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

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On Sep 2018

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"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."

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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,
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
(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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : OC15 - OC17 Full Version

Brixia Chest X-ray Scoring System in Critically Ill Patients with COVID-19 Pneumonia for Determining Outcomes

Published: August 1, 2021 | DOI:
Nishant Agrawal, Samruddhi Dhanaji Chougale, Prashant Jedge, Shivakumar Iyer, John Dsouza

1. Senior Resident, Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India. 2. Assistant Professor, Department of Respiratory Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India. 3. Assistant Professor, Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India. 4. Professor and Head, Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India. 5. Professor, Department of Radiodiagnosis, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India.

Correspondence Address :
Dr. Samruddhi Dhanaji Chougale,
Pritai, Plot No. 14, Kashid Colony, Rajopadhyenagar, Kolhapur-416012, Maharashtra, India.


Introduction: In early stage of disease of Coronavirus Disease 2019 (COVID-19) infection chest Computed Tomography (CT) imaging is considered as the most effective method for detecting lung abnormalities. A Brixia Chest X-ray (CXR) scoring system which uses an 18-point severity scale to grade lung abnormalities due to COVID-19 was developed to improve the risk stratification for infected patients.

Aim: To ascertain the validity of Brixia scoring system and to measure the outcome in COVID-19 patients.

Materials and Methods: A retrospective study was conducted from 1st April 2020 to 31st July 2020, at a tertiary care hospital in India. Baseline CXR of COVID-19 patients were scored based on Brixia scoring system. The lungs were divided into six equal zones. Subsequently, scores (from 0-3) were assigned to each zone, based on lung abnormalities. A group comparison was implemented using Chi-Square test for categorical variables. Whereas an independent t-test was applied for continuous variables that followed normal distribution.

Results: The study included 130 patients. The mean age was 57.09±13.73 years, 70.8% patients included were males. Out of 130 patients, 79 patients died. Among patients who died the mean CXR score was calculated to be 12.13±2.50. The mean CXR score was calculated to be 11.18±2.30 in patients who recovered and got discharged. During the process of comparison of CXR scores with the outcomes, the t-value came out to be 2.20 and the resulting p-value was 0.03 (statistically significant).

Conclusion: Brixia score more than 12 was associated with increased mortality due to COVID-19, with p-value of 0.03.


Coronavirus disease-2019, Outcome scoring, Pneumonia severity, Radiographic abnormality

The prodigious burden of coronavirus disease 2019 (COVID-19) pandemic has challenged the healthcare system. Globally there have been 170 million cases and more than three million deaths reported till date (1).

A new beta coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) belonging to Orthocoronavirinae sub family of Coronaviridae family, is a causative agent for COVID-19 (2),(3) It causes pneumonia with severe respiratory distress (4). Though the mortality rate in mild COVID-19 disease is not significantly high, in the critically ill patients it is high with COVID-19 pneumonia. Considering recent mortality estimates (5) one should be aware of the risks associated with its fatal outcome. Of this factors, older age, co-morbidities like diabetes and hypertension and severity of disease at presentation are directly associated with the outcome (6). Similarly disease severity in the form of deranged laboratory parameters such as virus induced cytokine storm syndrome and radiological lung involvement can also be used as predictor of fatal mortality (7). CXR at the time of presentation has role in depicting the mortality when it is scored using Brixia system.

As of date, in patients infected with COVID-19 lung abnormalities in early course of the disease and for quantitatively assessing severity and progression, chest CT imaging is considered as the most effective method (4),(8). In spite of CXR not being considered sensitive enough for detecting pulmonary involvement in the early course of disease (4),(9). CXR is a useful diagnostic tool for monitoring lung abnormalities in Intensive Care Units (ICUs) while CT imaging can be used in the early stage of disease (10). CXR has low sensitivity (about 69%) to diagnose COVID-19, but it can be used in predicting clinical outcomes (10). In order to increase the risk stratification within infected patients, a CXR scoring system titled as Brixia score is created for quantifying as well as monitoring the severity of lung abnormalities (10). Not many studies have evaluated the predictive value of the scoring system. Therefore, the aim of this study was to compare the novel CXR severity score with that of mortality in patients with moderate to severe COVID-19 disease in ICU (patients having Saturation of Peripheral Oxygen (SpO2) <94%).

Material and Methods

It was a study carried out on a retrospective basis at a tertiary care hospital in India. As it is a retrospective observational, non interventional study, departmental approval was taken and institute ethical committee approval was waivered. Through retrospective analysis, baseline CXR of COVID-19 patients admitted in critical care unit were retrieved, from 1st April 2020 to 31st July 2020 and the data was analysed on 27th October 2020.

Inclusion criteria: Data of every COVID-19 patient admitted to the ICU and requiring oxygen either in the form of High Flow Nasal Cannula (HFNC), a non rebreathing reservoir mask with 15L of O2/min, Non Invasive Ventilation (NIV) or invasive mechanical ventilation was selected and their baseline CXR taken at the time of admission was scored.

Exclusion criteria: Patients who had chronic organ failure in the form of chronic liver disease, chronic respiratory failure, chronic kidney failure or cardiac arrest and those with chronic neurological were excluded from the study.

Study Procedure

An experienced radiologist, who was blinded to the patient’s details and outcome, had scored these CXR, on the basis of Brixia scoring system. The final scores were compared against final outcomes of the patients, death or discharge. Correlation of final outcome with gender and with age was also calculated.

This Brixia CXR scoring system includes two steps:

Initially on frontal chest x-ray (antero-posterior projection according to the patient position) the lungs were divided into six zones (Table/Fig 1).

• Upper zones A and D- above the inferior wall of the aortic arch.
• Middle zones B and E- from below the inferior wall of the aortic arch to above the inferior wall of the right inferior pulmonary vein (i.e., the hilar structures).
• Lower zones C and F- below the inferior wall of the right inferior pulmonary vein (i.e., the lung bases).

For technical reasons, for bedside CXR (in critically ill patients) it was difficult to identify some anatomical landmarks and hence in these cases, each lung was divided into three equal zones. Scoring was done then with similar steps given below.

The next step was scoring the lung zones from 0-3 based on lung abnormalities that were detected on the frontal chest radiograph as follows:

• Score of 0 was assigned for no lung abnormalities
• Score of 1 implied the presence of interstitial infiltrates
• Score of 2 meant both interstitial and alveolar infiltrates but with interstitial predominance
• Score of 3 implied both interstitial and alveolar infiltrates but with alveolar predominance

Subsequently, the total scores of all the six lung zones were added to obtain an overall “CXR SCORE” ranging 0-18. An example of our CXR report is shown in (Table/Fig 2), in which a total score is of 10.

Statistical Analysis

Statistical Package for the Social Sciences (SPSS) software version 25.0 was used for all statistical analysis. Descriptive statistics was used to show the results of continuous variables whereas, frequency and percentages were used for categorical variables. Chi-square test was done for group comparison of categorical variables. Independent t-test was done for continuous variables exhibiting normal distribution. Across all results, a level of significance of 5% was used. Results are shown with a confidence interval of 95% and a p-value <0.05 was considered to be significant.


(Table/Fig 3) shows the flowchart of patients, 13 out of 143 patients were excluded and finally 130 were assessed for eligibility. Out of 130 patients, 79 patients died.

The mean age was 57.09 years among the patients who did not survive, whereas, the mean CXR score was found to be 12.13±2.498, whereas 53.94 years was the mean age among patients who were finally discharged, and their mean CXR score was 11.18±2.304. There was no significant association between age and gender with CXR score (Table/Fig 4), (Table/Fig 5), (Table/Fig 6).


COVID-19 pandemic has challenged us in last few months, starting from diagnosing to managing the disease.To manage and predict the outcomes there is need of an easy-to-use, robust chest radiography algorithm. In present study, authors have explored the value of initial chest radiography in predicting final outcome in patients with COVID-19 admitting in critical care unit. The Brixia CXR scoring system was actually designed for assessing the severity of lung involvement in patients who are admitted with COVID-19 illness. It is a very simple method which can be duplicated even in other clinical scenarios. When baseline CXR score was compared with patient’s final outcome, the p-value was 0.03, which was statistically significant implying association between the two. Hence, this scoring system can be adopted for accurately predicting the outcome in patients infected with COVID-19. The results were in sync with study by Bhorgesi A et al., (6).

Bhorgesi A et al., in his study scored initial CXRs of 302 patients with Brixia scoring system and concluded that high Brixia score was associated with a highest risk of in hospital mortality (6). According to the study by Toussie D et al., (11), each patient’s Emergency Department (ED) chest radiograph was divided into six zones and examined for opacities, scores were collated into a total concordant lung zone severity score and according to this chest radiograph severity score was predictive of risk for hospital admission and intubation.

In the present study, most of the patients who died had score of more than 12; while among patients with score of less than 12, most of them were recovered and got discharged.

There are other CXR scoring systems such as Severe Acute Respiratory Infection (SARI) CXR Severity Scoring System and Radiographic Assessment of Lung Edema (RALE) classification (12). The SARI CXR scoring system was used in the pre COVID era for confirmed acute respiratory infections and its goal was to simplify the clinical grading of CXR reports into five different severity categories in hospitalised patients. It is subjective for a reporting physician (13). The RALE classification system presented by Wong HYF et al., (10). The authors adapted and simplified the RALE score proposed by Warren MA et al., in 2018 (14).

The major strength of this study is its large sample size. This is one such study which has assessed the effectiveness of this particular scoring system to forecast the final outcome with regard to discharges and deaths in patients infected with COVID-19.However, several other studies like Bernheim A et al., and Pan F et al., have investigated role of CT (15),(16). Advantage of CXR in critically ill over CT is that CXR can be done bedside easily; on contrary for CT patient needs to be shifted to the CT room. The radiologist who was the observer was blinded to the patient’s details and outcome, in turn decreasing the observer bias.

The average age in this study was found to be higher in death outcome group which is in-line with other studies like Ruan Q et al., (7), Wang Z et al., (17), Yuan M et al., (18), Zhou F et al., (19). The mentioned studies have shown a linkage between elderly age and poor prognosis in COVID-19 patients. As CT imaging could not be done for all patients, as the hospital is a large teaching hospital with just one CT machine available and hence becomes difficult to carry out the same on a routine basis.


The major limitation of this study was that the authors used only the baseline CXR severity score as an independent indicator of prognosis of the final outcome. The next limitation was the absence of a follow-up on a long-term basis for all the discharged patients. Therefore, many more studies will be required to analyse the worsening of opacities on the chest radiographs which will be done on a follow-up basis with regard to the final outcome of our patients.


Brixia score more than 12 was associated with higher risk of mortality due to COVID-19. It provides the point information for bedside clinical assessment of COVID-19 patients. Considering difficulty in shifting of patients with severe disease for CT, and its non-feasibility for all the patients, reliance on CXR is the need of time for COVID-19 management in ICU.


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DOI and Others


Date of Submission: Feb 03, 2021
Date of Peer Review: May 18, 2021
Date of Acceptance: Jun 19, 2021
Date of Publishing: Aug 01, 2021

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Feb 04, 2021
• Manual Googling: Jun 16, 2021
• iThenticate Software: Jul 13, 2021 (15%)

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