Risk stratification of hospital admissions for COVID-19 pneumonia by chest radiographic scoring in a Johannesburg tertiary hospital
DOI:
https://doi.org/10.7196/SAMJ.2023.v113i2.16681Keywords:
COVID-19, LungsAbstract
Background. Chest radiographic scoring systems for COVID-19 pneumonia have been developed. However, little is published on the utility
of these scoring systems in low- and middle-income countries.
Objectives. To perform risk stratification of COVID-19 pneumonia in Johannesburg, South Africa (SA), by comparing the Brixia score with
clinical parameters, disease course and clinical outcomes. To assess inter-rater reliability and developing predictive models of the clinical
outcome using the Brixia score and clinical parameters.
Methods. Retrospective investigation was conducted of adult participants with established COVID-19 pneumonia admitted at a tertiary
institution from 1 May to 30 June 2020. Two radiologists, blinded to clinical data, assigned Brixia scores. Brixia scores were compared with
clinical parameters, length of stay and clinical outcomes (discharge/death). Inter-rater agreement was determined. Multivariable logistic
regression extracted variables predictive of in-hospital demise.
Results. The cohort consisted of 263 patients, 51% male, with a median age of 47 years (interquartile range (IQR) = 20; 95% confidence
interval (CI) 46.5 - 49.9). Hypertension (38.4%), diabetes (25.1%), obesity (19.4%) and HIV (15.6%) were the most common comorbidities.
The median length of stay for 258 patients was 7.5 days (IQR = 7; 95% CI 8.2 - 9.7) and 6.5 days (IQR = 8; 95% CI 6.5 - 12.5) for intensive
care unit stay. Fifty (19%) patients died, with a median age of 55 years (IQR = 23; 95% CI 50.5 - 58.7) compared with survivors, of median
age 46 years (IQR = 20; 95% CI 45 - 48.6) (p=0.01). The presence of one or more comorbidities resulted in a higher death rate (23% v. 9.2%;
p=0.01) than without comorbidities. The median Brixia score for the deceased was higher (14.5) than for the discharged patients (9.0)
(p<0.001). Inter-rater agreement for Brixia scores was good (intraclass correlation coefficient 0.77; 95% CI 0.6 - 0.85; p<0.001). A model
combining Brixia score, age, male gender and obesity (sensitivity 84%; specificity 63%) as well as a model with Brixia score and C-reactive
protein (CRP) count (sensitivity 81%; specificity 63%) conferred the highest risk for in-hospital mortality.
Conclusion. We have demonstrated the utility of the Brixia scoring system in a middle-income country setting and developed the first SA
risk stratification models incorporating comorbidities and a serological marker. When used in conjunction with age, male gender, obesity
and CRP, the Brixia scoring system is a promising and reliable risk stratification tool. This may help inform the clinical decision pathway in
resource-limited settings like ours during future waves of COVID-19.
References
Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382(8):727-733. https://doi.org/10.1056/NEJMoa2001017
Lomoro P, Verde F, Zerboni F, et al. COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review. Eur J Radiol Open 2020;7:100231. https://doi.org/10.1016/J.EJRO.2020.100231
Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382(18):1708-1720. https://doi.org/10.1056/nejmoa2002032
Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Eurosurveillance 2020;25(3):1-8. https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045
Yang Q, Liu Q, Xu H, Lu H, Liu S, Li H. Imaging of coronavirus disease 2019: A Chinese expert consensus statement. Eur J Radiol 2020;127(April):109008. https://doi.org/10.1016/j.ejrad.2020.109008
Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, et al. False-negative results of initial RT-PCR assays for COVID-19: A systematic review. PLoS One 2020;15(12 December):1-33. https:// doi.org/10.1371/journal.pone.0242958
Seidu AA, Hagan JE, Ameyaw EK, Ahinkorah BO, Schack T. The role of testing in the fight against COVID-19: Current happenings in Africa and the way forward. Int J Infect Dis 2020;98:237-240. https://doi.org/10.1016/j.ijid.2020.06.089
Ducray V, Vlachomitrou AS, Bouscambert-Duchamp M, et al. Chest CT for rapid triage of patients in multiple emergency departments during COVID-19 epidemic: Experience report from a large French university hospital. Eur Radiol 2021;31(2):795-803. https://doi.org/10.1007/s00330-020-07154-4
Rubin GD, Ryerson CJ, Haramati LB, et al. The role of chest imaging in patient management during the COVID-19 pandemic. Chest 2020;158(1):106-116. https://doi.org/10.1016/j.chest.2020.04.003
Toussie D, Voutsinas N, Finkelstein M, et al. Clinical and chest radiography features determine patient outcomes in young and middle age adults with COVID-19. Radiology 2020;297(1):E197-E206. https:// doi.org/10.1148/radiol.2020201754
Qin L, Yang Y, Cao Q, et al. A predictive model and scoring system combining clinical and CT characteristics for the diagnosis of COVID-19. Eur Radiol 2020;(30):6797-6807. https://doi.org/10.1007/ s00330-020-07022-1
Cozzi D, Albanesi M, Cavigli E, Moroni C, Bindi A, Luvarà S. Chest X‐ray in new coronavirus disease 2019 (COVID‐19) infection: Findings and correlation with clinical outcome. Radiol Med 2020;2019:0123456789. https://doi.org/10.1007/s11547-020-01232-9
Fang Y, Zhange H, Xie J, et al. Sensitivity of chest CT for COVID-19: Comparison to RT-PCR. Radiology 2020;296(2):E115-E117. https://doi.org/10.1148/radiol.2020200432
Ippolito D, Pecorelli A, Maino C, et al. Diagnostic impact of bedside chest X-ray features of 2019 novel coronavirus in the routine admission at the emergency department: Case series from Lombardy region. Eur J Radiol 2020;129(May):109092. https://doi.org/10.1016/j.ejrad.2020.109092
Cozzi A, Schiaffino S, Arpaia F, et al. Chest X-ray in the COVID-19 pandemic: Radiologists’ real-world reader performance. Eur J Radiol 2020;132(August):109272. https://doi.org/10.1016/j.ejrad.2020.109272
Balbi M, Caroli A, Corsi A, 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 2021;31(4):1999-
https://doi.org/10.1007/s00330-020-07270-1
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(April):35-42. https://doi.org/10.1016/j.clinimag.2020.04.001
Sadiq Z, Rana S, Mahfoud Z, Raoof A. Systematic review and meta-analysis of chest radiograph (CXR) findings in COVID-19. Clin Imaging 2021;80:229-238. https://doi.org/10.1016/j.clinimag.2021.06.039
Moodley S, Sewchuran T. Chest radiography evaluation in patients admitted with confirmed COVID-19 infection, in a resource-limited South African isolation hospital. S Afr J Radiol 2022;1(1):1-
https://doi.org/10.4102/sajr.v26i1.2262
Borghesi A, Zigliani A, Golemi S, 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-
https://doi.org/10.1016/j.ijid.2020.05.021
Borghesi A, Zigliani A, Masciullo R, et al. Radiographic severity index in COVID‐19 pneumonia:
Relationship to age and sex in 783 Italian patients. Chest Radiog 2020;125:461-464. https://doi.
org/10.1007/s11547-020-01202-1
Borghesi A, Maroldi R. COVID‐19 outbreak in Italy: Experimental chest X‐ray scoring system for quantifying and monitoring disease progression. Radiol Med 2020;125:509-513. https://doi. org/10.1007/s11547-020-01200-3
Wasilewski PG, Mruk B, Mazur S, Półtorak-Szymczak G, Sklinda K, Walecki J. COVID-19 severity scoring systems in radiological imaging – a review. Polish J Radiol 2020;85(1):e361-e368. https://doi. org/10.5114/pjr.2020.98009
Reeves RA, Pomeranz C, Gomella AA, et al. Performance of a severity score on admission chest radiography in predicting clinical outcomes in hospitalised patients with coronavirus disease (COVID-19). Am J Roentgenol 2021;217(3):623-632. https://doi.org/10.2214/AJR.20.24801
Yasin R, Gouda W. Chest X-ray findings monitoring COVID-19 disease course and severity. Egypt J Radiol Nucl Med 2020;51:193. https://doi.org/10.1186/s43055-020-00296-x
Singh A, Lim YH, Annamalaisamy R, et al. Chest X-ray scoring as a predictor of COVID-19 disease; correlation with comorbidities and in-hospital mortality. Scott Med J 2021;66(3):101-107. https://doi. org/10.1177/00369330211027447
Au-Yong I, Higashi Y, Giannotti E, et al. Erratum: Chest radiograph scoring alone or combined with other risk scores for predicting outcomes in COVID-19: A UK study. Radiology 2021;301(3):E444. https://doi.org/10.1148/radiol.2021219021
Maroldi R, Rondi P, Agazzi GM, Ravanelli M, Borghesi A, Farina D. Which role for chest X-ray score in predicting the outcome in COVID-19 pneumonia? Eur Radiol 2021;31(6):4016-4022. https://doi. org/10.1007/s00330-020-07504-2
Agrawal N, Chougale SD, Jedge P, Iyer S, Dsouza J. Brixia chest X-ray scoring system in critically ill patients with COVID-19 pneumonia for determining outcomes. J Clin Diagnostic Res 2021;15-17. https://doi.org/10.7860/jcdr/2021/48844.15197
Abo-Hedibah SA, Tharwat N, Elmokadem AH. Is chest X-ray severity scoring for COVID-19 pneumonia reliable? Polish J Radiol 2021;86(1):e432-e439. https://doi.org/10.5114/pjr.2021.108172 31. Warren MA, Zhao Z, Koyama T, et al. Severity scoring of lung oedema on the chest radiograph is
associated with clinical outcomes in ARDS. Thorax 2018;73(9):840-846. https://doi.org/10.1136/
thoraxjnl-2017-21128
Joseph NP, Reid NJ, Som A, et al. Racial and ethnic disparities in disease severity on admission chest radiographs among patients admitted with confirmed coronavirus disease 2019: A retrospective cohort study. Radiology 2020;297(3):E303-E312. https://doi.org/10.1148/radiol.2020202602
Sze S, Pan D, Nevill CR, et al. Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis. E Clin Med 2020;29-30:100630. https://doi.org/10.1016/j.eclinm.2020.100630
Jassat W, Cohen C, Tempia S, et al. Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: A cohort study. Lancet HIV 2021;8(9):e554-e567. https://doi.org/10.1016/S2352-3018(21)00151-X
Chu Y, Yang J, Shi J, Zhang P, Wang X. Obesity is associated with increased severity of disease in COVID-19 pneumonia: A systematic review and meta-analysis. Eur J Med Res 2020;25(1):1-15. https://doi.org/10.1186/s40001-020-00464-9
Kass DA, Duggal P, Cingolani O. Obesity could shift severe COVID-19 disease to younger ages. Lancet 2020;395(10236):1544-1545. https://doi.org/10.1016/S0140-6736(20)31024-2
Zhang F, Xiong Y, Wei Y, et al. Obesity predisposes to the risk of higher mortality in young COVID-19 patients. J Med Virol 2020;92(11):2536-2542. https://doi.org/10.1002/jmv.26039
Booth A, Reed AB, Ponzo S, et al. Population risk factors for severe disease and mortality in COVID-19: A global systematic review and meta-analysis. PLoS One 2021;16(3):1-30. https://doi.org/10.1371/ journal.pone.0247461
Pillay-van Wyk V, Bradshaw D, Groenewald P, et al. COVID-19 deaths in South Africa: 99 days since South Africa’s first death. S Afr Med J 2020;110(11):1093-1099. https://doi.org/10.7196/samj.2020. v110i11.15249
Mohamed F, Raal FJ, Mbelle M, et al. Glycaemic characteristics and outcomes of COVID-19 patients admitted to a tertiary hospital in Johannesburg. Wits J Clin Med 2020;2(3):123. https://doi. org/10.18772/26180197.2020.v2n3a1
Prattichizzo F, de Candia P, Nicolucci A, Ceriello A. Elevated HbA1c levels in pre-COVID-19 infection increases the risk of mortality: A systematic review and meta-analysis. Diabetes Metab Res Rev 2021;(May):1-8. https://doi.org/10.1002/dmrr.3476
Kim H, Tanser F, Tomita A, Vandormael A, Cuadros DF. Beyond HIV prevalence: Identifying people living with HIV within underserved areas in South Africa. BMJ Glob Heal 2021;6(4):1-10. https://doi. org/10.1136/bmjgh-2020-004089
Schalekamp S, Huisman M, van Dijk RA, et al. Model-based prediction of critical illness in hospitalised patients with COVID-19. Radiology 2020;298(1):e46-e54. https://doi.org/10.1148/RADIOL.2020202723 44. Gatti M, Calandri M, Biondo A, et al. Emergency room comprehensive assessment of demographic, radiological, laboratory and clinical data of patients with COVID-19: Determination of its prognostic value for in-hospital mortality. Intern Emerg Med 2021;2019:0123456789. https://doi.org/10.1007/
s11739-021-02669-0
Venturas J, Zamparini J, Shaddock E, et al. Comparison of outcomes in HIV-positive and HIV-negative patients with COVID-19: HIV-positive and negative patients with COVID-19. J Infect 2021;83(2):217- 227. https://doi.org/10.1016/j.jinf.2021.05.020
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