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

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Dr Mohan Z Mani

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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 : April | Volume : 16 | Issue : 4 | Page : OC24 - OC27 Full Version

Predictive Role of Chest Radiograph in COVID-19 Hospitalised Patients- A Retrospective Analysis


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53224.16242
Judah Nijas Arul, Mohan Kumar, Swathy Moorthy, Rajkumar Mani

1. Senior Resident, Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 2. Senior Resident, Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 3. Associate Professor, Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. 4. Professor, Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Swathy Moorthy,
Associate Professor, Department of General Medicine, Sri Ramachandra Institute
of Higher Education and Research, Porur, Chennai, Tamil Nadu, India.
E-mail: drswathymoorthy@sriramachandra.edu.in

Abstract

Introduction: The portable Chest Radiograph (CXR) has an indispensable role in large scale screening and diagnosis of Coronavirus Disease-2019 (COVID-19), especially in developing countries with limited resources. It can help in predicting the severity of lung involvement in the patients infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, especially in areas where the Computed Tomography (CT) is unavailable.

Aim: To determine the prognostic value of CXR at clinical presentation in assessing the disease severity and its correlation with inflammatory markers in COVID-19 hospitalised patients.

Materials and Methods: This was a single-centre retrospective study, conducted at Sri Ramachandra Institute of Higher Education and Research, from October 2020 to December 2020, on hospitalised COVID-19 patients. Clinically, the patients were categorised as mild, moderate and severe, based on their peripheral oxygen saturation- more than or equal to 94%, between 90-93%, and less than or equal to 89%, respectively. Blood samples, drawn at presentation to the hospital tested for various inflammatory markers proven to be predictive of disease severity, were documented for the analysis purpose. The CXRs done at the presentation, were scored based on the number of zones involved and type of abnormality present (ground glassing, consolidation and septal thickening). The CXRs were scored a minimum ‘0’ to a maximum of ‘9’. Correlation between the radiograph score and inflammatory markers were further analysed.

Results: Among the 456 study patients, 71.9% had mild, 15.1% had moderate and 13% had severe COVID-19 infection. The mean CXR score in each category was 1, 3 and 4, respectively (p-value <0.001). The study groups were grouped as mild and non mild (included the moderate and severe categories). A criterion CXR score of 2 was able to differentiate mild and non mild cases (sensitivity was 78.29%, specificity was 77.98%, positive predictive values was 58.38%, negative predictive values was 90.11%), with an accuracy of 78.1%. The inflammatory markers like Neutrophil Lymphocyte Ratio (NLR), Absolute Lymphocyte Counts (ALC), eosinophil%, D-dimer, Lactate Dehydrogenas (LDH), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), and ferritin showed statistically significant difference between the two groups (p-value<0.001).

Conclusion: The CXR can be used as a screening and predictive tool for disease severity in developing countries where access to Computed Tomography (CT) is limited. Given the possibility of subsequent waves of the COVID-19 pandemic and the risk of excessive radiation exposure from CT, CXR may be used as a reliable alternative.

Keywords

Coronavirus disease, Disease severity, Portable chest radiograph, Radiograph score

Chest imaging remains the primary modality that is used in the management of patients with infections causing lung involvement. A consensus statement was issued by the Fleischner Society exploring Computed Tomography (CT) of the chest as a prime imaging modality in the diagnosis, risk stratification and management of the Coronavirus Disease-2019 (COVID-19) patients (1), but many professional organisations in the developing world face issues such as non availability of CT. Also, owing to the rapid spread of infection, tests that are less time consuming and can be done quickly, should be adopted. To handle such situations, the Society of Thoracic Radiology and American College of Radiology have suggested the use of portable Chest Radiograph (CXR) to combat this crisis (2). The CXR has been shown to have a low sensitivity of 69%, in diagnosing COVID-19 lung involvement (3).

Studies among the severe acute respiratory syndromes observed in 2003 and other pneumonia causing infections, reported a positive correlation between poorer clinical outcomes and two or more zones involvement on CXRs (4),(5). However, pre-existing heart or lung conditions of the individuals and observer expertise influence the CXR interpretation. The CXR characteristics of COVID-19 infection, have been focused in few studies from countries like Italy and China. Peripheral ground glass opacities or consolidation noted in the lower and mid zones were the most predominant CXR findings observed (3),(6). The CXR in COVID-19 infected patients had variable sensitivity reported, with one study quoting sensitivity as high as 89% (7). The CXR severity was worser with advancing age, non survivors (8),(9),(10), and more likely for intubation and mechanical ventilation (11),(12).

CXR is the primary imaging modality adopted for the diagnosis and risk stratification of COVID-19 infection in the UK. The British society of Thoracic Imaging (BSTI) have recommended the use of severity grading in CXR as mild/moderate/severe in suspected COVID-19 infection, though no clear guidance exists on the constitutes of each severity grade (13). Other CXR grading systems have been used are the Radiographic Assessment of Lung Oedema (RALE) score, where the lungs are split into quadrants, and the involvement and density are scored, the quadrant scores are multiplied and then summed and is a 0-48 score (14), a simplified version of the RALE score, where each lung is given a score of 0-4 proportional to the amount of lung affected has also been tried (3). Brixia score, is yet another CXR score (9),(10), which is scored 0-18, where the left and right upper, middle and lower zones are each given a 0-3 score proportional to the lung involvement.

Toussie D et al., utilised a scoring system based on the number of lung zones involved in CXR. Lung fields on CXR were divided into six zones, three on each lung. A score of 2 or more correlated with need for hospital admission and a score of 3 or more was an independent predictor of need for mechanical ventilation (15). The present study was aimed to determine the prognostic value of CXR at clinical presentation in determining the severity of illness and its correlation with inflammatory markers in COVID-19 hospitalised patients.

Material and Methods

This was a single-centre retrospective study, conducted at Sri Ramachandra Institute of Higher Education and Research, during the period between October 2020 to December 2020. The approval from the Institutional Ethics Committee {IEC-NI/20/AUG/75/56 (COVID-19)} was obtained.

Inclusion criteria: Data of 456 adult patients admitted with COVID-19 illness, confirmed by Reverse Transcription-Polymerase Chain Reaction (RT-PCR) of the nasopharyngeal swab, over the age of 18 years were considered in the study.

Exclusion criteria: All COVID-19 positive patients, below the age of 18 years were excluded from the study.

Procedure

The clinical and demographic variables of all the patients were recorded. All the patients had undergone a CXR at the time of admission. The radiographs were analysed prospectively by a single trained physician, blinded to the patient’s history, other than the positive history of COVID-19 infection, to minimise observer bias. The radiographs were accessed from the preserved archived soft copies, and scored the involvement of lung abnormalities in the CXR.

To analyse the imaging each lung was divided into three zones; upper, middle and lower, based on the extension from apices to superior hilar markings, from superior to inferior hilar markings and from inferior hilar markings to costophrenic sulcus, respectively (Table/Fig 1). Each zone was scored based on presence or absence of opacity as 1 or 0 and a total score out of 6 was derived for the six zones in the CXR (15). Further scoring was done for the pattern of lung involvement- ground glass opacity, consolidation and septal thickening as 0, 1 and 2 respectively (with increasing severity of the opacity). These two scores were added together, to get total scores of minimum 0 to a maximum of 9. The final scores thus derived were correlated with the clinical severity and inflammatory markers like Neutrophil Lymphocyte Ratio (NLR), Absolute Lymphocyte Count (ALC), eosinophil%, D-dimer, Lactate Dehydrogenas (LDH), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), and ferritin documented at the time of presentation to the hospital.

Statistical Analysis

The data was analysed using Statistical Package for the Social Sciences (SPSS) software version 23.0. Continuous variables were expressed as mean and standard deviations. Percentage and frequency analysis was used for categorical variables. One-way Analysis of Variance (ANOVA) with Tukey’s post-hoc test were used to determine statistical significance in intergroup analysis. Spearman’s rank correlation coefficient was adopted to measure the degree of correlation between the CXR score and each of the variables. All the tests were two tailed and a p-value of <0.05 was considered statistically significant. Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the efficacy of CXR score in determining the outcomes of interest.

Results

The study included 456 COVID-19 hospitalised patient’s data, of which 328 patients were mild, 69 were moderate and 59 were severe. (Table/Fig 2) describes the baseline characteristics of study population and (Table/Fig 3) shows the CXR scoring among the mild, moderate and severe cases. Older age group was associated with moderate and severe infections, while gender did not show any difference with the disease severity. NLR, D-Dimer, Ferritin, CRP, ESR correlated positively with clinical severity while ALC, eosinophil percentage negatively correlated with the disease severity (Table/Fig 4). Overall, 61.9% of patients affected with mild illness had normal CXR, while 71.2% of moderate cases had 3 zones or lesser involved, and 47.5% of severe cases had more than 3 zones involved. The most frequently involved lobes in the CXR were- right lower lobe (72%), followed by the left lower lobe (55%).

CXR scores showed a statistically significant correlation with the inflammatory markers (Table/Fig 4). ROC analysis showed a CXR score of 2 to differentiate between mild and non mild cases with a sensitivity of 78.29%, 77.98% specificity, 58.38% positive predictive and 90.11% negative predictive value. This value had an accuracy of 78.1%, with 0.848 Area Under The Curve (AUC) as shown in (Table/Fig 5). (Table/Fig 6) shows the comparison of inflamatory markers between mild and non mild cases based on the criterion value 2 for CXR. (Table/Fig 7) describes the proposed CXR scoring system.

Discussion

COVID-19 pandemic has placed an unprecedented burden on healthcare demanding a robust and simple-to-use screening algorithm which can help in prioritising management and predicting outcomes. In this study, the value of CXR at admission was explored in evaluating COVID-19 patients. The severity of the CXR opacity at admission was associated with severe form of disease clinically as well as the inflammatory markers.

Nearly, 63% of COVID-19 pneumonia patients have normal CXR particularly in early stages of infection and develop radiological findings as the disease progresses (3) with bilateral lung involvement being a common finding (15). The index study also had similar findings- as the severity of the infection progressed, the number of zones involved in the CXR increased. The most common findings are ground glassing haze, consolidatory changes with patchy opacities which can progress to septal thickening (15),(16), followed by presence of nodules, pneumothorax and pleural effusion (1-3%) 26(16). In the present study, consolidation, and septal thickening was noted, and the frequency of involvement of various lobes was- right lower lobe (72%), followed by the left lower lobe (55%). Prior studies in COVID-19 and other pneumonias have shown a prediliction to right lower lobe involvement, which could be related to the anatomical positioning of the right lower lobe bronchus (15),(17). Age of the patients correlated with increased risk of higher CXR scores but gender did not demonstrate such correlation in the present study, which was in discordance with the observations of previous studies (11). Since most of the patients in the study were males, the correlation between CXR and sex was not significant.

In the index study, the severity score of CXR was determined by the sum of number of zones involved, similar to the study by Toussie D et al., along with the pattern of opacity (11). A score of more than 2 was able to effectively differentiate mild cases from moderate and severe ones with an accuracy of 78.1% and negative predictive value of 90.11%. In other words, the score could determine whether the patient would require oxygen therapy and hospitalisation for COVID-19 infection.

Many scoring systems have been in place like the the British Society of Thoracic Imaging (BSTI) which recommends the use of severity grading in CXR as mild/moderate/severe in suspected COVID-19 infection. In the RALE score, the lungs are divided into quadrants, and the involvement and density are scored 0-48, where the quadrant scores are multiplied and then summed (14), a simplified version, where each lung is given a score of 0-4 based on the proportion of lung affected has also been tried (3). Yet another CXR score, is the Brixia score [8,10], which is scored 0-18, where the left and right upper, middle and lower zones are each given a 0-3 score proportional to the lung involvement. All these scoring have been tried but when employed at the community becomes cumbersome calculating such high scores, so a simpler scoring that can be easily adopted which does not require more time and can be easily analysed was tried.

The index study tried a simpler scoring system similar to the method adopted by Toussie D et al., by dividing the CXR into 6 zones and further score based on the type of the opacity observed in the CXR (11). This method serves to be a user friendly approach for the community level doctors also who need no special training for identifying the number of zones involved and the pattern of opacity in the CXR. Though, newer approach was attempted, the method served an easy approach to assess the CXR at bedside even at the community level. Given the possibility of multiple waves of infection and risk of radiation exposure from CT, CXR could serve as an effective screening tool for predicting the need for hospitalisation among COVID-19 patients, effectively reducing the economic burden on healthcare system, especially in resource limited settings.

Limitation(s)

Correlation between the CXR and chest tomography and the amount of oxygen needed was not done. The score was not able to distinguish between severe disease and moderate infections, it was best suited to distinguish mild from non mild infections which included both moderate and severe forms.

Conclusion

In conclusion, this study demonstrated that CXR can be utilised as an effective tool to determine the clinical severity of COVID-19 infection. A CXR score of greater than 2 was able to distinguish moderate and severe infections from mild ones with an accuracy of 78.1%. Thus CXR may be used as a screening tool in determining the need for hospitalisation given that patients without mild infections require oxygen support thus reducing the burden on the healthcare system. However, the scoring method requires external validation for assessing the generalisability of the method.

References

1.
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. Radiology. 2020;296(1):172-80. [crossref] [PubMed]
2.
American College of Radiology. ACR recommendations for the use of CXRy and computed tomography (CT) for suspected COVID-19 infection. https:// www.acr. org/Advocacy-and-Economics/ACR-Position-Statements/Recommendationsfor-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection. Published March 11, 2020. Updated March 22, 2020. Accessed April 30, 2020.
3.
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]
4.
Hui DSC, Wong KT, Antonio GE, Lee N, Wu A, Wong V, et al. Severe acute respiratory syndrome: Correlation between clinical outcome and radiologic features. Radiology. 2004;233(2):579-85. [crossref] [PubMed]
5.
Antonio GE, Wong KT, Tsui ELH, Chan DPN, Hui DSC, Ng AWH, et al. CXR scores as potential prognostic indicators in severe acute respiratory syndrome (SARS). AJR Am J Roentgenol. 2005;184(3):734-41. [crossref] [PubMed]
6.
Durrani M, Haq IU, Kalsoom U, Yousaf A. Chest x-rays findings in covid 19 patients at a university teaching hospital-a descriptive study. Pakistan J Med Sci. 2020;36:S22-26. Doi: 10.12669/pjms.36.COVID19-S4.2778. [crossref]
7.
Schiaffino S, Ritella S, Cozzi A, Carriero S, Blandi L, Ferraris L, et al. Diagnostic performance of chest X-Ray for COVID-19 pneumonia during the SARS-CoV-2 pandemic in Lombardy, Italy. J Thorac Imaging. 2020;35:W105-06. Doi: 10.1097/RTI.0000000000000533. [crossref] [PubMed]
8.
Borghesi A, Maroldi R. COVID-19 outbreak in Italy: Experimental chest X-ray scoring system for quantifying and monitoring disease progression. Radiol Medica. 2020;125:509-13. Doi: 10.1007/s11547-020-01200-3. [crossref] [PubMed]
9.
Borghesi A, Zigliani A, Masciullo R, Golemi S, Maculotti P, Farina D, et al. Radiographic severity index in COVID-19 pneumonia: Relationship to age and sex in 783 Italian patients. Radiol. Medica. 2020;125:461-64. Doi: 10.1007/s11547-020-01202-1. [crossref] [PubMed]
10.
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. Doi: 10.1016/j.ijid.2020.05.021. [crossref] [PubMed]
11.
Toussie D, Voutsinas N, Finkelstein M, Cedillo MA, Manna S, Maron SZ, et al. Clinical and CXRy features determine patient outcomes in young and middleaged adults with COVID-19. Radiology. 2020;297:E197-206. Doi: 10.1148/radiol.2020201754. [crossref] [PubMed]
12.
Balbi M, Caroli A, Corsi A, Milanese G, Surace A, Di Marco F, et al. Chest X-ray for predicting mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department. Eur Radiol. 2020. Doi: 10.1007/s00330-020-07270-1. [crossref] [PubMed]
13.
Thoracic Imaging in COVID-19 Infection|The British Society of Thoracic Imaging https://www.bsti.org.uk/media/resources/files/BSTI_COVID-19_Radiology_Guidance_version_2_16.03.20.pdf.
14.
Homayounieh F, Zhang EW, Babaei R, Mobin HK, Sharifian M. Clinical and imaging features predict mortality in COVID-19 infection in Iran. PLoS One. 2020;15(9):e0239519. Doi: 10.1371/journal.pone.0239519. [crossref] [PubMed]
15.
Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Pena RV, Rivera YH, Escalera-Antezana JP, et al., Latin American Network of Coronavirus Disease 2019-COVID-19 Research (LANCOVID-19). Electronic address: https://www.lancovid.org. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020;34:101623. Doi: 10.1016/j.tmaid.2020.101623 pmid:32179124. [crossref] [PubMed]
16.
Jacobi A, Chung M, Bernheim A, Eber C. Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clin Imaging. 2020;64:35-42. Doi: 10.1016/j.clinimag.2020.04.001 pmid:32302927 [crossref] [PubMed]
17.
Wang Q, Zhang Z, Shi Y, Jiang Y. Emerging H7N9 influenza A (novel reassortant avian-origin) pneumonia: Radiologic findings. Radiology. 2013;268(3):882-89. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/53224.16242

Date of Submission: Nov 20, 2021
Date of Peer Review: De 29, 2021
Date of Acceptance: Jan 28, 2022
Date of Publishing: Apr 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. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 23, 2021
• Manual Googling: Jan 27, 2022
• iThenticate Software: Feb 17, 2022 (10%)

ETYMOLOGY: Author Origin

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