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

Users Online : 145828

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI 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
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,
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 : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : OC10 - OC15 Full Version

Role of Modified RALES and Brixia Scores in Predicting the COVID-19 Positivity among the Suspected Patients: A Cross-sectional Observational Study

Published: March 1, 2022 | DOI:
Nitin Sinha, Divesh Jalan, Princi Jain

1. Professor, Department of Internal Medicine, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India. 2. Assistant Professor, Department of Orthopaedics, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India. 3. Associate Professor, Department of Internal Medicine, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India.

Correspondence Address :
Princi Jain,
Associate Professor, Department of Medicine, Atal Bihari Vajpayee Institute of Medical
Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India.


Introduction: Computed Tomography (CT) chest plays an important role in triaging and managing patients of suspected COVID-19, especially in those where Coronavirus Disease 2019 (COVID-19) report is pending but CT chest has constraints of availability and cost. Chest X-ray (CXR) is a readily available investigation and is cheaper than a CT chest. Hence, any scoring on CXR which proves to be helpful in triaging and managing suspected COVID-19 patients will alleviate the dependency on CT chest. Modified Radiographic Assessment of Lung Edema Score (mRALES) and Brixia scores have been used to assess severity of disease and prognosis in COVID-19 confirmed cases. However, these two scores have never been used as a method to predict the confirmed COVID-19 pateints among the the suspected COVID-19 cases.

Aim: To evaluate the role of mRALES and Brixia score along with clinical and laboratory parameters in predicting confirmed positive cases among suspected COVID-19 patients.

Materials and Methods: This retrospective cross-sectional, observational study was conducted in Department of Medicine at Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India, from 1st December 2020 to 15th December 2020. Case records of patients admitted with severe acute respiratory illness (suspected COVID-19) were accessed and used to fill up a proforma where clinical and laboratory parameters were recorded. Chest radiographs (posteroanterior and anteroposterior) of the patients were evaluated to calculate mRALES and Brixia scores. Sensitivity, specificity, positive preditive value and negative predictive value were calculated. The p-value <0.05 was considered as statistically significant.

Results: Out of the 113 patients, 62 were males and 51 females. The COVID-19 positivity rate was 15.04% (n=17). Mean age of patients was 52.64±15.63 years. Overall, the mean mRALES and Brixia scores were not statistically different between negative (mRALES=3.94±2.51, Brixia=7.29±4.642), and confirmed COVID-19 (mRALES=4.25±2.56, Brixia=7.73±4.84) patients. However, in the subgroup of patients with history of obstructive airway disease, Brixia score was significantly higher among COVID-19 positive patients (7.09±4.70) as compared to COVID-19 suspected patients (0.53±4.31). Presence of low TLC {<9550/mm3 with sensitivity of 70.62%, specificity of 67.3%, Positive Predictive Value (PPV) of 26.7% and Negative Predictive Value (NPV) of 92.4%} and low ANC (<7580/mm3 with sensitivity of 64.7%, specificity of 63.2%, PPV of 22.9% and NPV of 90.5%) significantly predicted the COVID-19 positivity among the suspected COVID-19 patients.

Conclusion: mRALES and Brixia scores on CXR are not significantly different between suspected and confirmed COVID-19 patients and hence, cannot be used to judge who among suspected COVID-19 patients will turn out to be COVID-19 positive later. However, a TLC of less than 9550/ mm3 and an ANC of less than 7580/mm3 can predict COVID-19 positivity among suspected patients.


Absolute neutrophil count, Chest X-ray scores, Coronavirus disease 2019, Obstructive airway disease, Radiographic assessment of lung edema score, Total leucocyte count

Along with Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) (1) imaging has turned out to be a valuable tool in “ruling in” and “ruling out” suspected COVID-19 patients (2),(3). The choice between imaging modalities like Computed Tomography (CT) chest and Chest X-ray (CXR) depends on local resources and expertise available at the site. In United States of America, CXR has been extensively used in the triage of patients with COVID-19 infection (4). But, this triaging was to differentiate between those patients who would require critical care and those who would not. These two scores have never been used to predict who among the suspected COVID-19 will turn out to be positive. The most frequent radiographic findings are airspace opacities described as consolidation with bilateral, peripheral, and lower zone predominant distribution. The radiological picture on CXR also consists of atypical pneumonia or organising pneumonia (5),(6).

In most of the hospitals including the present study hospital, patients of suspected COVID-19 are placed in a common ward till the time their RT-PCR report is available. A distinction between those who have high likelihood of being COVID-19 positive from those who have a less likelihood can help in placing them in isolation wards at the outset. This can reduce transmission of infection.

Radiographic Assessment of Lung Edema Score (RALES) was initially, used for the assessment of pulmonary oedema and Acute respiratory distress syndrome (ARDS) (7). Due to its heavy handed calculations and observer bias, it is used in a simplified and convenient form called modified RALES (mRALES) in confirmed COVID-19 patients (8).

Brixia score was exclusively developed for the COVID-19 disease severity assessment by Borghesi and Maroldi R in Italy (9). In a study on 302 Caucasian patients with COVID-19, only Brixia score, patient age, and conditions that induced immunosuppression were the significant predictive factors for in-hospital mortality. On receiver operating characteristic curve analyses, the optimal cut-off values for Brixia score and patient age were 8 points and 71 years, respectively (10). A retrospective study including 130 patients in India used Brixia CXR scoring system found that, Brixia score more than 12 was associated with increased mortality (p-value=0.03). The mean Brixia CXR score was calculated to be 12.13±2.50 among dead patients and 11.18±2.30 in patients who were discharged (11).

In this study, two CXR scores (mRALES score and Brixia score) were studied among suspected COVID-19 patients and their role along with other clinical and laboratory parameters in predicting confirmed COVID-19 disease among suspected COVID-19 patients was evaluated.

Material and Methods

This retrospective cross-sectional, observational study was conducted in Department of Medicine at Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India, from 1st December 2020 to 15th December 2020. An approval of the Ethical Committee of the institute was taken {vide letter no. 485(21/2021)IEC/ABVIMS/RMLH/513}.

Inclusion and Exclusion criteria: All the suspected COVID-19 patients admitted in the designated ward between 1st and 15th December 2020 were included in the study. All patients lacking with appropriate records/data required were excluded from the study.

Methodology: Case records were accessed and a proforma was filled that recorded the demographic details, detailed history (presenting symptoms like fever, cough, sore throat, loss of taste or smell, diarrhoea, constipation, nausea, vomiting, body ache, running nose, headache, altered sensorium, pain abdomen, skin rash, chest pain, medical history regarding any co-morbidities like diabetes, hypertension, bronchial asthma, chronic obstructive airway disease, tuberculosis, interstitial lung disease, coronary artery disease, peripheral vascular disease, cerebro-vascular accident, chronic kidney disease, chronic liver disease, malignancy, immunosuppressive drugs or steroids intake, organ transplant, thyroid disorders, seizure disorder), examination (complete general physical and systemic examination) findings of the patient. The investigations recorded were haemogram with Erythrocyte Sedimentation Rate (ESR), Total Leucocyte Count (TLC), Absolute Neutrophil Count (ANC), Neutrophil Lymphocyte Ratio (NLR), Platelet Lymphocyte Ratio (PLR), C-reactive Protein (CRP), Serum Lactate Dehydrogenase (LDH), liver function tests, kidney function tests, arterial blood gas analysis, Chest X-ray posteroanterior and anteroposterior (CXR PA/AP) view and12 lead electrocardiogram.

Ministry of Health and Family Welfare, Government of India (MOHFW, GOI) clinical classification of COVID-19 infection was used in this study (12). According to this classification, suspected COVID-19 is defined as:

A. A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND a history of travel to or residence in a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset
B. A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset
C. A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalisation) AND in the absence of an alternative diagnosis that fully explains the clinical presentation.

Further grading of patients was done as follows as mentioned in (Table/Fig 1):

COVID-19 was confirmed, if the nasopharyngeal/oropharyngeal sample was positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV 2) Ribonucleic Acid (RNA) using RT-PCR method. However, COVID-19 was considered negative if two reports, done at least 48 hours apart, did not detect SARS-CoV-2 RNA. RT-PCR was done using the GENES2ME kit by PCR amplification and fluorescence channel settling techniques. It uses the Cycle Threshold value (CT value) of 37 as a cut-off to differentiate the positive or negative results.

Chest X-ray

CXR of the patients were evaluated by the authors when they treated the patients to calculate mRALES and Brixia scores.

1. Modified Radiographic Assessment of Lung Edema Score (mRALES): Calculated by as follows (8):

• 0 is no involvement;
• 1 is <25% of lung involved;
• 2 is 25-50% of lung involved;
• 3 is >50-75% lung involved;
• 4 is >75% of lung involved

Score for each lung is calculated and scores of both lungs are added to get the final mRALES (Table/Fig 2). Severity based on mRALES is defined as follows (13),(14):

• Mild: 0-2,
• Moderate: 3-5,
• Severe: 6-8

2. Brixia score: In Brixia scoring format, designed exclusively for COVID-19 confirmed patients, the lungs are divided into six zones on AP/PA view as shown in (Table/Fig 3).

• Upper zones (A and D): above the inferior wall of the aortic arch;
• Middle zones (B and E): below the inferior wall of the aortic arch and 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.

A score (from 0 to 3) is assigned to each zone based on the lung abnormalities detected:

• Score 0- No lung abnormalities;
• Score 1- Interstitial infiltrates;
• Score 2- Interstitial and alveolar infiltrates (interstitial predominance);
• Score 3- Interstitial and alveolar infiltrates (alveolar predominance).

The scores of the six lung zones are then added to obtain an overall “CXR score” ranging from 0 to18 (9).

Statistical Analysis

All the details from the filled proforma were recorded on Statistical Package for Social Sciences (SPSS) software (version 16. IBM Inc., Chicago). The qualitative variables are expressed as percentages and all quantitative variables were recorded as Mean±SD. mRALES and Brixia scores were compared between different severity grades of COVID-19 using Kruskal-Wallis H test. These scores were also compared between COVID-19 patients who tested positive by RT-PCR and those who tested negative. This comparison was done using Mann-Whitney U test. To identify factors that predicted COVID-19 positivity, univariate analysis for each factor was done. Sensitivity, Specificity, PPV and NPV of the factors that were found to be significantly different between the two groups on univariate analysis were calculated. The p-value <0.05 was considered as statistically significant.


Between 1st and 15th December 2020, 113 patients who got admitted in suspected COVID-19 wards and whose case records were complete were included in this study. Mean age of the patients was 52.64±15.63 years. There were 62 males and 51 females, and the mean duration of symptoms was 6.6±6.3 days. The symptoms at presentation and presence of various co-morbidities of all the suspected COVID-19 patients are detailed in (Table/Fig 4).

mRALES and Brixia scores among males were 4.50±2.56 and 8.08±2.50, respectively and among females were 3.84±2.50 and 7.16±4.53, respectively. Both the scores were not significantly different between the two genders (p-value=0.15 and p-value=0.30 for mRALES and Brixia score, respectively). mRALES and Brixia CXR scores comparison between the mild, moderate and severe suspected COVID- 19 patients is shown in (Table/Fig 5). The scores were not significantly different between the three groups.

The COVID-19 positivity rate was 15.04%, 17 patients positive out of 113. Comparison of mRALES and Brixia scores between the two groups (COVID-19 positive and negative) is described in (Table/Fig 6). Both the scores had no significant difference between the two groups.

Comparison of mRALES and Brixia scores between the patients having co-morbidities and those without any co-morbidities is depicted in (Table/Fig 7). The patients with history of airway disease, had significantly lower Brixia score in COVID-19 positive patients as compared to COVID-19 negative patients (p-value=0.003).

The comparison of mRALES and Brixia scores according to duration of symptoms showed that scores did not differ significantly with increasing duration of symptoms (Table/Fig 8).

On univariate analysis, it was observed that presence of low TLC (p-value=0.02) and low ANC (p-value=0.016), significantly predicted the COVID-19 positivity among the suspected COVID-19 patients (Table/Fig 9). With an Area Under the Receiver Operating Characteristics (AUROC) of 0.73 (Table/Fig 10), TLC <9,550/mm3 had sensitivity of 70.62% and specificity of 67.3% in predicting COVID-19 positivity. AUROC (Table/Fig 11) of ANC <7,580/mm3 was 0.733 with sensitivity of 64.7% and specificity of 63.2% in predicting COVID-19 positivity (Table/Fig 12).


Warren MA et al., used the RALES scoring system initially to assess the extent and severity of pulmonary oedema and ARDS (7). It was simplified to mRALES by Wong HYF et al, whose study found that at the time of hospital admission, 41% of the patients had mRALES of 1-2 on baseline CXR, while 31% patients had normal radiographs that progressed over time, reaching peak by 10-12 days among COVID-19 positive patients. This study also demonstrated that 91% of patients tested positive for RT-PCR while 59% showed abnormalities on baseline CXR (8). In the present study, all suspected patients had CXR changes, however only 15.04% were RT-PCR positive. CXR changes among RT-PCR negative patients can be due to infectious agents other than SARS-CoV-2. Both mRALES and Brixia scores were not significantly different between COVID-19 positive and COVID-19 negative patients in the present study, which further reaffirms that CXR scores show no relation with RT-PCR reports. Hence, these scores cannot be used for demarcating those suspected COVID-19 patients who are likely to come RT-PCR positive from those who are likely to come negative.

A study by Li MD et al., that enrolled 468 confirmed COVID-19 positive patients, showed that the age and mRALES were significantly higher in 134 patients (29%) who were intubated or died within 3 days of hospital admission. Also, mRALES was 9 (5-12.2) in those who were intubated and 3.0 (1.5-5.7) in non intubated with highly significant p-value of <0.001 (15). Brixia score was exclusively devised for COVID-19 positive patients and was first published by Borghesi A and Maroldi R. The score was significantly higher in patients who died than those discharged from the hospital (p≤0.002) (9). A study conducted by Maroldi R et al., stated that Brixia score correlated with patient outcome in COVID-19 positive patients and found a prognostic value. A total of 953 patients were included in the study, 677 were discharged and 276 died during hospitalisation. The score was significantly higher in those who died (median: 12; IQR: 9-14) compared to those who got discharged (median: 8; IQR: 5-11) (p-value <0.0001) (16).

In the present study, both the scores were not significantly different between suspected COVID-19 patients with varying degrees of severity of disease at presentation. This could be due to the fact that the severity was assessed based on clinical parameters at the time of presentation. X-ray scores based on changes in X-rays might not be reflective of the severity assessed by clinical parameters. Also, as the study centre is a tertiary care hospital, patients often come after receiving some basic treatment before being referred. This can also influence the X-ray scores. Hence, mRALES and Brixia scores cannot be used to predict severity of disease among suspected COVID-19 patients.

The authors could not find any study where Brixia and mRALES scores have been used to predict COVID-19 positivity among suspected COVID-19 patients. This is probably first study where these scores have been evaluated in suspected COVID-19 patients.

In a cross-sectional observational study done by Agrawal A et al., from 19th March to 15th April 2020 in 102 patients with positive SARS-CoV-2 RT-PCR, 85 (83.33%) patients were asymptomatic (group A) and 17 (16.67%) were symptomatic (group B). Most common symptom was fever, followed by dry cough with haemoptysis being least common. Co-morbidities were seen in 18 patients, six of which were in group B. The most prevalent co-morbid condition was diabetes mellitus followed by hypertension, and Chronic Obstructive Pulmonary Disease (COPD). Haematologically, group B had significantly higher mean total leukocyte count (TLC), neutrophil percentage, NLR, PLR, AST, ALT and LDH values (p-values <0.05). However, lymphocyte count was significantly lower in group B than group A (p-value=0.001) (17).

In the present study, which included both COVID-19 positive and COVID-19 negative patients, most common symptom was fever which was observed in all the patients followed by breathlessness and cough. Haemoptysis was not seen in any case. Most common co-morbidities noticed were diabetes mellitus followed by hypertension and obstructive airway disease.

Guan WJ et al., provided data on the clinical characteristics of 1,099 COVID-19 cases with laboratory confirmation during the first two months of the epidemic in China. Majority of patients had lymphocytopenia (83.2%) on admission. A 36.2% had thrombocytopenia, and 33.7% had leukopenia (18). Another study by Najim RH and Kadhim SR, found that patients with positive RT-PCR had significant decrease in total White blood cells (3040±1000)/mm3 count and lymphocytes (23.6) in comparison to those with negative RT-PCR for COVID-19 (19). In the present study, TLC among COVID-19 positive patients was 8482±4255/mm3 as compared 12471±6713/mm3 to COVID-19 negative patients. TLC (<9550/mm3) was seen to be a significant predictor of COVID-19 positivity among the suspected COVID-19 patients. The higher TLC in COVID-19 negative patients could be due to some other aetiological agent. At the value TLC <9550/mm3, AUROC was 0.73 to predict COVID-19 positivity with a sensitivity of 70.62% and specificity of 67.3%.

ANC was a significant predictor of COVID-19 positivity among the suspected patients. ANC among COVID-19 positive patients was 6670±3577/mm3 as compared to 10395±6100/mm3 in COVID-19 negative patients. At the value ANC <7580/mm3, AUROC was 0.733, sensitivity was 64.7% and specificity was 63.2% in predicting the COVID-19 positivity. This can be attibuted to the excessive cytokines and chemoattractants circulating in blood due to cytokine storm in COVID-19 (20) and also the hypoxia because of immunothrombosis and ARDS (21).

Neutrophils have been shown to be involved in innate immunity, as well as the state of hyperinflammation seen in COVID-19 patients. The mechanism involves a complex array of receptors and adhesion molecules for various ligands and excessive formation of Neutrophil Extracellular Traps (NETs) (22),(23).

In a study from Iran on 200 patients, 70 were COVID-19 RT-PCR positive. White blood cells count among positive patients was 4043±1002/mm3 as compared to 6894±1982/mm3 and this difference was statistically significant (24). This study also shows that TLC was lower in COVID-19 positive patients as compared to COVID-19 negative patients. Other parameters that were found to predict the presence of COVID-19 positivity in the study from Iran were CRP, ALT, AST and LDH. However, none of these were found to be predictive of COVID-19 positivity in the present study.


The study sample size was limited. Another limitation was not investigating for other aetiological agents in patients who had CXR changes and were COVID-19 negative by RT-PCR. The possibility, even though minimal, of CXR scores getting modified due to receiving any treatment prior to presenting to our hospital cannot be ruled out completely.


Triaging suspected COVID-19 patients who are less likely to have RT-PCR positive from those who are more likely to have RT-PCR positive is the need of the hour as this can prevent cross infections. CXR scores (mRALES and Brixia) that have been used in previous studies to determine prognosis in COVID-19 positive patients were evaluated in this study to determine their role in triaging suspected COVID-19 patients into those who are more likely to come COVID-19 positive. Both these scores were not found to be useful for this purpose. These scores were not statistically different in different severity categories. However, low TLC (<9550/mm3) and low ANC (<7580/mm3) were found to predict COVID-19 positivity among suspected COVID-19 patients. More studies to evaluate factors predicting COVID-19 positivity among suspected COVID-19 patients are required.

Author contributions: NS- conception of idea and design of the study, collection of data, data analysis, drafting the article and proof reading, DJ- conception of idea and design of the study, Statistical analysis, interpretation of data for the work, drafting the article and proof reading, PJ- conception of idea and design of the study, collection of data, drafting the article and proof reading.


Drame M, Teguo MT, Proye E, Hequet F, Hentzien M, Kanagaratnam L, et al. Should RT-PCR be considered a gold standard in the diagnosis of COVID-19? J Med Virol. 2020;92(11):2312-13. [crossref] [PubMed]
Sverzellati N, Milanese G, Milone F, Balbi M, Ledda RE, Silva M. Integrated radiologic algorithm for COVID-19 pandemic. J Thorac Imaging. 2020;35(4):228-33. [crossref] [PubMed]
Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al. The role of chest imaging in patient management during the COVID-19 pandemic: A multinational consensus statement from the fleischner society. Chest. 2020;158(1):106-16. [crossref] [PubMed]
Kim HW, Capaccione KM, Li G, Luk L, Widemon RS, Rahman O, et al. The role of initial chest X-ray in triaging patients with suspected COVID-19 during the pandemic. Emerg Radiol. 2020;27(6):617-21. [crossref] [PubMed]
Rodrigues JCL, Hare SS, Edey A, Devaraj A, Jacob J, Johnstone A, et al. An update on COVID-19 for the radiologist- A British society of Thoracic Imaging statement. Clin Radiol. 2020;75(5):323-25. [crossref] [PubMed]
Kooraki S, Hosseiny M, Myers L, Gholamrezanezhad A. Coronavirus (COVID-19) outbreak: What the department of radiology should know. J Am Coll Radiol. 2020;17(4):447-51. [crossref] [PubMed]
Warren MA, Zhao Z, Koyama T, Bastarache JA, Shaver CM, Semler MW, et al. Severity scoring of lung oedema on the chest radiograph is associated with clinical outcomes in ARDS. Thorax. 2018;73(9):840-46. [crossref] [PubMed]
Wong HYF, Lam HYS, Fong AH, Leung ST, Chin TW, Lo CSY, et al. Frequency and distribution of chest radiographic findings in patients positive for COVID-19. Radiology. 2020;296(2):E72-78. [crossref] [PubMed]
Borghesi A, Maroldi R. COVID-19 outbreak in Italy: Experimental chest X-ray scoring system for quantifying and monitoring disease progression. Radiol Med. 2020;125(5):509-13. [crossref] [PubMed]
Borghesi A, Zigliani A, Golemi S, Carapella N, Maculotti P, Farina D, et al. Chest X-ray severity index as a predictor of in-hospital mortality in coronavirus disease 2019: A study of 302 patients from Italy. Int J Infect Dis. 2020;96:291-93. [crossref] [PubMed]
Agrawal N, Chougale SD, Jedge P, Iyer S, Dsouza J. Brixia chest X-ray scoring system in critically Ill patients with COVID-19 pneumonia for determining outcomes. Journal of Clinical and Diagnostic Research. 2021;15(8):OC15-17. [crossref]
Clinical Management protocol for COVID-19. Accessed on 04.03.2022.
Yasin R, Gauda W. Chest X ray findings monitoring COVID-19 disease course and severity. Egypt J Radiol Nucl Med. 2020;51:193. [crossref] [PubMed]
Colman J, Zamfir G, Sheehan F, Berrill M, Saikia S, Saltissi F. Chest radiograph characteristics in COVID-19 infection and their association with survival. Eur J Radiol Open. 2021;8:100360. Doi: 10.1016/j.ejro.2021.100360. [crossref] [PubMed]
Li MD, Arun NT, Gidwani M, Chang K, Deng F, Little BP, et al. Automated assessment of COVID-19 pulmonary disease severity on chest radiographs using convolutional Siamese neural networks. medRxiv [Preprint]. 2020 May 26:2020.05.20.20108159. Doi: 10.1101/2020.05.20.20108159. [crossref]
Maroldi R, Rondi P, Agazzi GM, Ravanelli M, Borghesi A, Farina D. Which role for chest x-ray score in predicting the outcome in COVID-19 pneumonia? Eur Radiol. 2020;31(6):4016-22. [crossref] [PubMed]
Agrawal A, Tyagi P, Mahavar S, Banerjee S, Sharma R, Bhandhari S, et al. Study of hematological and biochemical parameters in a cohort of Indian COVID-19 patients admitted in a tertiary care centre. International Journal of Advances in Medicine. 2020;7(12):1840-45. [crossref]
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. China medical treatment expert group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708-20. [crossref] [PubMed]
Najim RH, Kadhim SR. Biochemical and hematological parameters as a predictor for COVID-19 infection in 65 patients diagnosed by real time- PCR in Kirkuk city. Sys Rev Pharm. 2020;11(5):797-99.
Borges L, Pithon-Curi TC, Curi R, Hatanaka E. COVID-19 and neutrophils: The relationship between hyperinflammation and neutrophil extracellular traps. Mediators Inflamm. 2020;2020:8829674. Doi: 10.1155/2020/8829674. [crossref] [PubMed]
Reusch N, De Domenico E, Bonaguro L, Schulte-Schrepping J, Baßler K, Schultze JL, et al. Neutrophils in COVID-19. Front Immunol. 2021;12:652470. Doi: 10.3389/fimmu.2021.652470. [crossref] [PubMed]
Saffarzadeh M, Juenemann C, Queisser MA, Lochnit G, Barreto G, Galuska SP, et al. Neutrophil extracellular traps directly induce epithelial and endothelial cell death: A predominant role of histones. PLoS One. 2012;7(2):e32366. Doi: 10.1371/journal.pone.0032366. [crossref] [PubMed]
Villanueva E, Yalavarthi S, Berthier CC, Hodgin JB, Khandpur R, Lin AM, et al. Netting neutrophils induce endothelial damage, infiltrate tissues, and expose immunostimulatory molecules in systemic lupus erythematosus. J Immunol. 2011;187(1):538-52. [crossref] [PubMed]
Mardani R, Ahmadi Vasmehjani A, Zali F, Gholami A, Mousavi Nasab SD, Kaghazian H, et al. Laboratory parameters in detection of COVID-19 patients with positive RT-PCR; a diagnostic accuracy study. Arch Acad Emerg Med. 2020;8(1):e43.

DOI and Others

DOI: 10.7860/JCDR/2022/51204.16102

Date of Submission: Jul 08, 2021
Date of Peer Review: Nov 22, 2021
Date of Acceptance: Jan 03, 2022
Date of Publishing: Mar 01, 2022

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

• Plagiarism X-checker: Jul 09, 2021
• Manual Googling: Dec 27, 2021
• iThenticate Software: Jan 01, 2022 (17%)

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)