients or at risk of developing cytokine storm. Apart from clinical and laboratory parameters, High Resolution Computed Tomographic (HRCT) chest scan is a promising tool to identify patients very early in the course of COVID-19 disease.

Aim: To find whether high chest CT Severity Score (CTSS) on HRCT thorax scan predict the clinical requirement of tocilizumab injection in COVID-19 patients.

Materials and Methods: In this retrospective study, during the period from May 2020 to July, 2020, 250 patients with confirmed Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) diagnosed with COVID-19 in first or repeat sample and who also underwent HRCT scan of the chest, were assigned chest CTSS. From the data obtained, patients were categorised into two groups based on mild and severe CTSS. Patients with higher CTSS have a higher future possibility of developing the cytokine storm and hence the requirement of tocilizumab can be reliably predicted. All statistical analysis was performed in IBM Statistical Package for the Social Sciences (SPSS) version 20.

Results: Out of a total of 250 patients, 72 patients were given tocilizumab injection. The average CTSS was 29.8±6.38 in the tocilizumab injection group. Only 8% of patients with mild CTSS received tocilizumab injection while 60% of patients with severe CTSS received tocilizumab injection (p<0.001). Out of 72 patients who received tocilizumab injection, 16.7% had mild CTSS while 83.3% had severe CTSS (p<0.001). Average values of inflammatory markers like C-Reactive Protein (CRP), D-Dimer, Ferritin, Lactic De-Hydrogenase (LDH), and IL-6; were significantly higher in severe CTSS and tocilizumab group (p<0.001).

Conclusion: CTSS may be used as a new decisive tool in triaging in-hospital COVID-19 patients. Categorising patients in mild and severe CTSS early in the disease course, even before the marked worsening of laboratory parameters and development of cytokine storm may help initiate early treatment and thereby save many lives.

Keywords

Coronavirus disease 2019, Cytokine storm, Inflammatory markers, Pandemic, Recombinant antibody

The ongoing COVID-19 pandemic has spread rapidly across the globe. The novel coronavirus SARS-CoV-2 is the culprit. The first pneumonia cases were identified in Wuhan, the capital city of Hubei province (China), in December 2019 (1). As of January 11 2021, 91,328,321 cases and 1,953,182 deaths have been reported across the globe, and India is one of the worst-hit countries currently (2).

The clinical spectrum varies widely from asymptomatic, mild Upper Respiratory Tract Infection (URTI) to severe pneumonia which may progress to Acute Respiratory Distress Syndrome (ARDS) with respiratory failure requiring oxygenation support or intubation (3),(4).

Imaging plays a vital role in the diagnosis and monitoring changes during treatment. In highly suspected subjects with a negative result of Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR), HRCT scan of the chest is the modality of choice (5),(6). HRCT is a very sensitive radiological modality for the diagnosis of lung involvement in COVID-19, with varied radiological patterns in the disease course (7),(8). Though CT, being limited by specificity (inability to differentiate different viruses), confirmatory diagnosis requires nasopharyngeal swabs and virus RNA extraction by RT-PCR (9),(10).

Several CT scoring systems have emerged and research is ongoing to assess the clinical and prognostic implications of severe lung involvement on CT (11). Visual assessment or Artificial Intelligence (AI) aided quantitative analysis of the CT exam can be used for this purpose.

Tocilizumab is a recombinant monoclonal antibody to IL-6 receptor of the host cells (12),(13). Till now, an increasing number of studies across the world have reported the use of tocilizumab in treating COVID-19 patients or at risk of developing cytokine storm (14),(15). Many of them have shown promising results in proving that treatment with tocilizumab, might reduce the risk of invasive mechanical ventilation or death in patients with severe COVID-19 pneumonia (16).

The purpose of this study is to find an answer to a question that can high chest CTSS predict the clinical requirement of tocilizumab injection in COVID-19 subjects later in the course of the disease? Thus, able to triage the high-risk patients early in the course of the disease even before laboratory and clinical parameters start to worsen.

Material and Methods

A retrospective, cross-sectional analysis of the hospital medical records of 250 hospitalised patients between May 2020 to July 2020 with confirmed RT-PCR diagnosis of COVID-19 on first or repeat samples was conducted in Tertiary care centre, Gujarat, India. Ethical approval from the institutional ethical committee was taken (UNMICRC/ALLIED/2020/01). Data was analysed in August 2020 and September 2020. The data of 250 patients was collected from May 2020 to July 2020.

Inclusion criteria: A total of 250 patients with severe pneumonia clinically and who also underwent an HRCT scan of the chest were included in the study.

Exclusion criteria: The patients who had high chest CTSS but were not able to receive tocilizumab due to contraindications like co-existent infection, history of severe allergic reactions to monoclonal antibodies, active symptomatic gastrointestinal tract conditions that might predispose patients to bowel perforation, severe haematological, renal, or liver function impairments. Those patients with high CTSS but died before the tocilizumab injection were also excluded.

Severe pneumonia was defined as at least one of the following: the presence of a respiratory rate of 30 or more breaths per minute, peripheral blood oxygen saturation (SpO2) of less than 93% in room air and a ratio of arterial oxygen partial pressure (PaO2) to fractional inspired oxygen (FiO2) of less than 300 mm Hg in room air, this is according to Chinese management guidelines for COVID-19 (version 6.0) (3),(17).

All CT examinations were performed in the second week from symptoms onset, ranging from day 8 to day 10. Patients’ demographics and laboratory findings were also collected.

Chest CT Analysis and Scoring System

All patients underwent a 128 slice SOMATOM Definition AS+(Siemens Healthcare, Germany) CT scanner. The parameters were set at 120 kVp; 100-200 mAs; pitch, 1-1.2; and collimation, 128×0.6. All images were viewed with both lung (width, 1200 HU; level, -600 HU) and mediastinal (width, 350 HU; level, 50 HU) window settings.

Various CT scoring systems are available for severity scoring of COVID-19 pneumonia depending on the varying degrees of lobar or segmental volume involvements. In lobar scoring system, five lung lobes are assigned a score of 0, 1, 2, 3 or 4 depending upon the percentage of lobar involvement and classified as none (0%), minimal (1-25%), mild (26-50%), moderate (51-75%), or severe (76-100%). The total score is the sum of the five lobe scores (range from 0 to 20). The segmental scoring system divides segments of both lungs into 20 regions, only the ground glass or consolidative lung opacities were considered for evaluation of the 20 lung regions while fibrotic or atelectatic bands were excluded (18). Scores of 0, 1, and 2 were assigned respectively for parenchymal opacification of 0%, less than 50%, or equal or more than 50% of each region.

The CTSS was defined as the sum of the individual scores in the 20 segments of lung (10 on either side). The total score may range from 0 to 40 points. The individual scores in each lung, as well as the total CTSS were higher in severe COVID-19 when compared with mild cases (p<0.05). In the study by Yang et al., (18), the requisite CTSS threshold for identifying severe COVID-19 was 19.5 (area under the curve, 0.892), sensitivity and specificity being 83.3% and 94%, respectively.

According to consensus by two experienced radiologists, the segmental scoring system was chosen over the lobar system. The segmental scoring system was found to be simpler, less subjective, and more reliable to reproduce as compared to lobar system. All the CT images were reviewed independently by two experienced radiologists, who were blinded to the demographics, clinical data and laboratory indicators. For the ease of interpretation, a cut off of 20 was finalised (instead of 19.5 in the study by Yang R et al., (18)), a score of <20 being considered as mild and score ≥20 being considered as severe. The final score considered was the average of the scores given by two independent radiologists. The scoring performa used is as shown in (Table/Fig 1).

A standard protocol was devised by the team of pulmonologists and intensive care specialists of the institute for tocilizumab injection. Patients who showed SpO2 of less than 93% and a PaO2/FiO2 ratio of less than 300 mm Hg in room air or a more than 30% decrease in their PaO2/FiO2 ratio in the previous 24 hour during hospitalisation, were given tocilizumab injection. As per institutional protocol, patient was administered intravenous tocilizumab at a dose of 8 mg/kg body weight (up to a maximum of 800 mg) (19).

Statistical Analysis

All statistical analysis was performed in IBM SPSS version 20. Quantitative variables were expressed as the mean±standard deviation (SD) and qualitative variables were expressed as a percentage (%). A comparison of parametric values between two groups was performed using the independent sample t-test. Categorical variables were compared using the chi-square test. A nominal significance was taken as a two-tailed p-value <0.05.

Results

Out of a total of 250 patients, 175 patients were males and 75 patients were females. Out of 72 patients who were given tocilizumab injection, 56 were males and 16 were females. The average age of the patients was 56.88±13.68 years in whole study while it was 59.42±11.96 years in the tocilizumab injection group.

The average CTSS was 19.58±8.84. It was 29.8±6.38 in the tocilizumab injection group. Out of 72 patients who received tocilizumab injection, 12 belong to mild score group with the average score being 17.58±1.44 and 60 belong to severe score group with the average score being 32.31±3.43. From mild CTSS group, only 8% of patients received tocilizumab injection while from severe CTSS group, 60% of patients received tocilizumab injection (p<0.001). Gender, age and CTSS parameters in mild and severe group and tocilizumab injection group are shown in (Table/Fig 2). CTSS groups and tocilizumab injection association are shown in (Table/Fig 3), (Table/Fig 4). Average values of CRP, Ferritin, LDH, and IL-6 were significantly higher in severe CTSS and tocilizumab group (p <0.001). All parameters are summarised in (Table/Fig 5), (Table/Fig 6), (Table/Fig 7).

Discussion

The rapid rate with which the pandemic is spreading not only in India but across the globe has created panic in the health care system. Flooding of the hospitals with patients, scarcity of Intensive Care Unit (ICU) beds, increased demand for oxygen units, and ventilators are major concerns especially in developing and overpopulated countries like India. Thus, triaging is the key to better patient management and outcome.

Chest radiographs, though being a low-cost examination modality, are limited by low sensitivity in early diagnosis of suspected COVID-19 patients. (20),(21),(22). A High Resolution CT scan of the chest has high sensitivity in the early diagnosis of lung involvement in COVID-19 patients (Table/Fig 8) (23),(24),(25). Various CT severity scoring systems have emerged on HRCT. Assessment can be done subjectively by visual method. Many AI based automated volume quantification tools are also now available.

The typical imaging manifestations of early COVID-19 are patchy, rounded, peripheral segmental, or subsegmental ground-glass opacities, with or without consolidation (Table/Fig 9), (Table/Fig 10) (22). Based on typical CT findings proposed in various studies, Yuan M et al., have proposed a scoring method to screen patients based on the admittance CT scan (11). Yang R et al., in their study devised a semi-quantitative scoring method using the amount of lung opacification involving 20 lung regions as a surrogate for COVID-19 burden (18). More recently, Li K et al., also described a visual, quantitative analysis of lung damage, based on the degrees of parenchymal loss, which correlated with a score of clinical severity (26). The CTSS was higher in severe cases of COVID-19 pneumonia when compared to mild cases and the same were the results of their study. This study adhered to the threshold of 19.5 to identify severe COVID-19 as proposed in their study. The segmental scoring system was chosen over the lobar system due to simplicity, less subjectivity, and more reliable reproducibility by visual quantitative evaluation. This relatively undemanding method could help early triaging and reliably predict the future possibility of developing cytokine storm and hence the need for tocilizumab injection, particularly in circumstances of restricted availability of healthcare assets.

Currently, laboratory blood parameters and clinical oxygen requirements guide the management of patients with severe COVID-19 pneumonia. A significant high risk of developing ARDS and cytokine storm in patients with high CTSS was found (Table/Fig 11), (Table/Fig 12). By categorising patients based on mild and severe CTSS, the future possibility of cytokine storm and hence the requirement of tocilizumab can be reliably predicted. Lanza E et al., have studied a similar concept and showed that quantitative chest CT analysis in COVID-19 predicts the need for future oxygenation support and intubation (27). Similar kind of study conducted by our institute also showed correlation of high chest CTSS with clinical requirement of oxygen (28).

Limitation(s)

It was a retrospective analysis co-morbid conditions and clinical information of the patients were not combined. This may explain a few of the patients with mild CTSS ending up with tocilizumab injection. CTSS is based on the assumption that lung opacities represent COVID-19 disease burden but histopathological confirmation of the same is lacking. CTSS considered was an average of only two experienced radiologists (independent blinded analysis). A single CT study of in-hospital patients done in the second week of symptoms onset was analysed. The data was retrieved from medical records, hence there may have been a human error of perception and memory in providing the exact day of symptoms onset. Also, follow-up scans were not considered. The segmental scoring system was chosen over the lobar scoring system based on departmental protocol decision. Analysis through AI has been proven to be more precise over visual manual analysis, but there is limited availability and high cost of AI and also the manual method fairly serves the purpose of the intended study. Team of pulmonologists and intensive care specialists of the institute decided which patients were to be given the tocilizumab injection, based on the standard protocol. Validity of CTSS still needs to be determined by external validation studies with multicenter larger cohorts.

Conclusion

CTSS serves as a new guiding tool in triaging in-hospital COVID-19 subjects. Categorising patients in mild and severe CTSS early in the disease course, even before the marked worsening of laboratory parameters and development of cytokine storm may save energy, health resources, help to triage severe patients, and above all may save many lives.

Acknowledgement

The authors acknowledge Mr. Sanjay Patel, Research Department, U N Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India for his tremendous help for data analysis.

References

1.
Guan W, Ni ZY, Hu Y, Liang C, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708-20. https://doi.org/ 10.1056/NEJMoa2002032. [crossref] [PubMed]
2.
COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU).coronavirus.jhu.edu.
3.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Published: March 11, 2020. Doi: https://doi.org/10.1016/S0140-6736(20)30566-3. [crossref]
4.
Poston JT, Patel BK, Davis AM. Management of critically ill adults with COVID-19. JAMA 2020;323(18):1839-41. PMID: 32215647. https://doi.org/10.1001/jama.2020. 4914. [crossref] [PubMed]
5.
Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, et al. Use of Chest CT in combination with negative RT-PCR assay for the 2019 novel coronavirus but high clinical suspicion. Radiology. 2020;295(1):22-23. Published Online: Feb 12, 2020. https: // doi.org /10.1148 / radiol.2020200330. [crossref] [PubMed]
6.
Xie X, Zhong Z, Zhao W, Zheng C, Wang F, Liu J, et al. Chest CT for typical 2019-nCoV pneumonia: Relationship to negative RT-PCR testing. Radiology. 2020;296(2):E41-45. [crossref] [PubMed]
7.
Shi H, Han X, Jiang N, Jiang N, Cao Y, Alwalid O, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis. 2020;20:425-34. [crossref]
8.
Chung M, Bernheim A, Mei X, Zhang N, Huang M, Zeng X, et al. MD CT imaging features of 2019 novel coronavirus (2019-nCoV). Radiology. 2020;295(1):202-07. [crossref] [PubMed]
9.
Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of chest CT in diagnosis and management. AJR Am J Roentgenol. 2020;214(6):1280-86. Doi: 10.2214/AJR.20.22954. Epub 2020 Mar 4. PMID: 32130038. [crossref] [PubMed]
10.
Lescure FX, Bouadma L, Nguyen D, Parisey M, Wicky PH, Behillil S, et al. Clinical and virological data of the first cases of COVID-19 in Europe: A case series. Lancet Infect Dis. 2020;20(6):697-706. https://doi.org/10.1016/S1473-3099(20) 30200-0. [crossref]
11.
Yuan M, Yin W, Tao Z, Tan W, Hu Y. Association of radiologic findings with mortality of patients infected with 2019 novel coronavirus in Wuhan, China. PLoS One. 2020;15(3):e0230548. Published 2020 Mar 19. Doi: 10.1371/journal.pone.0230548. [crossref] [PubMed]
12.
Hennigan S, Kavanaugh A. Interleukin-6 inhibitors in the treatment of rheumatoid arthritis. Ther Clin Risk Manag. 2008;4:767-75. [crossref] [PubMed] [PubMed]
13.
Swerdlow DI, Holmes MV, Kuchenbaecker KB, Engmann JEL, Shah T, Sofat R, et al. The interleukin-6 receptor as a target for prevention of coronary heart disease: A mendelian randomization analysis. Lancet. 2012;379:1214-24. [crossref]
14.
Klopfenstein T, Zayet S, Lohse A, Balblanc JC, Badie J, Royer PY, et al. Tocilizumab therapy reduced intensive care unit admissions and/or mortality in COVID-19 patients. Med Mal Infect. 2020;50(5):397-400; published online May 6. Doi: 10.1016/j.medmal.2020.05.001. [crossref] [PubMed]
15.
Toniati P, Piva S, Cattalini M, Garrafa E, Regola F, Castelli F, et al. Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: A single center study of 100 patients in Brescia, Italy. Autoimmun Rev 2020;19(7):102568. published online May 3. Doi: 10.1016/j.autrev.2020.102568. [crossref] [PubMed]
16.
Guaraldi G, Meschiari M, Cozzi-Lepri A, Milic J, Tonelli R, Menozzi M, et al. Tocilizumab in patients with severe COVID-19: A retrospective cohort study. Lancet Rheumatol 2020;2(8):E474-84. AUGUST 01, 2020 Published:June 24, 2020. Doi: https://doi.org/10.1016/S2665-9913(20)30173-9. [crossref]
17.
National Health Commission of the People’s Republic of China. Chinese management guideline for COVID-19 (version 6.0). Feb 19, 2020.
18.
Yang R, Li X, Liu H, Zhen Y, Zhang X, Xiong Q, et al. Chest CT Severity Score: An imaging tool for assessing severe COVID-19. Radiology- Cardiothoracic Imaging, RSNA- Radiology Society of North America. Published Online: Mar 30, 2020, https://doi.org/10.1148/ryct.2020200047. [crossref] [PubMed]
19.
Le RQ, Li L, Yuan W, Shord SS, Nie L, Habtemariam BA, et al. FDA approval summary: Tocilizumab for treatment of chimeric antigen receptor t cell-induced severe or life-threatening cytokine release syndrome. Oncologist. 2018;23:943-47. [crossref] [PubMed]
20.
Bandirali M, Sconfienza LM, Serra R, Brembilla R, Albano D, Pregliasco FE, et al. Chest X-ray findings in asymptomatic and minimally symptomatic quarantined patients in Codogno, Italy during COVID-19 Pandemic. Radiology. 2020;295(3):E7. [crossref] [PubMed]
21.
Wong HYF, Lam HYS, Fong AHT, Leung ST, Chin TWY, Lo CSY, et al (2019) Frequency and distribution of chest radiographic findings in COVID-19 positive patients. Radiology. 2020;296(2):E72-78. [crossref] [PubMed]
22.
Ng MY, Lee EY, Yang J, Yang F, Li X, Wang H, et al. Imaging profile of the COVID-19 infection: Radiologic findings and literature review. Radiology: Cardiothoracic Imaging. 2020;2:e200034. [crossref] [PubMed]
23.
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology. 2020;296(2):E32-40. [crossref] [PubMed]
24.
Revel MP, Parkar AP, Prosch H, Silva M, Sverzellati N, Gleeson F, et al. COVID-19 patients and the radiology department-advice from the European Society of Radiology (ESR) and the European Society of Thoracic Imaging (ESTI). Eur Radiol. 2020. https://doi.org/10.1007/s00330-020-06865-y. [crossref] [PubMed]
25.
Paul NS, Roberts H, Butany J, Chung TB, Gold W, Mehta S, et al. Radiologic pattern of disease in patients with severe acute respiratory syndrome: The Toronto experience. RadioGraphics. 2004;24(2):553-63. [crossref] [PubMed]
26.
Li K, Fang Y, Li W, Pan C, Qin P, Zhong Y, et al. CT image visual quantitative evaluation and clinical classification of coronavirus disease (COVID-19). Eur Radiol. https://doi.org/10.1007/s00330-020-06817-6. [crossref] [PubMed]
27.
Lanza E, Muglia R, Bolengo I, Santonocito OG, Lisi C, Angelotti G, et al. Quantitative chest CT analysis in COVID-19 to predict the need for oxygenation support and intubation. Eur Radiol. 2020;30:6770-78. https://doi.org/10.1007/s00330-020-07013-2. [crossref] [PubMed]
28.
Rana Y, Patel D, Sheth M, Chhodvadiya S, Patel S, Garachh M, et al. Chest CT severity score to forecast clinical requirement of oxygen support in Covid-19 patients. Int J Radiol Diagn Imaging. 2021;4(1):103-09. Doi: 10.33545/26644436.2021.v4.i1b.170. [crossref]

DOI and Others

10.7860/JCDR/2021/47309.15148

Date of Submission: Oct 22, 2020
Date of Peer Review: Dec 31, 2020
Date of Acceptance: May 03, 2021
Date of Publishing: Jul 01, 2021

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? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 22, 2020
• Manual Googling: Apr 26, 2021
• iThenticate Software: May 25, 2021 (23%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com