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\begin{document}

\title{Clinical, laboratory and chest computed tomography aspects of
hospitalized patients with COVID-19 in northern Iran}



\author[1]{ali sharifpour}%
\author[1]{sepideh Safanavaei}%
\author[2]{Rabeeh  Tabaripour }%
\author[3]{fatemeh Taghizadeh}%
\author[1]{maryam nakhaei}%
\author[1]{atikeh abadi}%
\author[2]{Mahdi Fakhar}%
\author[1]{Elham Sadat  Banimostafavi }%
\author[1]{Sayed  Rasooli}%
\author[1]{Masoud aliyali}%
\author[1]{Siavash abedi}%
\author[1]{Hossein  Hossein Mehravaran }%
\affil[1]{Mazandaran University of Medical Sciences Faculty of Medicine}%
\affil[2]{Affiliation not available}%
\affil[3]{Mazandaran University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
The clinical symptoms, blood laboratory data, O2 saturation and high
resolution computed tomography (HRCT) findings are critical factors in
diagnosis of COVID-19 infection. In this study, 105 hospitalized
patients suspected of having COVID-19 were evaluated. Finally, the data
of 83 confirmed cases by HRCT and RT-PCR were analyzed. 61.40\% of the
patients had a comorbidity disease. 89.20\% had fever, 92.00\% cough,
91.40\% dyspnea. Abnormal CRP seen in 77.80\% of the patients following
by 66.70\% lymphopenia, and 60.30\% neutrophilia. Also, ALP (abnormal
vs. normal) and score of HRCT assessment variables had a significant
effect on the positiveness of HRCT findings. 87.95\% had abnormal HRCT
with 41\% bilateral multilobar patchy ground glass opacity (GGO).
Moreover, there was a statistically significant association between
level of O2 saturation and HRCT results. Our findings showed that male
patients with middle age and comorbidity disease were more susceptible
to the COVID-19 infection. Additionally, clinical features, blood
laboratory findings, O2 saturation and HRCT findings are critical
factors in prognosis of COVID-19 infection.%
\end{abstract}%



\sloppy


Ali Sharifpour\textsuperscript{1, 2}\textsubscript{,} Sepideh Safanavaei
\textsuperscript{1, 2}, Rabeeh
Tabaripour\textsuperscript{1}\textsubscript{,} Fatemeh
Taghizadeh\textsuperscript{3}\textsubscript{,} Maryam
Nakhaei\textsuperscript{1}, \textsubscript{~}Atikeh
Abadi\textsuperscript{1}, Mahdi
Fakhar\textsuperscript{1}\textsubscript{,}\textsuperscript{~} Elham
Sadat Banimostafavi \textbf{*}\textsuperscript{1,4} , isa Nazar
\textsuperscript{5},~ Masoud Aliyali \textsuperscript{1,2}
\textsubscript{,} Siavash Abedi\textsuperscript{1,2}\textsubscript{,}
Hossein Mehravaran \textsuperscript{1,2} \textsubscript{} \textbf{{}}

1 Toxoplasmosis Research Center, Communicable Diseases Institute,
Iranian National Registry Center for Lophomoniasis (INRCL), Mazandaran
University of Medical Sciences, PO Box 48471-91971, Sari, Iran{}

2 Pulmonary and Critical Care Division, Imam Khomeini Hospital, Iranian
National Registry Center for Lophomoniasis (INRCL), Mazandaran
University of Medical Sciences, Sari, Iran

3 Student Researches Committee, Psychiatry and Behavioral Sciences
Centre, Addiction Institute, Mazandaran University of Medical Sciences,
Sari, Iran~{}

4 Department of Radiology, Imam Khomeini Hospital, Mazandaran University
of Medical Sciences, Sari, Iran

5 Student Research Committee, Department of Epidemiology and
Biostatistics, School of Health, Mashhad University of Medical Sciences,
Mashhad, Iran{}

\par\null\par\null

\textbf{Introduction}

A current outbreak of pneumonia related to a novel coronavirus, termed
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was
reported in Wuhan, Hubei province, China in December 2019. The infection
spread across other countries round the world (Zhu et al.). On January
30, 2020, the World Health Organization (WHO) stated the outbreak a
Public Health Emergency of International Concern (Sohrabi et al.,
2020).the symptoms of COVID-19 can be fever, dry cough,
fatigue,~shortness of breath, myalgia or even no symptoms (Diao et al.,
2020, Wan et al., 2020, Shang et al., 2020, Huang et al., 2020, Zarghami
et al., 2020).likewise, the studies revealed that older age, male
gender, leukocytosis, and Blood laboratory findings, also, comorbidities
such as high lactate dehydrogenase level, cardiac injury, hypertension,
diabetes mellitus, hypothyroidism, coronary artery disease, smoking and
hyperglycemia, were related to weak prognosis in COVID-19 patients
(Zhang et al., 2020b, Li et al., 2020, Zarghami et al., 2019).Though,
information concerning to clinical features of COVID-19 is still making
it difficult for physicians to distinguish the causative agents without
related laboratory analysis(Wu and McGoogan, 2020).Furthermore,~reverse
transcription-polymerase chain reaction~(RT-), the gold standard for
confirming diagnosis of COVID-19, has some restrictions, such as false
negative results and limited sampling method and the rate of high false
negative and unavailability of in the early stage of the outbreak
restricted fast diagnosis of infection in patients(Fang et al.,
2020).~The high resolution computed tomography (HRCT) of the chest is
progressively recognized as a strong indicator for early diagnosis, and
can be the key to the evaluation of COVID-19 suspected patients because
the changes in~chest imaging~sometimes maybe earlier than symptoms (He
et al., 2020). HRCT is strongly recommended because it is very sensitive
to detecting early disease, assessing the nature and extent of lesions
(Yang et al., 2020a). Other investigators examined chest HRCTs in
infected patients and found high rates of ground-glass opacities and
consolidation, sometimes with a rounded morphology and peripheral lung
distribution (Yang et al., 2020b, Pan et al., 2020, Chung et al., 2020).

Chest HRCT can identify the early phase lung infection(Wong et al.,
2020, Kanne, 2020) and prompt larger public health surveillance and
response systems (Ng et al., 2020). Currently, chest HRCT have been
recommended as main evidence for confirmed clinical and laboratory
diagnosis. Considering the previous studies, the purpose of the study is
to make the early diagnosis, by describing the complete chest HRCT
appearances, related laboratory analysis and clinical features of
patients with COVID-19, who were hospitalized to the Imam Khomeini
Hospital .

\textbf{Patients and Methods}

In this cross-sectional study, 105 patients suspected of having COVID-19
hospitalized in Imam Khomeini Hospital, during February 2020, were
enrolled. Finally, the data of 83 confirmed cases by HRCT were analyzed.
Demographic, clinical, HRCT features and laboratory data of the patients
were extracted and analyzed. All HRCT images were reviewed blindly by 2
radiologists with working experiences to the clinical evidence.~The
severity of lung involvement was scored and classified into 3 categories
(category 0: negative findings, category 1: less than 50\% of the lung
involvement, and category 2: up to 50\%) of the lung involvement. The
current study was reviewed and approved by the Research Ethical
Committee, XXXX (IR.XXXX.REC.1399.102\textbf{)} .

\textbf{Statistical analysis}

Quantitative variables as mean \selectlanguage{ngerman}± SD and qualitative variables also were
reported as frequency (\%). Chi-square and Fisher's exact tests were
used for categorical variable comparison. In addition, to compare the
median of quantitative variables in the two groups test was used. Then,
first to determine the factors associated with the positiveness of HRCT
result univariate logistic model was fitted, and those variables which
had P \textless{} 0.25 were entered into the multiple model. Receiver
operating characteristic (ROC) curves were constructed to test the
ability of final model to predict the positiveness of HRCT result. All
analysis was carried out in the version 20.0 and STATA Release version
12. P\textless{}0.05 was considered statistically significant.

\textbf{Results}

The mean age of the patients was 58.12±17.19, and 46 (55.40\%) were
males. There was not a statistically significant difference between the
mean age of men and women (p \textgreater{} 0.05). 33(89.20\%) of the
patients had fever, 46 (92.00\%) cough, and 53(91.40\%) had dyspnea.
Furthermore, 6(7.23\%) had chill and 9(10.84\%) had myalgia (Table1). As
well, analysis of the laboratory results showed that abnormal WBC was
seen in 34(42.00\%) of the patients, 54 (66.70\%) lymphopenia,
47(60.30\%) neutrophilia, 56(77.80\%) abnormal C-reactive protein (CRP),
18(22.00\%) abnormal platelet count test (), 40(66.70\%) abnormal
lactate dehydrogenase (LDH), and 53(80.30\%) had abnormal erythrocyte
sedimentation rate (ESR). Moreover, the mean of O2 saturation was
93.89±4.77, while, 37(44.60\%) of them had insufficient O2 saturation.
Furthermore, 32(54.20\%) of cases had abnormal serum
glutamic-oxaloacetic transaminase (SGOT), and 22(37.30\%) of cases had
abnormal serum glutamic-pyruvic transaminase (SGPT), and 27(46.60\%) of
them had abnormal Alkaline phosphatase (ALP) (Table2, Table3). Analysis
of the HRCT results showed that 73 (87.95\%) had abnormal HRCT as
follows: bilateral multilobar patchy ground glass opacities (GGO)
16(19.30\%), bilateral multilobar patchy ground glass opacities and
bilateral alveolar consolidations 18 (21.70\%), Pleural effusion
7(8.40\%), bilateral alveolar consolidations 6(7.20\%), unilateral
/single lobar ground glass opacities 2 (2.40\%), unilateral/single lobar
alveolar consolidation 2 (2.40\%), centrilobular nodules/tree in bud
opacities 1(1.20\%), other mixed disease13 (15.60\%) and any other
findings 3 (3.60\%).

Moreover, 22(42.30\%) of women and 30 (57.70\%) of men tested positive
for HRCT, which there was not a statistically significant association
between the gender and HRCT result based on the results from the
chi-square test (p \textgreater{} 0.05). The mean age of the patients
with negative and positive of HRCT was 58.13\(\pm\)18.26 and
58.12\(\pm\)16.70. Mann-Whitney test showed that there was
not a statistically significant difference between the median of age in
the two groups of HRCT result (p \textgreater{} 0.05). So that, 16
(30.80\%) patients under the 50\% lung involvement and 36 (69.20\%) were
over the 50\% lung involvement (Table 1). Distribution dotplot of HRCT
assessment of patients based on the HRCT result presented in figure 1.
The mean W.B.C of the patients with negative and positive of HRCT was
16.90\(\pm\)34.70 and
10.96\(\pm\)20.36.Mann-Whitney test showed that there was a
statistically significant difference between the median of W.B.C in the
two groups of HRCT result (p \textless{} 0.05) (Table 2). The mean O2
Saturation of the patients with negative and positive of HRCT tests was
95.03\(\pm\)4.49 and 93.21\(\pm\)4.85,
respectively. Based on the results from Mann-Whitney, there was a
statistically significant difference between the median of O2 saturation
in the two groups of HRCT result (p \textless{} 0.05). Out of a total of
52 positive cases, 23(44.20\%) positive cases at the level of normal
oxygen and 29(55.80\%) positive cases occurred at the level of abnormal
oxygen. Based on the results from chi-square test, there was a
statistically significant association between level of O2 saturation and
HRCT results (p\textless{}0.05). The mean ALP of the patients with
negative and positive of HRCT tests was 544.67\(\pm\)516.51
and 313.84\(\pm\)227.36, respectively. Results from the
Mann-Whitney test showed that there was not a statistically significant
difference between the median of ALP in the two groups of HRCT result (p
\textgreater{} 0.05). In patients with normal ALP, 24(64.90\%) of the
cases had a positive HRCT and in abnormal ALP patients, 13(35.10\%) of
cases had a positive HRCT , which there was a statistically significant
association between the level of ALP and HRCT result based on the
results from the chi-square test(p \textless{} 0.05) (Table 3).
Frequency distribution of past medical history (PMH) among patients with
suspected COVID-19 under study presented in Table which 51 (61.40\%) of
patients had PMH.

Multiple logistic regression showed that ALP (abnormal vs. normal) and
score of HRCT assessment variables had a significant effect on the
positiveness of HRCT result (P\textless{}0.05). So that, by adjusting
the effect of other variables, the odds of positiveness of HRCT result
with abnormal ALP was 0.04 times as than those with normal ALP and this
difference is statistically significant (P\textless{}0.05). Furthermore,
by adjusting for the effects of other variables, for each unit increase
in the score of HRCT assessment, the odds of positiveness of HRCT result
of the patients were 5.17 times than those who did not have an increase
(P\textless{}0.05). But other variables had no significant effect on the
positiveness of HRCT result (P\textgreater{}0.05) (Table 5). The area
under the ROC curve of the model was 0.96, which indicate the good
predictive power of the model (Figure 2).

\textbf{Discussion}

COVID-19 infection was seen typically in middle-aged, man gender and
elderly patients, and patients with other diseases were more susceptible
to disease. A greater number of men was found than that of women, which
was similar to previous studies (Wang et al., 2020, Jiang et al., 2020).
women have a humoral immune response and greater innate than men and are
thus less susceptible to many parasitic, fungal, bacterial, and viral
diseases, while being more prone to developing a malignancies or
autoimmune disease (Schurz et al., 2019). While these sex differences in
rates of mortality may be due to sex- specific life styles (smoking,
alcohol etc.)(Wrapp, Zarghami et al., 2019). Cough, fever, and dyspnea
were main symptoms. abnormal lymphocyte, neutrophil, , SGOT, and SGPT,
increased CRP concentration and increased LDH concentration were the
laboratory features of COVID-19 infection in present study. abnormal
HRCT was seen in 88\% of the patients as main indicator to evaluate the
COVID-19 disease severity as other researchers(He et al., 2020, Zhang et
al., 2020b).furthermore, WBC count, O2 saturation, and were associated
to lung involvement significantly, statically.

\textbf{Other studies in clinical and laboratory findings}

a metanalyses showed that the main clinical manifestations of COVID-19
were fever , cough , and dyspnea (Jiang et al., 2020). in a study with
208 patients, median age was 50.5 years, 51.4\% of them were men and
48.6\% were women. 7.7\% of the patients had pulmonary diseases, 19.7\%
hypertension, and 6.3\% diabetes. In our study, 26.5\% of the patients
had diabetes, hypertension and Asthma. Among all symptoms, 70.2\% and
55.3\% were belonged to fever and cough respectively. In compatible,
20.2\%~cases~had decreased white blood cell count,~and 29.3\% cases~had
declined lymphocyte count.~74\% of them~had elevated CRP, and 11.1\% had
elevated LDH in the present study (Zhang et al., 2020b). In a
retrospective cohort study, The mean age of the patients were 59.5 years
and 67\% patients were male (Shi et al., 2020).In a study,~of 138
hospitalized patients, the median age was 56 years and 54.3\% were men.
Common symptoms were included fever 98.6\%, and dry cough 59.4\%.
Lymphopenia occurred in 70.3\% patients. HRCT showed bilateral patchy
shadows or ground glass opacity in the lungs of all patients (Wang et
al., 2020). In a Meta analysis study, including a total of 50404
patients with 2019-nCoV infection, the incidence of fever was 90.9\% ,
and cough was 70.8\%, moreover the incidence of abnormal chest CT was
95.6\% (Sun et al., 2020), abnormal HRCT in our study was 88\%. In a
study in Beijing of 262 patients, the median age of patients was 47.5
and 48.5\% of them were men. The most common symptoms at the onset of
illness were fever (82.1\%), cough (45.8\%), dyspnea (6.9\%) (Tian et
al., 2020) that compatible with our study. In the other study(Zhang et
al., 2020a) of 140 hospitalized COVID\selectlanguage{english}-19 cases, a 1:1 ratio of men and
women COVID-19 patients was found(50.7\%), with a median age of 57.0~.
Fever (91.7\%), cough (75.0\%) were the most common clinical
manifestations, whereas hypertension (30.0\%) and diabetes mellitus
(12.1\%) were the most common comorbidities (Zhang et al., 2020a).
Bilateral patchy opacity or ground glass (89.6\%) was the most common
radiological finding. Lymphopenia (75.4\%) and eosinopenia (52.9\%) were
seen in most cases. Eosinopenia with lymphopenia may be an indicator for
diagnosis. Allergic diseases, asthma, and COPD are not risk factors for
SARS-CoV-2 infection (Zhang et al., 2020a). The most common
comorbidities in our study were hypertension, diabetes mellitus and
asthma. Also, bilateral multilobar patchy ground glass opacities,
bilateral multilobar patchy ground glass opacities and bilateral
alveolar consolidations were the most common radiological findings in
present study. Another study showed that of 1099 patients, the median
age of the patients was 47 years; 41.9\% of the patients were female.
The common symptoms were fever and cough. Ground-glass opacity was the
most common radiologic finding on chest CT (56.4\%). 83.2\% of the
patients had lymphocytopenia. Patients often presented without fever,
and many did not have abnormal radiologic findings(Guan et al., 2020).
Ground-glass opacity in present study was higher common finding. Similar
to our study, lymphocytopenia in COVID-19 patients was seen in the other
studies(Surveillances, 2020, Diao et al., 2020).In a metha analysis, for
656 patients, fever 88.7\%, cough 57.6\% and dyspnea 45.6\% were the
most prevalent manifestations(Rodriguez-Morales et al., 2020).Of the 99
patients with 2019-nCoV pneumonia, The average age of the patients was
55*5 years, including 67 men and 32 women. 83\% of the patients had
fever, 82\% cough, 31\% shortness of breath, and 11\% myalgia. According
to imaging findings, 75\% patients showed bilateral pneumonia, 14\%
patients showed multiple mottling and ground-glass opacity, and 1\%
patient had pneumothorax (Chen et al., 2020).Of the 10 cases, the
average age was 56.5 years , 60\% of the patients were males, Dry cough
was the main symptom, followed by fever and fatigue. Chest computed
tomography results were nonspecific, mainly with ground-glass
attenuation and/or shadow images (Xia et al., 2020). Fever 72\%, and
cough 83\% were common symptoms in a study. 33\% of them had an abnormal
chest radiograph finding or lung crepitations. Lymphopenia was present
in 39\% (Young et al., 2020).~~A total of 5700 patients were included
with median age, 63 years, and 39.7\% female. The most common
comorbidities were hypertension 56.6\%, and diabetes 33.8\% (Richardson
et al., 2020). In a study, The prevalence of asthma in patients with
COVID-19 was 0.9\% (Li et al., 2020). During the course of a study 21
COVID-19 positive patients were admitted in , Jaipur, 66.66\% of the
patients were men and 80.90\% were less than 60 years of old. Almost
33.33\% patients were asymptomatic and of those who were symptomatic,
cough was seen in 85.71\% that followed by myalgia (64.28\%), fever
(78.57\%), and dyspnea (28.57\%). 14.28 \% of the cases had co
morbidities in the form of diabetes mellitus, hypertension,
hypothyroidism, or coronary artery disease. moreover, 52.38\% of the
patients had lymphopenia(Bhandari et al., 2020). These patterns in
comorbidities and lymphopenia were seen in our study, too.

\textbf{Other studies in HRCT findings}

is an important component in the diagnostic procedure for patients with
suspected COVID-19 infection. Chest CT has limited sensitivity and
negative predictive value early after symptom onset, and has little
weakness in diagnosis of COVID-19 combined to personal history, clinical
symptoms, and initial laboratory findings, and may therefore serve as a
standard method for diagnosis of COVID-19 based on its features and
transformation rule, the limited number of RT- kits in some centers
before initial RT- screening (Bernheim et al., 2020, Chen et al., 2020).
Although 12\% of patients were without abnormal lung changes on initial
CT images in present study.

In a study, the most HRCT findings were bilateral parenchymal
ground-glass opacities, without or with consolidation in the lung
periphery. Especially, 75\% patients with chest HRCT findings related to
COVID-19 pneumonia had negative results of concurrent nucleic acid tests
(He et al., 2020). Then, 21.70\% of positive chest HRCT patients in
present study had normal CRP. According to imaging examination in a
study, 75\% patients showed bilateral pneumonia, 14\% patients showed
multiple mottling and ground-glass opacity, and 1\% patient had
pneumothorax (Chen et al., 2020).

In a study, The CRP, ESR, and LDH presented significantly positive
correlation with the pneumonia severity on CT. The highest temperature
and the severity of opacifications assessed on initial CT were
significantly related to the progression of opacifications on follow-up
CT(Xiong et al., 2020). In present study, LDH had significantly positive
correlation with HRCT. In a study, GGO was the most common manifestation
of COVID-19 pneumonia, which could be followed by consolidation and
fibrosis.Total CT score, GGO score and fibrosis score of male patients
were significantly higher than female in the second week. Male patients
had higher consolidation score and fibrosis score than female in the
third week. Total CT score and GGO score had weak to moderate
correlation with arterial blood gas indices (Shang et al., 2020). In our
study, 42.30\% of women and 57.70\% of men had positive HRCT for COVID-
a meta-analysis, 40 studies with 4183 COVID-19 patients, the rate of
positive CT scan in COVID-19 patients was 94.5\%. Bilateral lung
involvement, GGO pulse consolidation or reticular, consolidation,
reticular, presence of nodule findings and GGO, in CT scan of COVID-19
pneumonia patients were respectively estimated to be 64.9\% , 49.2\% ,
30.3\% , 17.0\% ,16.6\%, 94.5\% . The lung lesions distribution in
patients with COVID-19 was 70.0\% peripheral, 3.9\% central, and31.1\%
peripheral and central (Karimian and Azami, 2020). In a study, of 1014
patients, 59\% had positive RT- results, and 88\% had positive chest CT
scans. The sensitivity of chest CT in suggesting COVID-19 based on
positive RT- results was 97\%. In patients with negative RT- results,
75\% had positive chest CT findings; 48\% were categorized as highly
likely cases, with 33\% as probable cases. 60\% to 93\% of cases had
positive CT consistent with COVID-19 prior to the initial positive RT-
results (Ai et al., 2020).

A total of 14 articles including 1115 patients, pure GGO 69\%,
consolidation 47\% and ``air bronchogram sign'' 46\% were more common
than the atypical lesion of ``crazy-paving pattern'' 15\%. while 67\% of
patients showed a predominant peripheral distribution (Wan et al.,
2020). In a study, included 52\% men, and the mean age was 49*5 years.
The major pattern of abnormality observed was bilateral 79\%, peripheral
54\%, and GGO 65\%. A weak relevance was between the fibrosis score and
the value of PaO2 and SpO2(Dai et al., 2020). There was a statistically
significant association between level of O2 saturation and HRCT results
in present study. In a study, with median age of 45 , 98\% patients had
evidence of abnormal CT compatible with viral pneumonia at baseline
(Fang et al., 2020).

It suggested the critical importance to combine the two methods in the
early stage of the disease to exclude the SARS-CoV-2 infection. These CT
performances of COVID-19 were similar to previous studies. The O2
saturation decreased in patients, which were in consistence with the
alteration of indices in patients with lung involvement. the bilateral
GGO was higher in the present study. Our results support the use of
chest CT for screening for -19 for patients with clinical and laboratory
features compatible with COVID-19 infection(Shi et al., 2020).
Additionally, a positive relevance was found between the HRCT score, O2
saturation, that was, a patient with higher CT score tended to have
lower O2 saturation.

\textbf{Limitation}

There were several limitations in this study. First, none of the
patients underwent a~lung biopsy~or autopsy, because of the
comparatively better outcomes of the patients in this study. Therefore,
the HRCT findings of the lung could not be verified by~histopathology.
Finally, this was a study with initial HRCT images during
hospitalization, mainly demonstrated the early~pulmonary lesions~in
patients with COVID- further longitudinal research was needed to focus
on the long-term follow-up, to provide dynamic HRCT evaluation for
pulmonary lesions and to obtain the data of long-term pulmonary function
changes.

\textbf{Conclusion}

In the present study, middle-aged, male gender and elderly patients, and
patients with comorbidity were more susceptible to the COVID-19
infection. W.B.C count, O2 saturation, and ALP were related to lung
involvement significantly. Cough, fever, and dyspnea were main
symptoms(Zarghami et al., 2020). Abnormal HRCT was a main indicator to
evaluate the COVID-19 disease. As a whole, clinical feature, blood
laboratory findings, O2 saturation and HRCT findings are critical
factors in prognosis of COVID-19 infection.

\textbf{Disclosure statement}

No potential conflict of interest was reported by the author(s).

\textbf{Ethical approval}

The current study was reviewed and approved by the Research Ethical
Committee, XXXX (IR.XXXX.REC.1399.102\textbf{)} .

\textbf{Data availability statement}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

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