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

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Dr Mohan Z Mani

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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."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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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.
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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 : September | Volume : 16 | Issue : 9 | Page : OC21 - OC24 Full Version

Correlation between NEWS, CT Severity Score and RT-PCR Cycle Threshold Value among Mild and Moderate COVID-19 Patients


Published: September 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56743.16876
Sricharan Vijayakumar, Sandeep Garg, Anju Garg, Sunita Aggarwal, Vikas Manchanda, Ranvijay Singh, Sanjit Kumar

1. Postgraduate Resident, Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 2. Director Professor, Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 3. Director Professor and Head, Department of Radiodiagnosis, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 4. Director Professor, Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 5. Professor, Department of Microbiology, Maulana Azad Medical College, New Delhi, India. 6. Senior Resident, Department of Medicine, Lok Nayak Hospital, New Delhi, India. 7. Postgraduate Resident, Department of Medicine, Lok Nayak Hospital, New Delhi, India.

Correspondence Address :
Dr. Sricharan Vijayakumar,
4/3, Guru Kewal Residency, 12th Cross, 8th Main, Malleswaram, Bengaluru-560003, Karnataka, India.
E-mail: sricharanembar@gmail.com

Abstract

Introduction: The clinical diagnosis of COVID-19 is supplemented by clinical severity indices. These indices are the National Early Warning Score (NEWS, which aids in risk stratification), CT severity score (radiological severity score), and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) cycle threshold (Ct value, which provides a semi-quantitative measure of viral load).

Aim: To assess the correlation between NEWS at admission, RT-PCR Ct value and CT severity score in mild and moderate COVID-19 patients.

Methods and Materials: This prospective cohort study was conducted in Maulana Azad Medical College and Lok Nayak hospital, New Delhi, from January to June 2021. The study included 50 subjects (25 with mild COVID-19 and 25 with moderate COVID-19). NEWS was calculated at admission and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Ct value was estimated using real-time RT-PCR. CT severity score was calculated based on High Resolution Computed Tomography (HRCT) chest findings. The correlation among the parameters was determined using Pearson correlation formula.

Results: The mean age of subjects in the mild and moderate COVID-19 groups were 49.52 years and 51.84 years, respectively. The mean RT-PCR Ct value of E gene was 24.48 and Rdrp gene was 24.56 in the mild COVID-19 group; while in the moderate group it was 23.72 for both E gene and Rdrp genes. The correlation between NEWS and Ct value of E gene (r-value=-0.06, p-value=0.68), Ct value of Rdrp gene (r-value=-0.03, p-value=0.79) and the correlation between CT severity score and Ct value of E gene (r-value=-0.05, p-value=0.73), Ct value of Rdrp gene (r-value=-0.06, p-value=0.68) was negative and insignificant. The mean CT severity score in mild COVID-19 group was 3.92, and in moderate COVID-19 group was 9.88. A significant positive correlation was found between the CT severity score and NEWS at admission.

Conclusion: The clinical severity of COVID-19 as estimated by NEWS corroborates with CT severity score while the relationship between RT-PCR Ct value and clinicoradiological severity needs to be ascertained by further research.

Keywords

Coronavirus, Ct value, National early warning score, Reverse transcription-polymerase chain reaction

The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in widespread mortality in India and worldwide (1). Patients with co-morbidities such as diabetes, hypertension, chronic kidney, liver and lung diseases have been found to be at high-risk for progression to severe COVID-19. Hence, there is a need for rapid, reliable, efficient and accurate methods to diagnose COVID-19 timely in order to prevent transmission, minimise complications and mortality associated with it. The utility of microbiological, immunological, biochemical and radiological techniques has come to the forefront in supplementing the clinical diagnosis of COVID-19. While the microbiological methods are used to confirm the diagnosis by definitively detecting the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) viral genome, the radiological methods are often used for differentiating COVID-19 from other infections and estimating the severity of disease based on the quantification of lung involvement. In this regard, National Early Warning Score (NEWS), Reverse Transcription-Polymerase Chain Reaction cycle threshold (RT-PCR Ct) value and CT Severity Score (CT-SS) have been useful adjuncts in establishing the diagnosis.

The clinical severity of COVID-19 is the most important tool for triaging and risk stratification. The NEWS is an early warning score which was developed by the Royal College of Physicians in 2012. Itutilizes six bedside vital parameters (heart rate, systolic blood pressure, respiratory rate, temperature, level of consciousness and oxygen saturation at room air or the use of supplemental oxygen) (2). Each of these parameters is stratified based on the degree of derangement and assigned a score. A higher score signifies that the patient’s vital parameters are deranged to a greater extent and clinical monitoring is needed more frequently. The aggregate NEWS is obtained by adding the individual parametric scores. The maximum NEWS that can be obtained is 20. Thus, NEWS serves as a proxy for the clinical severity to facilitate rapid triaging and employment of prompt and appropriate clinical responses. NEWS has been correlated with clinical severity and outcome of COVID-19 in some studies (3).

Computed Tomography (CT) of chest has been a valuable tool especially in suspected patients having typical symptoms of COVID-19 whose RT-PCR reports are pending or inconclusive as it establishes the diagnosis and aids in quick isolation. The sensitivity of chest CT is more than 90% according to some studies. On the basis of typical findings of COVID-19 pneumonia on chest CT, Li K et al., proposed a semi-quantitative scoring system used to quantify the extent of damaged lung tissue depending on the percentage area of the lung involved (4). In this scoring system, each lobe was assigned a score from zero to five according to the estimated percentage area of lung involvement. The composite score,known as the CT Severity Score (CT-SS), is obtained by the sum of the individual lobar scores and ranges from 0 to 25 (Table/Fig 1). CT-SS is an indicator of the burden of lung damage due to COVID-19 pneumonia and has been shown to be correlated with numerous factors such as age, time since symptom onset, biomarkers of clinical severity and clinical outcomes.

RT-PCR is a highly sensitive and specific molecular method employed for the laboratory diagnosis of COVID-19. Quantitative RT-PCR yields Cycle threshold (Ct) values which provide an estimate of the viral load in the sample. The Cycle threshold or Ct value is defined as the number of cycles of amplification at which the fluorescence of a PCR product crosses the threshold, exceeding the background signal. The greater the amount of target nucleic acid in the sample, the sooner the fluorescence crosses the threshold and lower the Ct value (5). Ct value is semiquantitative, with a 3-fold increase in Ct value corresponding to a 10-fold decrease in target nucleic acid. The Ct value is inversely proportional to the viral load of SARS-CoV-2 in a given sample. The Ct value also depends on a number of factors such as site of sample collection, day since onset of symptoms, age of the patient, type of RT-PCR kit used. Few studies have indicated that the RT-PCR Ct value of SARS-CoV-2 is correlated with clinical outcome and severity of COVID-19 (6).

This study aimed to evaluate the role of NEWS, Ct value and CT-SS together in the clinical context of COVID-19 and the correlation between them. It is of critical importance to decipher the correlation between clinical severity indices and radiological and microbiological indices ascertaining severity as it facilitates in quicker diagnosis and management of COVID-19.

Material and Methods

This prospective cohort study was conducted in Maulana Azad Medical College and Lok Nayak hospital, New Delhi, from January to June 2021. The Institutional Ethics Committee of Maulana Azad Medical College had approved the study (letter No. 244 dated 14/01/2021). The study was conducted in the general wards when the hospital was converted into an exclusively COVID-19 dedicated centre. The study enrolled 50 subjects, as a sample size of convenience.

Inclusion criteria: Adult (aged >18 years) COVID-19 positive patients, confirmed by either RT-PCR or Rapid Antigen Test (RAT) who presented with an oxygen saturation (SpO2) of more than 90% on room air were included as subjects after taking informed consent.

Exclusion criteria: Patients with shock, Multiorgan Dysfunction Syndrome (MODS) or Acute Respiratory Distress Syndrome (ARDS) and patients admitted in Intensive Care Unit (ICU). Severe COVID-19 patients (who had an SpO2 of less than 90% on room air) were not included in this study as it was assumed that their radiological severity (CT severity score) would corroborate easily with clinical severity.

The subjects were divided into two groups of 25 each:

• Mild COVID-19 patients whose SpO2 was ≥94% on room air
• Moderate COVID-19 patients whose SpO2 was 90-93% on room air.

Procedure

In both the groups, the NEWS was calculated based on the vital parameters on the day of admission. Baseline blood investigations including Complete Blood Count (CBC), Kidney Function Tests (KFT), Liver Function Tests (LFT), Prothrombin Time and International Normalized Ratio (PT/INR), D-dimer was done. The RT-PCR sample was sent for SARS-CoV-2 and the Ct values of E gene and Rdrp gene were obtained. High Resolution Computed Tomography (HRCT) chest was done and the CT-Severity Score (CT-SS) was calculated based on the severity of lung involvement. The subjects were monitored regularly and in case of any evidence of clinical deterioration, appropriate blood markers were sent for corroboration. The following outcomes were assessed: discharge, transfer to ICU, first evidence of respiratory failure, coagulopathy, acute kidney injury, acute liver injury, acute myocardial injury or death.

Statistical Analysis

The data obtained was processed by Statistical Package for Social Sciences (SPSS) version 25.0, tabulated and represented graphically for interpretation. Continuous variables were presented as mean and standard deviation and were compared by Student's t-test. Categorical variables were presented as frequencies or percent values and compared by Chi-square test. The p-value less than 0.05 was considered significant for all tests. The correlation between NEWS, Ct value and CT severity score was done using Pearson correlation formula. The NEWS at admission was correlated with Ct value and CT-SS. The Ct value was also correlated with CT-SS.

Results

The mean age in the mild COVID-19 group was 49.52 years and in the moderate COVID-19 group was 51.84 years (Table/Fig 2). The gender distribution showed that 68% (34/50) of the subjects were males while 32% (16/50) of them were females.

On comparison of the hematological parameters, there was a statistically significant difference in the mean platelet count between the mild and moderate COVID-19 group (3.04 L versus 2.19 L, p-value=0.01). Among the biochemical parameters, a statistically significant difference between the mild and moderate COVID-19 groups was found in the following parameters- mean AST, mean ALT, mean D-dimer and mean serum ferritin (Table/Fig 3).

NEWS was used as the marker of clinical severity of COVID-19. The mean NEWS at admission was significantly greater in the moderate COVID-19 group (3.04) than in the mild COVID-19 group (0.36).

Analysis of the RT-PCR Ct values revealed that in mild COVID-19 patients, the mean Ct value of E gene was 24.48 and that of Rdrp gene was 24.56. In moderate COVID-19 patients, the mean Ct value of both E gene and Rdrp genes were 23.72. There was no statistically significant difference in the Ct values of both E gene (p-value=0.57) and Rdrp gene (p-value=0.54) between the groups (Table/Fig 4).

The mean CT severity score in mild COVID-19 patients was significantly lower (3.92) than in the moderate COVID-19 patients (9.88) (Table/Fig 4).

The assessment of outcomes showed that overall, 76% (38/50) patients were discharged, 12% (6/50) patients developed sepsis, and 12% (6/50) patients developed respiratory failure and were transferred to ICU (Table/Fig 5). There were no deaths among the study subjects. There were no incidences of acute kidney injury (serum creatinine more than two times of upper limit normal), acute liver injury (serum AST/ALT more than two times of upper limit normal), acute myocardial injury (serum CPK-MB>10% of serum total CPK) or coagulopathy (INR>1.5 times of normal reference)among the study subjects. The mean duration between admission and outcome was significantly higher in the mild COVID-19 group compared to moderate COVID-19 group (9.04 days vs 7.44 days, p-value=0.10) (Table/Fig 6).

There was a statistically significant positive correlation between CT-SS and NEWS at admission in both the mild and moderate COVID-19 groups (Table/Fig 7). There was a negative and insignificant correlation between CT-SS and Ct values of E gene and Rdrp gene. The correlation between NEWS at admission and Ct values of E gene and Rdrp gene was also negative and insignificant (Table/Fig 8), (Table/Fig 9).

Discussion

The study aimed to assess the correlation between NEWS which is a marker of clinical severity, RT-PCR Ct value which is a marker of viral load and CT-SS which is a marker of radiological severity of COVID-19. This study is probably the first study till date to incorporate all the three parameters together in the assessment of COVID-19 severity.

The radiological severity as determined by CT severity score corroborated with the clinical severity as determined by NEWS. The mean CT-SS in the moderate COVID-19 group was significantly greater than that of the mild COVID-19 group (p-value<0.01). Similar findings were reported in other studies; in a study by Abbasi B et al., a positive correlation between CT severity score and mortality and clinical severity (as determined by time to ICU admission, time to intubation and time to death) was found (7).

The analysis of correlation between the parameters provided useful insights. The correlation between the RT-PCR Ct value of E gene with NEWS (r-value=-0.06, p-value=0.68) and the Ct value of Rdrp gene with NEWS (r-value=-0.03, p-value=0.79) was negative but statistically insignificant. Other studies utilizing various markers as proxy for clinical severity have yielded different results. A study by Romero-Alvarez D et al found a negative but significant correlation between the Ct value of RT-PCR and ICU admission (8). In this study, patients were taken irrespective of COVID-19 clinical severity. Another study by Tanner AR et al., revealed that the RT-PCR Ct value at admission is independently associated with the risk of mortality in addition to other factors such as age, NEWS2 and cardiovascular co-morbidities (9). In the present study only patients belonging to mild and moderate COVID-19 clinical severity were taken and hence, this study provides an insight into this correlation in a limited subset of patients.

There was a significant positive correlation between CT-SS and NEWS at admission (r-value=0.55, p-value<0.001) in both the mild and moderate COVID-19 groups. A study by Akdur G et al., yielded similar findings; a higher CT severity score was associated with time-to-death within 14 and 90 days and the combined use of NEWS at admission and CT severity score yielded greater accuracy as NEWS≥7 and CT-SS>11 were associated with the highest hazard ratio (10). Since a higher clinical severity is associated with a higher NEWS, the correlation between the NEWS at admission and CT severity score can therefore be extrapolated and the results of our study concurs with this finding.

The correlation between RT-PCR Ct value of E gene and CT severity score (r-value=-0.05, p-value=0.73) and that of Ct value of Rdrp gene and CT severity score (r-value=-0.06, p-value=0.68) was also negative but insignificant. A similar study conducted by Bakir A et al., analysed the relationship between the chest CT score and Ct value as a proxy for viral load; the results showed a positive correlation between the Ct value and chest CT score (r-value=0.197, p-value=0.01) (11). Since chest CT score and CT-SS are similar measures used for quantification of lung involvement in COVID-19, the results of our study can be said to concur with this study. Another study by Liu Z et al., examined the correlation between Lung Severity Score (LSS) which is similar to CT-SS and RT-PCR Ct value and found that LSS was inversely related to Ct value (r-value=-0.588, p-value=0.003). However, this study categorized patients into severe and non-severe COVID-19 and this negative correlation between LSS and Ct value was found only in severe COVID-19 (12). Hence, there is paucity of data in the literature describing the relationship between the RT-PCR Ct value and CT Severity Score. Hence, the present study is one of the first studies which describes the correlation between these parameters in a specific subset of COVID-19 patients.

Limitation(s)

Firstly, at the time of this study, there were no published studies that measured the correlation between RT-PCR Ct value, NEWS and CT severity score, hence it was difficult to corroborate with a benchmark and get guidance from reliable resources. Secondly, due to the limited sample size of 50 and the inclusion criteria which permitted to enrol only patients of mild and moderate severity, estimation of data accuracy and extrapolation to the larger population was not possible. Thirdly, since this study was conducted around the time of the second wave of COVID-19 pandemic in India, resource constraints did not permit a follow-up CT chest or RT-PCR Ct value to look for any temporal variation in those parameters.

Conclusion

The utility of NEWS, CT severity score, RT-PCR Ct value and other various clinical, radiological and immunological indices for supplementing the clinical diagnosis of COVID-19 cannot be overemphasized especially in a pandemic situation. Further studies delving into the correlation between clinical severity and other markers of disease severity should be actively encouraged as they can pave way for novel and effective interventions to combat this deadly COVID-19 pandemic.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/56743.16876

Date of Submission: Mar 31, 2022
Date of Peer Review: Apr 26, 2022
Date of Acceptance: Jun 10, 2022
Date of Publishing: Sep 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: Apr 06, 2022
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• iThenticate Software: Aug 16, 2022 (8%)

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