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

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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 : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : TC05 - TC11 Full Version

Predictive Value of Chest CT Score in Assessing Disease Severity and Short-term Mortality in COVID-19 Pneumonia at a Tertiary Care Centre in Northern India: A Prospective Observational Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51808.16168
Pradeep Kumar Roul, Ashish Kaushik, Poonam Sherwani, Kriti Yadav, Aditi Saini, O Budha Charan Singh, Anjum Syed, Prasan Kumar Panda

1. Junior Resident, Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 2. Senior Resident, Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 3. Associate Professor, Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 4. Senior Resident, Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India. 5. Junior Resident, Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 6. Junior Resident, Department of General Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 7. Additional Professor, Department of General Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India. 8. Assistant Professor, Department of General Medicine, All Ind

Correspondence Address :
Dr. Pradeep Kumar Roul,
Junior Resident, Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Virbhadra Road, Pashulok, Rishikesh, Uttarakhand, India.
E-mail: drpkroul@gmail.com

Abstract

Introduction: Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infection, also known as Coronavirus Disease-2019 (COVID-19) is the global pandemic, first described in Wuhan city of China in December 2019. Its diagnosis depends upon real time Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). On chest Computerised Tomography (CT), it is almost similar to other viral pneumonia with extensive parenchymal involvement. Semiquantitative scores depicting this extensiveness of involvement could correlate with disease severity, laboratory parameters, mortality like Intensive Care Unit (ICU) admission, requirements of ventilatory support and longer hospital stay.

Aim: To define the role of chest CT score in determining disease severity, predicting poor prognosis and mortality of COVID-19 pneumonia in short-term follow-up.

Materials and Methods: This prospective study enrolled 547 admitted real time RT-PCR positive patients for COVID-19 at All India Institute of Medical Sciences, Rishikesh, India from 15th April 2021 to 31st May 2021. All patients were assigned semi-quantitative CT scores based on the extent of lung parenchymal involvement of 20 lung regions in chest CT. Finally, 205 patients were enrolled for the final analysis. Clinical severity was matched with chest CT scoring and laboratory findings. Survival curves along with univariate and multivariate analysis was applied to define the role of CT scoring in predicting short-term prognosis.

Results: Total 205 subjects were included in the study, of which the chest CT score showed a significant association with clinical severities (p-value <0.001). CT score was correlating significantly with increased serum C-Reactive Protein (CRP) (p-value=0.001) and D-dimer (p-value=0.01), and decreased lymphocyte count (p-value <0.001). A CT score ≥31 was found to be associated with an increased risk of mortality in both univariate and multivariate analysis {Odd Ratio (OR)=276.8; 95% Confidence Interval (CI)=45.21-1695.43; p-value <0.001}.

Conclusion: Chest CT score can be imaging measure of disease severity and predict a higher probability of mortality in score ≥31. It can also predict other defined variables of short-term prognosis. So, it has an advantage in speedy diagnostic workflow of symptomatic cases, timely referral of patients to higher centre, and better management of critical care resources.

Keywords

Coronavirus disease-19, Computed tomography severity score, Ground glass opacity

The COVID-19 infection has resulted in 190,860,860 confirmed cases and 4,101,414 deaths as of 21st July 2020 (1). The concern regarding high infectivity, morbidity and mortality with COVID-19 infection has resulted in worldwide lockdown to contain the spread of disease (2). Currently, different parts of the world are preparing for the third and subsequent wave of infection including community transmission (1). Fever, fatigue, cough and dyspnoea are the common clinically presenting complaints and quite similar to other respiratory virus infections, more specifically other coronavirus infections like Middle East Respiratory Syndrome (MERS) Coronavirus and SARS-CoV-2 (3),(4).

On non contrast chest CT imaging, it resembles viral pneumonia as symmetrical involvement of lung parenchyma with Ground Glass Opacity (GGO), with or without associated consolidation, predominately in peripheral and posterior distribution (5),(6). Authors hypothesise that extent of lung parenchymal involvement, depicting as chest CT score could correlate with the clinical severity of COVID-19 infection and predicts disease outcome.

There is growing evidence of insensitivity of single RT-PCR testing for diagnosis of COVID-19 infection (7),(8). The sensitivity of RT-PCR testing depends upon sample collection technique and test’s technical characteristics. Inadequate sampling is also an add-on to this cumbersome test when a quick diagnosis is sought. In symptomatic patients with the first RT-PCR negative test, chest CT imaging can be a supplement (9). The relatively lower sensitivity of a single RT-PCR testing with a long turnaround time insinuates that a large bulk of COVID-19 patients could not be isolated quickly to contain the disease. Management of these patients based on the clinical severity.

The primary objective of the present research was to examine the role of CT score in assessing the disease severity and predicting short-term mortality. Secondary objective was to bring out a cut-off of CT score beyond which they had experienced a higher mortality in the present study population. Thirdly, its role in predicting other variables of prognosis like ICU admission, ventilatory support, and long hospital stay was also investigated.

Material and Methods

This prospective observational study was conducted in the Department of Radiodiagnosis and Imaging and Department of General Medicine at All India Institute of Medical Sciences, Rishikesh, India, from 15th April 2021 to 31st May 2021 after getting ethical clearance from Institutional Ethics Committee (letter No- AIIMS/IEC/20/441, Reg No: ECR/736/Inst/UK/2015/RR-18), following the principles of the Declaration of Helsinki.

Authors initially enrolled all patients who were admitted to the Emergency Department of the institute with clinical suspicion of COVID-19 infection during the study period (n=547). The criteria for clinical suspicion of COVID-19 infections were based upon guidelines laid by World Health Organisation (WHO) (10). Informed consent was obtained from all patients before enrolment into the study.

Inclusion criteria: Patient admitted in the institute with clinical suspicion of COVID-19 infection.

Exclusion criteria: Two serial RT-PCR reports coming out to be negative with a gap of one day within them (As per our institutional protocol to say someone negative for COVID-19 infection), patients with primary and metastatic lung neoplasms, active pulmonary tuberculosis, any acute medical and surgical conditions that had independent risk of mortality were excluded from the study. Previously diagnosed with Interstitial Lung Disease (ILD) cases or patients with contraindication of CT scan, patients who refused for consent or had poor chest CT imaging due to excessive motion artifacts etc., were also excluded from the study.

Finally, 205 patients were enrolled for the study. During this study, all patients were managed with standard guidelines for clinical management and they were not enrolled in any other studies (Table/Fig 1).

Clinical Workflow and Disease Staging

Detailed present and past clinical history, and vital parameters such as respiratory rate, pulse rate, oxygen saturation was maintained in predefined clinical sheets. Chest CT and laboratory investigation like complete haemogram, Arterial Blood Gas (ABG), serum level of acute phase reactants like C-Reactive Protein (CRP), D-dimer, Procalcitonin (PCT) and Lactate Dehydrogenase (LDH) was carried out routinely within one day of hospital admission. Whenever a first RT-PCR came negative, a repeat RT-PCR was done after a gap of one day.

Disease severity classification was done using the Chinese Centers for Disease Control and Prevention (CDC) guidelines as mild, severe and critical (11). To know the evolution of disease in chest CT, the course of the disease was divided into early (<7 days) and late (≥7 days) phase based on the days of symptoms (12). All patients were followed for clinical progression throughout their hospital stay. Hospital stay was divided as short (<20 days) and long (≥20 days) (13).

In all stages blinding was maintained, neither the clinician nor the radiologist knew about each other’s findings to prevent selection bias, only conventional CT reports were provided.

CT Protocol

Maintaining appropriate infection prevention and control measures, image acquisition was done using a single source Multidetector Computed Tomography (MDCT) scanner Ingenuity core 64 slice (Philips, Netherlands), in a supine position during a single inspiratory breath-hold, from the apex of the lung to the costophrenic angle. The scanning parameters were KVp=120; mAs=40; rotation time-0.5 second; pitch-1.0; section thickness-5 mm; intersection space-5 mm. Images were reconstructed at 1 mm slice thickness in all three planes and viewed in the mediastinal (C=60, W=400 and Matrix=512) and lung (C=-600, W=1600 and Matrix=768) windows.

Image analysis: Three radiologists with 5-10 years of experience in chest radiological reporting reviewed all the provided reconstructed images independently and had been completely blinded to the clinical and laboratory findings. In case of any discrepancies in the interpretation, the final result was reached by blinded voting among them. The standard radiological terms were used as described in the standard glossary for thoracic imaging reported by the Fleischner Society (14). CT scoring was done as proposed by Yang R et al., which was an adaptation of previously clinically and laboratory parameters correlating scoring technique to describe lung involvement in patients of SARS (15),(16). The 18 anatomical segments of both lobes of the lung were divided into twenty lung regions, each lung region was scored as 0 (no involvement) 1 (<50% lung involvement), and 2 (>50% lung involvement) (Table/Fig 2).

Statistical Analysis

Statistical analysis was applied using Statistical Package for the Social Sciences (SPSS) software version 23.0. For a single and multiple comparisons, Mann-Whitney and Kruskal-Wallis tests were performed respectively. The association with CT Severity Score (CT SS) was done using the 2-tailed Chi-square test or Fisher’s-exact test. The Receiver Operating Characteristic (ROC) curve was drawn to determine the optimal cut-off point for CT score as an all-cause mortality. Pearson Chi-square, continuity correction, likelihood ratio, Fisher’s-exact test and linear by linear association tests were applied to define association of CT score with variables. Kaplan-Meier test which was used to evaluate the relationship between CT score and all-cause mortality, which was compared with the logrank test. Cox proportional hazards regression modelling was performed to determine the Hazard Ratio (HR) for CT score as an all-cause mortality predictor.

Results

The mean turn around time was 14.3±2 hours for RT-PCR and 22±10 minutes for chest CT. Another 30 minutes were required for sanitation of the CT machine before it was ready for the next patient. Out of 205 cases, 71.7% were males and 28.3% were females. Maximum cases were seen in the age range of >45 to 65 years. Diabetes mellitus was the most common co-morbidity, seen in 40.5% of patients; followed by hypertension (37.1%). A 20% of patients had both diabetes mellitus and hypertension. In clinical presentation; fever was seen in 77.1% of patients; followed by cough (63.4%) and shortness of breath (53.6%) (Table/Fig 3).

Chest CT finding regarding imaging features, complications, lobar involvement, disease localisation are presented in (Table/Fig 4). The most common chest CT finding (Table/Fig 5) was Ground Glass Opacities (GGO) seen in 156 patients (76.1%), followed by parenchymal consolidation (n=143; 69.7%) and crazy paving pattern (n=101; 49.3%).

Auxillary findings (Table/Fig 6) like fibrosis (n=98; 47.8%), subpleural lines (n=82; 40%), mediastinal lymphadenopathy (n=46; 22.4%), and reversed halo sign (n=3; 1.5%) was also seen. Significant lower lobe involvement was seen with right sided preference.

On the anterio-posterior dimension, there is more involvement of the posterior location with peripheral predominance (Table/Fig 7). Nine patients showed normal chest CT.

Authors also noticed various complications like pleural effusion, systemic venous thrombosis and spontaneous pneumothorax (Table/Fig 8). CT score in early versus late phase disease (Table/Fig 9) (12). GGO was more seen in the early phase whereas consolidation, crazy paving, fibrosis, subpleural lines and mediastinal lymphadenopathy were more seen in the late phase with a significant p-value (p-value <0.05).

CT score versus clinical severity: The chest CT score showed significant association with clinical severity; higher the score, more the severity clinically. The mean CT scores in mild, severe, and critical groups of patients were 13.73±8.51, 23.49±3.75 and 32.42±4.01, respectively (p-value <0.0001). It is described in (Table/Fig 10), (Table/Fig 11).

Clinical severity in age, sex and co-morbidities adjusted cohort: The milder form of the disease was more common in the younger population; however, there were no statistically significant patterns in the cases of severe and critical patients. There was no sex predilection while comparing different clinical severity groups. More severe forms of disease, predominantly critical forms were seen in patients having any known co-morbidities. CT score has no significant association with age, sex and co-morbidities (Table/Fig 12), (Table/Fig 13), (Table/Fig 14).

Short term prognosis in age, sex and co-morbidities adjusted cohort: Although parameters of short-term prognosis were more prevalent in the older age group; however, statistical significance was seen in ICU admission, ventilator support and death. On crosstab statistics, a significant association of CT score was seen with ICU admission, ventilator support and death. However, no significant association with long hospital stays was seen (Table/Fig 12), (Table/Fig 13), (Table/Fig 14).

A statistically significant higher number of ICU admission and deaths were noticed in patients with any known co-morbidities in comparison to previously healthy individuals. In case of diabetes and hypertension, the same prognostic parameters were seen at lower CT score than previously healthy individuals. On crosstab statistics, CT score had no significant association with co-morbidities.

Kaplan-Meier survival curves and univariate and multivariate analyses: Out of the 205 cases in the present study cohort, 46 patients (22.4%) died during hospital stay out of which 42 had known co-morbidities. Diabetes mellitus was reported in 27 (58.7%) of 46 deaths, followed by hypertension in 23 (50%) patients and other co-morbidities in 7/46 (15.2%). Four (6.1%) patients who had no known co-morbidities also died during hospital stay. In the present study death was only seen in critical group patients (Table/Fig 14).

As per Kaplan-Meier analysis and ROC curve, the mortality risk was significantly higher with the increase in CT Score, using an estimated cut-off of ≥30.5 {logrank p-value <0.0001; HR-46.30 (CI:14.35-149.34); p-value <0.001} on a follow-up period of 30 days. Area under ROC Curve (Table/Fig 15) was reported to be 0.97 (p-value <0.0001). Bivariate analysis showed a significant association of CT SS with phase of disease (p-value <0.001), clinical severity (p-value <0.001), lymphocytopenia (p-value <0.001), raised CRP level (p-value <0.001), raised LDH level (p-value <0.001), raised D-dimer level (p-value <0.001), raised PCT level (p-value <0.001) and mortality (p-value <0.001).

Univariate analysis demonstrated a higher risk of mortality with an increase in age, associated co-morbidities, higher CT SS, and raised CRP and D-dimer levels. Multivariate analysis applied on significant statistical variables proven by univariate analysis confirmed the role of CT score as an independent predictor of death (OR=276.8; 95% CI=45.21-1695.43; p-value <0.001) together with co-morbidities (OR=19.36; 95% CI=3.50-107.09; p-value=0.001) and raised D-dimer (OR=25.02; 95% CI=1.90–328.43; p-value=0.014). The Nagelkerke R Square is estimated at 0.820 indicating that 82.0% of the variance in mortality can be predicted from the linear combination of high CT severity score, presence of co-morbidity and high D-dimer levels supposed to be the predictors of mortality.

Discussion

The most common imaging findings of COVID-19, in the present study were bilateral GGOs with or without consolidation, with a predominant peripheral, lower lobe and posterior anatomic distribution. It is quite consistent with previous studies (12),(15),(17). The reason for the more common imaging occurrence of GGO in the early phase of disease can be attributed to the acute phase alveolar injury leading to air space oedema, bronchiolar fibrin depositions and interstitial thickening (18). As the disease progress, there is activation of humoral as well as cell-mediated immune system by virus specific B and T-cells; causing intense production of proinflammatory markers leading to uncontrolled autoimmune reaction. A combination of alveolar oedema, bacterial superinfection, and interstitial inflammatory changes are seen in the late phase, which may explain the higher prevalence of consolidations and crazy-paving pattern in the late phase (19).

Raised leukocyte count, decreased lymphocyte count, raised serum CRP, LDH, PCT and D-dimer levels were commonly observed in COVID-19 patients. These correlated strongly with higher CT scores. Raised serum CRP and D-dimer levels may be explained as a result of the pronounced inflammatory activation and disseminated coagulopathy, characteristics of severe disease (20),(21). Raised serum PCT can be seen in the setting of secondary bacterial infection, suggesting a bad prognosis (22). CT score, co-morbidities and serum level of D-dimer has a significant predictor of mortality on multivariate analysis. Age and serum level of CRP shows significant risk of mortality on univariate analysis; however, no significant association was defined on multivariate analysis.

A Kaplan-Meier survival analysis was performed between CT score and days of hospital stay, to confirm chest CT findings’ prognostic significance for an observational period of 30 days. By using this method, the present study was able to demonstrate that a cut-off CT score of 30.5 is predictive of mortality. But a score of 30.5 is not possible in this study scoring system, so authors took it as ≥31. Similar observations were previously published by Colombi D et al., and Francone M et al., (23),(24). CT severity score more than 31 out of 40 was associated with poor prognosis in the present study population which is comparable to observation made by Francone M et al., (24). They have found score equal or more than 18 out of 25 had poor outcome.

There was a significantly higher mortality in a population of more than 60 years of age in comparison to younger ones. The univariate analysis also proved increased risk of mortality with an increase in age. No significant gender preponderance was seen with the severe form of disease and bad prognosis.

A chest CT score, the objective value of the radiologist’s observation, depicting the extent of lung involvement can correlate well with disease severity and active phase inflammatory marker findings. It can also predict the outcome or clinical course of the disease, as it represents the disease burden. This prospective study explored all the clinical utility of chest CT score in predicting disease severity and short-term prognosis of the disease. Apart from this, a CT score can come in handy in the management of patients in a few more ways.

Due to the short turnaround time of chest CT in comparison to RT-PCR, it can be very useful in the early isolation of patients to contain the disease in the hospital. There is a statistically significant difference between the turnaround time of chest CT and RT-PCR. In 29 patients with first RT-PCR negative, authors had to repeat RT-PCR for diagnosis. This further increases the time for diagnosis. Sometimes sampling is also poor; causing more delay in diagnosis. Although, the diagnostic role of CT remains controversial and a hot debate topic in the current pandemic situation. A group of researchers believe chest CT has higher sensitivity (25),(26) in comparison to RT-PCR while others believe vice-versa (27). Several authors and radiological fraternities do not believe in the use of CT as a first-line investigation due to radiation exposures (28). In the present study, CT also did not appear much sensitive; nine patients were RT-PCR positive despite their chest CT imaging were normal. Due to less turnaround time and significant association with laboratory parameters, CT score can be helpful speedy diagnostic workflow of symptomatic patients. In COVID-19 infection, there is more extensive involvement of lung parenchyma in comparison to other viral pneumonia (5),(6),(29). A higher CT score has a more probability of the COVID-19 infection. So, authors recommend the use of chest CT routinely in all symptomatic severe patients.

Limitation(s)

The present study had some limitations as recall bias regarding the previous diagnosis of ILD or any co-morbidities and authors experienced a higher number of critical patients and mortality in this study group in comparison to our national data as we were a referral center. The survival analysis study lacks longer follow-up data. Due to the smaller sample size, authors could not define the role of individual co-morbidity in disease mortality. Authors suggest a future prospective study with a larger sample size, co-morbidity adjusted individual cohort and a study to look predictive value of CT score for delayed complications.

Conclusion

Chest CT findings are quite evident and correlating well with the novel acute phase reactants. So, CT score can be used as an imaging tool to predict the future course of disease and plan management accordingly in areas lacking with the modern laboratories. In a developing country, this can guide timely referral of patients to higher centers with better intensive care facilities. Whereas in the developed country, it can help hospital administration for better preparedness for critical events and management of hospital resources. Due to its objectiveness, it can make communication easier between the caregivers and the caregiver, and the patient’s caretaker. The higher chest CT score with higher probability of COVID-19 infection can be helpful in containing the disease by early isolation.

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DOI and Others

DOI: 10.7860/JCDR/2022/51808.16168

Date of Submission: Aug 08, 2021
Date of Peer Review: Nov 22, 2021
Date of Acceptance: Jan 05, 2022
Date of Publishing: Mar 01, 2022

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: Aug 12, 2021
• Manual Googling: Jan 04, 2022
• iThenticate Software: Jan 11, 2022 (9%)

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