Prognostic implications of neutrophil-lymphocyte ratio in COVID-19

Ayurvedic management through telemedicine of covid hypoxia non-dependent of oxygen support in a patient with chest CT score of 18/25- A case report

This paper is the first known documentation of a covid patient in ARDS and MODS who recovered from home through Ayurveda telemedicine and when not completely dependent on oxygen. The covid patient suffered from fever, body ache, breathlessness, fatigue, and was admitted to the hospital when his SpO2 was at 56, his CT scores at 18/25, Corads 6 and his NL ratio was at 9. The patient was shifted to another hospital as he refused treatment in the first hospital; in the second hospital also he refused treatment and got himself discharged against medical advice when his SpO2 was at 65, RR 40. The patient sought Ayurvedic treatment through phone voluntarily when in MODS. He showed clinical improvement within a day and the SpO2 steadily raised to reach 94 in 27 days. He may have required invasive mechanical ventilation for COVID-19 ARDS reflected by his raised covid biomarkers (Malik et al., 2021) [1]. But this was not necessitated; also other risk factors for poor outcomes were his old age, comorbidities as diabetes, kidney injury and liver injury. This paper records that oral and ophthalmic administration of Ayurveda medicines can immediately increase SpO2 levels. This case study also opens up possibilities of emergency care in Ayurveda with respect to hypoxia.

Role of platelet-to-lymphocyte count ratio (PLR), as a prognostic indicator in COVID-19: A systematic review and meta-analysis

Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in the ongoing context of the COVID-19 pandemic. The platelet-to-lymphocyte count ratio (PLR), has emerged as a potential tool for risk stratification of critically ill patients with sepsis. The current systematic review explores the utility of PLR as a prognostic predictor of COVID-19 patients. We screened the electronic databases until May 15, 2021 after enrolling in PROSPERO (CRD42021220269). Studies evaluating the association between PLR on admission and outcomes in terms of mortality and severity among COVID-19 patients were included. We retrieved 32 studies, with a total of 2768 and 3262 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher PLR levels on admission in comparison to survivors and non-severe patients (mean differences [MD] = 66.10; 95% confidence interval [CI]: 47.75-84.44; p < 0.00001 and MD = 86.74; 95% CI: 67.7-105.7; p < 0.00001, respectively). A higher level of PLR on admission in COVID-19 patients is associated with increased morbidity and mortality. However, the evidence is of low quality and further studies regarding the cut-off value of PLR are the need of the hour.

S, Kumar T, Bharti S, Bhadani PP. Association of Peripheral Blood Parameters With Outcomes of COVID-19 Infection in a Tertiary Care Setting of Eastern India: An Institute-Based Study

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the Coronavirus DISEASE 2019 (COVID-19) pandemic. Blood investigations play a vital role in providing information regarding the inflammatory process. Previous studies have shown that complete blood count parameters have clinical importance in predicting disease outcomes. However, there is a scarcity of literature published from our region in India.

Aims

The present study was conducted to describe the epidemiological, clinical, and hematological characteristics and outcomes of COVID-19 confirmed cases.

Material and methods

All real-time reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed SARS-CoV-2 cases admitted in our institute over three months, from July to September 2020, were included in the study population. The blood samples of SARS-CoV-2 positive cases were analyzed for complete blood counts and coagulation profile on admission and at the time of discharge (most recent in case of mortality).

Results

A total of 252 RT-PCR confirmed SARS-CoV-2 cases were included in the study. The most common age group affected was 46 to 60 years, and the male-to-female ratio was 2.45:1. The most common clinical symptom was dyspnea, and the commonest comorbidity was hypertension. The statistical analysis showed a significant association of age, absolute neutrophil count (ANC) D-dimer, neutrophil-to-lymphocyte ratio (NLR), and platelets-to-lymphocyte ratio (PLR) with intensive care unit (ICU) admission and death. Gender, dyspnea, and absolute eosinophil count (AEC) showed significant association with ICU patients only, while liver disease and absolute lymphocyte count (ALC) had a significant association with death.

Conclusion

There are many notable clinical and hematological manifestations of COVID-19. Age, gender, dyspnea, comorbid liver disease, ANC, ALC AEC, NLR, PLR, and D- dimer may help clinicians predict the disease progression and reduce mortality risk.

Anti-Inflammatory Effects of Immunostimulation in Patients with COVID-19 Pneumonia

Background: The effects of immunomodulators in patients with Coronavirus Disease 2019 (COVID-19) pneumonia are still unknown. We investigated the cellular inflammatory and molecular changes in response to standard-of-care + pidotimod (PDT) and explored the possible association with blood biomarkers of disease severity. Methods: Clinical characteristics and outcomes, neutrophil-to-lymphocyte ratio (NLR), plasma and cell supernatant chemokines, and gene expression patterns after SARS-CoV-2 and influenza (FLU) virus in vitro stimulation were assessed in 16 patients with mild-moderate COVID-19 pneumonia, treated with standard of care and PDT 800 mg twice daily (PDT group), and measured at admission, 7 (T1), and 12 (T2) days after therapy initiation. Clinical outcomes and NLR were compared with age-matched historical controls not exposed to PDT. Results: Hospital stay, in-hospital mortality, and intubation rate did not differ between groups. At T1, NLR was 2.9 (1.7–4.6) in the PDT group and 5.5 (3.4–7.1) in controls (p = 0.037). In the PDT group, eotaxin and IL-4 plasma concentrations progressively increased (p < 0.05). Upon SARS-CoV-2 and FLU-specific stimulation, IFN-γ was upregulated (p < 0.05), while at genetic transcription level, Pathogen Recognition Receptors (TRLs) were upregulated, especially in FLU-stimulated conditions. Conclusions: Immunomodulation exerted by PDT and systemic corticosteroids may foster a restoration in the innate response to the viral infection. These results should be confirmed in larger RCTs.

Chemokine-Based Therapeutics for the Treatment of Inflammatory and Fibrotic Convergent Pathways in COVID-19

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the SARS-CoV-2 betacoronavirus and has taken over 761,426 American lives as of the date of publication and will likely result in long-term, if not permanent, tissue damage for countless patients. COVID-19 presents with diverse and multisystemic pathologic processes, including a hyperinflammatory response, acute respiratory distress syndrome (ARDS), vascular injury, microangiopathy, tissue fibrosis, angiogenesis, and widespread thrombosis across multiple organs, including the lungs, heart, kidney, liver, and brain. C-X-C chemokines contribute to these pathologies by attracting inflammatory mediators, the disruption of endothelial cell integrity and function, and the initiation and propagation of the cytokine storm. Among these, CXCL10 is recognized as a critical contributor to the hyperinflammatory state and poor prognosis in COVID-19. CXCL10 is also known to regulate growth factor-induced fibrosis, and recent evidence suggests the CXCL10-CXCR3 signaling system may be vital in targeting convergent pro-inflammatory and pro-fibrotic pathways. This review will explore the mechanistic role of CXCL10 and related chemokines in fibrotic complications associated with COVID-19 and the potential of CXCL10-targeted therapeutics for early intervention and long-term treatment of COVID-19-induced fibrosis.

The Relationship between Routine Blood Parameters and the Prognosis of COVID-19 Patients in the Emergency Department

The aim of this study is to investigate the routine blood parameters of COVID-19 patients at the time of admission to the emergency department and their relationship with the severity of the disease and prognosis. A total of 500 patients, who were diagnosed with severe COVID-19 and hospitalized in the intensive care unit between 01.04.2020 and 01.02.2021 in the emergency department of a pandemic hospital, were retrospectively analyzed. Demographic, clinical, and laboratory data of the patients were obtained from the hospital registry system. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) were calculated using neutrophil, lymphocyte, monocyte, and platelet counts. These patients were divided into two groups: survivors and deceased. All parameters obtained from routine blood analysis were statistically compared between these two groups. While 280 out of 500 patients survived, 220 died. Of all patients, the mean age was 67 years and 51.8% were males. There was a significant difference between the two groups in terms of age, gender, length of hospital stay, need for mechanical ventilation, white blood cell, neutrophil, lymphocyte, monocyte, eosinophil, platelet counts, CRP, ferritin, procalcitonin values, NLR, MLR, and PLR (p < 0.001 for all). While NLR alone and MLR + NEU and NLR + PLR + MLR combinations had the highest AUC values (0.930, 0.947, and 0.939, respectively), MLR and PLR alone showed the lowest AUC values (0.875 and 0.797, respectively). The sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) in the prediction of death according to the cutoff values of the parameters have been determined. A significant correlation was determined between age, NLR, MLR, and PLR and duration of hospital stay (p < 0.001 for all). Routine blood parameters and NLR, MLR, and PLR can assist emergency physicians to identify the severity and early prognosis of COVID-19 patients.

KLF2 regulates neutrophil activation and thrombosis in cardiac hypertrophy and heart failure progression

It is widely recognized that inflammation plays a critical role in cardiac hypertrophy and heart failure. However, clinical trials targeting cytokines have shown equivocal effects, indicating the need for a deeper understanding of the precise role of inflammation and inflammatory cells in heart failure. Leukocytes from human subjects and a rodent model of heart failure were characterized by a marked reduction in expression of Klf2 mRNA. Using a mouse model of angiotensin II–induced nonischemic cardiac dysfunction, we showed that neutrophils played an essential role in the pathogenesis and progression of heart failure. Mechanistically, chronic angiotensin II infusion activated a neutrophil KLF2/NETosis pathway that triggered sporadic thrombosis in small myocardial vessels, leading to myocardial hypoxia, cell death, and hypertrophy. Conversely, targeting neutrophils, neutrophil extracellular traps (NETs), or thrombosis ameliorated these pathological changes and preserved cardiac dysfunction. KLF2 regulated neutrophil activation in response to angiotensin II at the molecular level, partly through crosstalk with HIF1 signaling. Taken together, our data implicate neutrophil-mediated immunothrombotic dysregulation as a critical pathogenic mechanism leading to cardiac hypertrophy and heart failure. This neutrophil KLF2-NETosis-thrombosis mechanism underlying chronic heart failure can be exploited for therapeutic gain by therapies targeting neutrophils, NETosis, or thrombosis.

Comparative study of hematological and radiological feature of severe/critically ill patients with COVID-19, influenza A H7N9, and H1N1 pneumonia

OBJECTIVES

This study aimed to explore clinical indexes for management of severe/critically ill patients with COVID-19, influenza A H7N9, and H1N1 pneumonia by comparing hematological and radiological characteristics.

METHODS

Severe/critically ill patients with COVID-19, H7N9, and H1N1 pneumonia were retrospectively enrolled. The demographic data, clinical manifestations, hematological parameters, and radiological characteristics were compared.

RESULTS

In this study, 16 cases of COVID-19, 10 cases of H7N9, and 13 cases of H1N1 who met severe/critically ill criteria were included. Compared with COVID-19, H7N9 and H1N1 groups had more chronic diseases (80% and 92.3% vs. 25%, p < 0.05), higher APACHE Ⅱ scores (16.00 ± 8.63 and 15.08 ± 6.24, vs. 5.50 ± 2.58, p < 0.05), higher mortality rates (40% and 46.2% vs. 0%, p < 0.05), significant lymphocytopenia (0.59 ± 0.31 × 10⁹ /L and 0.56 ± 0.35 × 10⁹ /L vs. 0.97 ± 0.33 × 10⁹ /L, p < 0.05), and elevated neutrophil-to-lymphocyte ratio (NLR; 14.67 ± 6.10 and 14.64 ± 10.36 vs. 6.29 ± 3.72, p < 0.05). Compared with the H7N9 group, ground-glass opacity (GGO) on chest CT was common in the COVID-19 group (p = 0.028), while pleural effusion was rare (p = 0.001).

CONCLUSIONS

The NLR can be used as a clinical parameter for the predication of risk stratification and outcome in COVID-19 and influenza A pneumonia. Manifestations of pleural effusion or GGO in chest CT may be helpful for the identification of different viral pneumonia.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Markers for Predicting the Severity in COVID-19 Patients: A Prospective Observational Study

Background: Coronavirus disease-2019 (COVID-19) pandemic has shown unpredictable course in individual patients. Few patients develop severe disease with progression after admission to a healthcare facility. Multiple parameters have been investigated to identify a marker to predict disease progression. Neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte (PLR) ratio has shown some promise. The current investigation explores the role of NLR and PLR to predict the disease progression.

Materials and methods: After obtaining ethics committee approval, 608 patients were screened for inclusion in the prospective observational study, and 201 patients were included in the final analysis. The NLR and PLR were derived from routinely obtained complete blood count analysis. The patients were followed to determine the development of severity of the disease during the course. The NLR and PLR were analyzed in both univariate and multivariable models to assess the association and prediction.

Results: In nonsevere (NS) group, the mean age of patients was 50.9 ± 16.3 years, and 66 (61.2%) were male, while in severe group (S), the mean age of patients was 53.7 ± 16.4 years, and 65 (69.89%) were male. NLR at day 1 and day 3 was significantly lower in survivors as compared to nonsurvivors, while the relation of PLR in both the groups was not statistically significant. The NLR is better in predicting the severity of disease as well as mortality than PLR.

Conclusion: The NLR calculated at the time of admission has high predictive value for disease deterioration and adverse clinical outcome.

How to cite this article: Singh Y, Singh A, Rudravaram S, Soni KD, Aggarwal R, Patel N, et al. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Markers for Predicting the Severity in COVID-19 Patients: A Prospective Observational Study. Indian J Crit Care Med 2021;25(8):847–852.

Prognostic value of neutrophil-to-lymphocyte ratio in COVID-19 patients: A systematic review and meta-analysis

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) is an accessible and widely used biomarker. NLR may be used as an early marker of poor prognosis in patients with COVID-19.

OBJECTIVE

To evaluate the prognostic value of the NLR in patients diagnosed with COVID-19.

METHODS

We conducted a systematic review and meta-analysis. Observational studies that reported the association between baseline NLR values (ie, at hospital admission) and severity or all-cause mortality in COVID-19 patients were included. The quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). Random effects models and inverse variance method were used for meta-analyses. The effects were expressed as odds ratios (ORs) and their 95% confidence intervals (CIs). Small study effects were assessed with the Egger's test.

RESULTS

We analysed 61 studies (n = 15 522 patients), 58 cohorts, and 3 case-control studies. An increase of one unit of NLR was associated with higher odds of severity (OR 6.22; 95%CI 4.93 to 7.84; P < .001) and higher odds of all-cause mortality (OR 12.6; 95%CI 6.88 to 23.06; P < .001). In our sensitivity analysis, we found that 41 studies with low risk of bias and moderate heterogeneity (I2  = 53% and 58%) maintained strong association between NLR values and both outcomes (severity: OR 5.36; 95% CI 4.45 to 6.45; P < .001; mortality: OR 10.42 95% CI 7.73 to 14.06; P = .005).

CONCLUSIONS

Higher values of NLR were associated with severity and all-cause mortality in hospitalised COVID-19 patients.

Myeloid cells in COVID-19 microenvironment

Varying differentiation of myeloid cells is common in tumors, inflammation, autoimmune diseases, and metabolic diseases. The release of cytokines from myeloid cells is an important driving factor that leads to severe COVID-19 cases and subsequent death. This review briefly summarizes the results of single-cell sequencing of peripheral blood, lung tissue, and cerebrospinal fluid of COVID-19 patients and describes the differentiation trajectory of myeloid cells in patients. Moreover, we describe the function and mechanism of abnormal differentiation of myeloid cells to promote disease progression. Targeting myeloid cell-derived cytokines or checkpoints is essential in developing a combined therapeutic strategy for patients with severe COVID-19.

Novel Systemic Inflammation Markers to Predict COVID-19 Prognosis

Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic, challenging both the medical and scientific community for the development of novel vaccines and a greater understanding of the effects of the SARS-CoV-2 virus. COVID-19 has been associated with a pronounced and out-of-control inflammatory response. Studies have sought to understand the effects of inflammatory response markers to prognosticate the disease. Herein, we aimed to review the evidence of 11 groups of systemic inflammatory markers for risk-stratifying patients and prognosticating outcomes related to COVID-19. Numerous studies have demonstrated the effectiveness of neutrophil to lymphocyte ratio (NLR) in prognosticating patient outcomes, including but not limited to severe disease, hospitalization, intensive care unit (ICU) admission, intubation, and death. A few markers outperformed NLR in predicting outcomes, including 1) systemic immune-inflammation index (SII), 2) prognostic nutritional index (PNI), 3) C-reactive protein (CRP) to albumin ratio (CAR) and high-sensitivity CAR (hsCAR), and 4) CRP to prealbumin ratio (CPAR) and high-sensitivity CPAR (hsCPAR). However, there are a limited number of studies comparing NLR with these markers, and such conclusions require larger validation studies. Overall, the evidence suggests that most of the studied markers are able to predict COVID-19 prognosis, however NLR seems to be the most robust marker.

HLA-DRB1*04 may predict the severity of disease in a group of Iranian COVID-19 patients

Human leukocyte antigen (HLA) genes with extreme diversity can make a contribution for individual variations to the immune response against SARS-COV-2 infection. This study aimed to explore the distributions of HLA class II alleles frequencies and their relations with disease severity in a group of Iranian COVID-19 patients. This prospective and case-control study was conducted on 144 COVID-19 patients including 46 cases with moderate form, 54 cases with severe and 44 cases with critical disease. HLA-DRB1 and -DQB1 allele families were determined by PCR-SSP method and compared between three groups of the patients and in comparison to 153 ethnic-matched healthy controls. The patients group showed lower frequencies of HLA-DRB1*15 (OR = 0.57, P = 0.06), DRB1*15 ~ DQB1*05 haplotype (P = 0.04) and DRB1*15/DRB1*04 genotype (P = 0.04) in compare with healthy controls. Moderate COVID-19 patients had higher frequencies of HLA-DRB1*04 (P = 0.03), HLA-DRB1*10 (P = 0.05) and DRB1*04/DRB1*11 genotype (P = 0.01). Also, a higher significantly frequency of HLA-DRB1*03 allele group was observed in the critical patients versus controls (P = 0.01). Multiple logistic regression analysis revealed that the presence of DRB1*04 allele group was negatively associated with development of severe and critical disease (OR: 0.289, P = 0.005). Our results indicate a possible contribution of some HLA class II alleles in disease severity and clinical features of COVID-19 disease.

Severe acute respiratory syndrome-coronavirus 2 in domesticated animals and its potential of transmission: A meta-analysis

BACKGROUND AND AIM

The coronavirus diseases-2019 (COVID-19) pandemic has caused a global lockdown, which has limited the mobility of the public, and thus, more time is spent with their pets. Unfortunately, many social media have blamed pet animals as a reservoir of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the etiologic agent of COVID-19, triggering a panic abandonment of pets. However, no article has summarized the information regarding the role of pets as SARS-CoV-2 reservoirs. This study aimed to evaluate the role of pets as a reservoir of SARS-CoV-2 on the basis of research papers (i.e., animal model, surveillance, and case report) published in 2020.

MATERIALS AND METHODS

The review was conducted using articles from the PubMed database in 2020, using the keywords "COVID-19 in domesticated animals," which were screened and analyzed. Only the data from research articles were mimicked and transformed to conduct a meta-analysis. The meta-analysis was conducted regarding the effects of inhabitation and viral shedding in pets. In this study, we used 95% confidence intervals.

RESULTS

A total of 132 papers in PubMed were related to the keywords, whereas only 12 papers were appropriate to answer the dynamics of the role of pets as the reservoir for SARS-CoV-2. Seven studies indicated the potential of cat-cat (4/7), human-cat (2/7), and human-dog (1/7) SARS-CoV-2 transmission. No study proved the presence of cat-human transmission. Another study showed that comingling did not affect SARS-CoV-2 viral shedding among a cat and dog. Furthermore, the viral shedding of cats and dogs caused asymptomatic manifestations and generated neutralizing antibodies within a short period of time.

CONCLUSION

SARS-CoV-2 transmission is present in domesticated animals, especially in pet cats and dogs, and transmission occurs between animals of the same species (cat-cat). The reverse zoonosis (zooanthroponosis) was found from human to cat/dog (comingled) with asymptomatic clinical signs due to the representation of neutralizing antibodies.

Curcumin Extraction, Isolation, Quantification and Its Application in Functional Foods: A Review With a Focus on Immune Enhancement Activities and COVID-19

An entirely unknown species of coronavirus (COVID-19) outbreak occurred in December 2019. COVID-19 has already affected more than 180 million people causing ~3.91 million deaths globally till the end of June 2021. During this emergency, the food nutraceuticals can be a potential therapeutic candidate. Curcumin is the natural and safe bioactive compound of the turmeric (Curcuma longa L.) plant and is known to possess potent anti-microbial and immuno-modulatory properties. This review paper covers the various extraction and quantification techniques of curcumin and its usage to produce functional food. The potential of curcumin in boosting the immune system has also been explored. The review will help develop insight and new knowledge about curcumin's role as an immune-booster and therapeutic agent against COVID-19. The manuscript will also encourage and assist the scientists and researchers who have an association with drug development, pharmacology, functional foods, and nutraceuticals to develop curcumin-based formulations.

Increased Neutrophil-Subset Associated With Severity/Mortality In ARDS And COVID19-ARDS Expresses The Dual Endothelin-1/VEGFsignal-Peptide Receptor (DEspR): An Actionable Therapeutic Target

Neutrophil-mediated secondary tissue injury underlies acute respiratory distress syndrome (ARDS) and progression to multi-organ-failure (MOF) and death, processes linked to severe COVID19. This 'innocent bystander' tissue injury arises in dysregulated hyperinflammatory states from neutrophil functions and neutrophil extracellular traps (NETs) intended to kill pathogens, but injure cells instead, causing MOF. Insufficiency of prior therapeutic approaches suggest need to identify dysregulated neutrophil-subset(s) and induce subset-specific apoptosis critical for neutrophil function-shutdown and clearance. We hypothesized that neutrophils expressing the pro-survival dual endothelin-1/signal peptide receptor, DEspR, are apoptosis-resistant just like DEspR+ cancer cells, hence comprise a consequential pathogenic neutrophil-subset in ARDS and COVID19-ARDS. Here, we report correlation of circulating DEspR+CD11b+ activated neutrophils (DESpR+actNs) and NETosing-neutrophils with severity in ARDS and in COVID19-ARDS, increased DEspR+ neutrophils and monocytes in post-mortem ARDS-patient lung sections, and neutrophil DEspR/ET1 receptor/ligand autocrine loops in severe COVID19. Unlike DEspR[-] neutrophils, ARDS patient DEspR+actNs exhibit apoptosis-resistance, which decreased upon ex vivo treatment with humanized anti-DEspR-IgG4S228P antibody, hu6g8. Ex vivo live-cell imaging of non-human primate DEspR+actNs showed hu6g8 target-engagement, internalization, and induction of apoptosis. Altogether, data differentiate DEspR+actNs as a targetable neutrophil-subset associated with ARDS and COVID19-ARDS severity, and suggest DEspR-inhibition as a potential therapeutic paradigm.

Differences in the neutrophil/lymphocyte ratio and the platelet/lymphocyte ratio in pregnant women with and without COVID-19

OBJECTIVE

To determine the differences in the neutrophil/lymphocyte ratio (NLR) and the platelet/lymphocyte ratio (PLR) in pregnant women with and without COVID-19.

METHODS

Observational, cross-sectional, retrospective, comparative, open, controlled study done from January to April 2021 at the UMAE Hospital de Gineco Obstetricia "Luis Castelazo Ayala" Instituto Mexicano del Seguro Social. Mexico City, Mexico: Patients were divided into those with a negative test for COVID-19 and those with a positive test, with the latter then being divided according to disease severity into mild, moderate, and severe groups. In all the NLR and PLR were calculated. Symptoms, vital signs, and oxygen saturation were documented.

STATISTICAL ANALYSIS

Central tendency and dispersion measures, Kruskal-Wallis test, Mann-Whitney U test, and chi-squared test were used. Sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio (OR) were calculated.

RESULTS

Seventy-seven patients were included, 24 without COVID-19 and 53 with COVID-19. There were 33, 10, and 10 patients in the mild, moderate, and severe disease groups, respectively. There was no difference in NLR between the groups and the PLR was significantly higher in the severe disease group. With a 5.1 NLR cutoff point, between normal and those with severe disease, the sensitivity was 70% and specificity 63%, whilst with a 221 PLR cutoff point, the sensitivity was 90% and the specificity 83% (OR 45, 95% CI 4.40-461.7).

CONCLUSION

PLR more than NLR was useful to detect pregnant patients with COVID-19 with severe disease.

Hemogram-derived ratios as prognostic markers of ICU admission in COVID-19

Background

The vast impact of COVID-19 call for the identification of clinical parameter that can help predict a torpid evolution. Among these, endothelial injury has been proposed as one of the main pathophysiological mechanisms underlying the disease, promoting a hyperinflammatory and prothrombotic state leading to worse clinical outcomes. Leukocytes and platelets play a key role in inflammation and thrombogenesis, hence the objective of the current study was to study whether neutrophil-to-lymphocyte ratio (NLR), platelets-to-lymphocyte ratio (PLR), the systemic immune-inflammation index (SII) as well as the new parameter neutrophil-to-platelet ratio (NPR), could help identify patients who at risk of admission at Intensive Care Units.

Methods

A retrospective observational study was performed at HM Hospitales including electronic health records from 2245 patients admitted due to COVID-19 from March 1 to June 10, 2020. Patients were divided into two groups, admitted at ICU or not.

Results

Patients who were admitted at the ICU had significantly higher values in all hemogram-derived ratios at the moment of hospital admission compared to those who did not need ICU admission. Specifically, we found significant differences in NLR (6.9 [4–11.7] vs 4.1 [2.6–7.6], p <  0.0001), PLR (2 [1.4–3.3] vs 1.9 [1.3–2.9], p = 0.023), NPR (3 [2.1–4.2] vs 2.3 [1.6–3.2], p <  0.0001) and SII (13 [6.5–25.7] vs 9 [4.9–17.5], p <  0.0001) compared to those who did not require ICU admission. After multivariable logistic regression models, NPR was the hemogram-derived ratio with the highest predictive value of ICU admission, (OR 1.11 (95% CI: 0.98–1.22, p = 0.055).

Conclusions

Simple, hemogram-derived ratios obtained from early hemogram at hospital admission, especially the novelty NPR, have shown to be useful predictors of risk of ICU admission in patients hospitalized due to COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00480-w.

Comparison of hemoglobin level and neutrophil to lymphocyte ratio as prognostic markers in patients with COVID-19

Background

Anemia can negatively affect the outcome of many diseases, including infections and inflammatory conditions.

Aim

To compare the prognostic value of hemoglobin level and the neutrophil/lymphocyte ratio (NLR) for prediction of coronavirus disease 2019 (COVID-19) severity.

Methods

In this retrospective cohort study, clinical data from patients with laboratory-confirmed COVID-19 were collected from hospital records from 10 April 2020 to 30 July 2020.

Results

The proportions of patients with mild, moderate, and severe COVID-19 differed significantly in association with hemoglobin levels, neutrophil counts, lymphocyte counts, NLR, and total leukocyte counts. Patients with severe COVID-19 had significantly lower hemoglobin levels than those with moderate or mild COVID-19. There were statistically significant negative associations between hemoglobin and D-dimer, age, and creatinine. The optimal hemoglobin cut-off value for prediction of disease severity was 11.6 g/dL. Using this cut-off value, hemoglobin had higher negative predictive value and sensitivity than NLR (92.4% and 51.3%, respectively). The specificity of hemoglobin as a prognostic marker was 79.3%.

Conclusion

Both NLR and hemoglobin level are of prognostic value for predicting severity of COVID-19. However, hemoglobin level displayed higher sensitivity than NLR. Hemoglobin level should be assessed upon admission in all patients and closely monitored throughout the disease course.

Possible role of higher serum level of myoglobin as predictor of worse prognosis in Sars-Cov 2 hospitalized patients. A monocentric retrospective study

BACKGROUND

Limited data on myoglobin and infectious diseases are available. In this study, we evaluate the potential role of myoglobin in predicting poor outcome in patients with Sars-Cov2 pneumonia.

METHODS

One hundred and twenty-one Sars-Cov 2 patients with an average age of 69.9 ± 13.2 years, and symptoms duration of 8.8 ± 7.9 days were enrolled in the study. At the admission, the serum levels of myoglobin, erythrocyte sedimentation rate, C reactive protein (CRP), procalcitonin, ferritin, creatine phosphokinase, creatinine, fibrinogen, d-dimers, lactic dehydrogenase, troponin (Tn-I), creatine kinase myocardial band (CK-MB), complement fractions C3 and C4, immunoglobulins, interleukin 6 were evaluated. We also assessed the patients' complete clinical history and performed a thorough physical examination including age, disease history, and medications.

RESULTS

Twenty-four (20%) patients died, and 18 (15%) patients required intensive care. The mean time between symptoms onset and death was 12.4 days ± 9.1. Univariate analysis of the patients' data highlighted some independent risk factors for mortality in COVID-19, including higher neutrophils rate (HR: 1.171), lower lymphocyte rate (HR: 0.798), high CK-MB serum levels (HR: 1.6), high Tn-I serum levels (HR: 1.03), high myoglobin serum levels (HR: 1.014), Alzheimer (HR 5.8), and higher CRP values (HR: 1.011). Cox regression analysis model revealed that higher serum values of myoglobin (HR 1.003; 95%CI: 1.001-1.006; p = 0.01), and CRP (HR 1.012; 95% CI: 1.001-1.023; p = 0.035) could be predictors of mortality in COVID-19 patients. The value of the myoglobin level for predicting 28 days-mortality using ROC curve was 121.8 ng/dL. Lower survival rate was observed in patients with serum levels of myoglobin>121.8 ng/dL (84% vs 20% respectively, p = 0.0001).

CONCLUSION

Our results suggest that higher serum levels of myoglobin could be a considerable and effective predictor of poor outcomes in COVID-19 patients; a careful follow-up in these patients is strongly suggested. The possibility of enhancing these findings in other cohorts of COVID-19 patients could validate the clinical value of myoglobin as a biomarker for worse prognosis in COVID-19.

A Bittersweet Response to Infection in Diabetes; Targeting Neutrophils to Modify Inflammation and Improve Host Immunity

Chronic and recurrent infections occur commonly in both type 1 and type 2 diabetes (T1D, T2D) and increase patient morbidity and mortality. Neutrophils are professional phagocytes of the innate immune system that are critical in pathogen handling. Neutrophil responses to infection are dysregulated in diabetes, predominantly mediated by persistent hyperglycaemia; the chief biochemical abnormality in T1D and T2D. Therapeutically enhancing host immunity in diabetes to improve infection resolution is an expanding area of research. Individuals with diabetes are also at an increased risk of severe coronavirus disease 2019 (COVID-19), highlighting the need for re-invigorated and urgent focus on this field. The aim of this review is to explore the breadth of previous literature investigating neutrophil function in both T1D and T2D, in order to understand the complex neutrophil phenotype present in this disease and also to focus on the development of new therapies to improve aberrant neutrophil function in diabetes. Existing literature illustrates a dual neutrophil dysfunction in diabetes. Key pathogen handling mechanisms of neutrophil recruitment, chemotaxis, phagocytosis and intracellular reactive oxygen species (ROS) production are decreased in diabetes, weakening the immune response to infection. However, pro-inflammatory neutrophil pathways, mainly neutrophil extracellular trap (NET) formation, extracellular ROS generation and pro-inflammatory cytokine generation, are significantly upregulated, causing damage to the host and perpetuating inflammation. Reducing these proinflammatory outputs therapeutically is emerging as a credible strategy to improve infection resolution in diabetes, and also more recently COVID-19. Future research needs to drive forward the exploration of novel treatments to improve infection resolution in T1D and T2D to improve patient morbidity and mortality.

Hemogram as marker of in-hospital mortality in COVID-19

The clinical impact of COVID-19 disease calls for the identification of routine variables to identify patients at increased risk of death. Current understanding of moderate-to-severe COVID-19 pathophysiology points toward an underlying cytokine release driving a hyperinflammatory and procoagulant state. In this scenario, white blood cells and platelets play a direct role as effectors of such inflammation and thrombotic response. We investigate whether hemogram-derived ratios such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio and the systemic immune-inflammation index may help to identify patients at risk of fatal outcomes. Activated platelets and neutrophils may be playing a decisive role during the thromboinflammatory phase of COVID-19 so, in addition, we introduce and validate a novel marker, the neutrophil-to-platelet ratio (NPR).Two thousand and eighty-eight hospitalized patients with COVID-19 admitted at any of the hospitals of HM Hospitales group in Spain, from March 1 to June 10, 2020, were categorized according to the primary outcome of in-hospital death.Baseline values, as well as the rate of increase of the four ratios analyzed were significantly higher at hospital admission in patients who died than in those who were discharged (p<0.0001). In multivariable logistic regression models, NLR (OR 1.05; 95% CI 1.02 to 1.08, p=0.00035) and NPR (OR 1.23; 95% CI 1.12 to 1.36, p<0.0001) were significantly and independently associated with in-hospital mortality.According to our results, hemogram-derived ratios obtained at hospital admission, as well as the rate of change during hospitalization, may easily detect, primarily using NLR and the novel NPR, patients with COVID-19 at high risk of in-hospital mortality.

Biomarkers Linked with Dynamic Changes of Renal Function in Asymptomatic and Mildly Symptomatic COVID-19 Patients

The catastrophic coronavirus disease 2019 (COVID-19) pandemic is currently a critical global issue. One well-known complication of COVID-19 in severe cases is acute kidney injury, but no research has given a description of its impact on the kidney in patients with mild symptoms. We explore the renal function changes in mild COVID-19 patients. This retrospective, single-center study included 27 participants with laboratory-detected severe acute respiratory syndrome coronavirus two (SARS-CoV-2) infection who were admitted to the Tri-Service General Hospital from 4 February to 26 May 2020 and analyzed their clinical features, radiological findings, and laboratory data. Data collected upon admission and discharge showed a median estimated glomerular filtration rate (eGFR) of 106.7 mL/min/1.732 m² and 112.2 mL/min/1.732 m², respectively, with a p-value of 0.044. A correlation between renal function and the severity of infection was also found and was statistically significant upon admission. Patients with a lower lymphocyte count or higher C-reactive protein, neutrophil count, and neutrophil-to-lymphocyte ratio presented with a decreased eGFR during their early infection phase. The biomarkers (CRP and NLR) may be linked with dynamic changes of renal function in COVID-19 patients who are asymptomatic or have mild symptoms.

Cytokines and Leukocytes Subpopulations Profile in SARS-CoV-2 Patients Depending on the CT Score Severity

The role of the adaptive microenvironment components in severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection is widely researched, but remains unclear. Studying the common dynamics of adaptive immune response changes can help understand the pathogenesis of coronavirus disease 2019 (COVID-19), especially in critical patients. The aim of the present study was to determine the cytokines concentration and leukocyte subpopulations profiles in the severe COVID-19 (n = 23) and critical (n = 18) COVID-19 group distinguished by the computed tomography (CT) severity score. We observed lower percentage of lymphocyte subpopulation, higher neutrophils to lymphocytes ratio (NLR) and higher IL-6 concentration in critical COVID-19 group than in severe group. CT severity score was negative correlated with proportion of lymphocytes, lymphocytes T, CD4+ cells, Treg cells and NK cells and positive correlated with neutrophils, NLR, and IL-6. In critical group more correlations between cytokines and lymphocytes were observed, mainly between TNF-α, IL-1β and lymphocyte subpopulations. The collective assessment of the cytokine profile, leukocyte subpopulations and the CT severity score can help to characterize and differentiate patient in advanced COVID-19 than the study of single parameters. We have shown that the interconnection of elements of the adaptive microenvironment can play an important role in critical COVID-19 cases.

[Pulse oximetry: Role in the COVID-19 patient at home]

La COVID-19 se comporta como una enfermedad heterogénea. Algunos pacientes pueden presentar hipoxemia sin disnea durante su evolución (hipoxemia silente). La pulsioximetría juega un papel crucial en la detección de la hipoxemia en estos pacientes, especialmente cuando permanecen en su domicilio. Pacientes con niveles de SpO₂ ≤ 92% o desaturaciónes ≥ 3% tras el ejercicio precisan de ingreso hospitalario. Los descensos progresivos de la saturación que alcancen niveles SpO₂ < 96% precisan de valoración clínica estricta (estudio radiológico, analítica sanguínea) para lo que será enviado a un centro sanitario.

Risk Score for Predicting In-Hospital Mortality in COVID-19 (RIM Score)

Infection by SARS-CoV2 has devastating consequences on health care systems. It is a global health priority to identify patients at risk of fatal outcomes. 1955 patients admitted to HM-Hospitales from 1 March to 10 June 2020 due to COVID-19, were were divided into two groups, 1310 belonged to the training cohort and 645 to validation cohort. Four different models were generated to predict in-hospital mortality. Following variables were included: age, sex, oxygen saturation, level of C-reactive-protein, neutrophil-to-platelet-ratio (NPR), neutrophil-to-lymphocyte-ratio (NLR) and the rate of changes of both hemogram ratios (VNLR and VNPR) during the first week after admission. The accuracy of the models in predicting in-hospital mortality were evaluated using the area under the receiver-operator-characteristic curve (AUC). AUC for models including NLR and NPR performed similarly in both cohorts: NLR 0.873 (95% CI: 0.849–0.898), NPR 0.875 (95% CI: 0.851–0.899) in training cohort and NLR 0.856 (95% CI: 0.818–0.895), NPR 0.863 (95% CI: 0.826–0.901) in validation cohort. AUC was 0.885 (95% CI: 0.885–0.919) for VNLR and 0.891 (95% CI: 0.861–0.922) for VNPR in the validation cohort. According to our results, models are useful in predicting in-hospital mortality risk due to COVID-19. The RIM Score proposed is a simple, widely available tool that can help identify patients at risk of fatal outcomes.

The clinical impact of bacterial co-infection among moderate, severe and critically ill COVID-19 patients in the second referral hospital in Surabaya

Background: Data on the prevalence of bacterial co-infections among COVID-19 patients are limited, especially in our country, Indonesia. We aimed to assess the rate of bacterial co-infections in hospitalized COVID-19 patients and report the most common microorganisms involved and the antibiotic use in these patients.

Methods: This study is a retrospective cohort study,among COVID-19 adult patients admitted to Universitas Airlangga Hospital Surabaya from 14 March-30 September 2020. The bacterial infection is defined based on clinical assessment, laboratory parameters, and microbiology results.

Results: A total of 218 patients with moderate to critical illness and confirmed COVID-19 were included in this study. Bacterial infection was confirmed in 43 patients (19.7%). COVID-19 patients with bacterial infections had longer hospital length of stay (17.6 6.62 vs 13.317.12), a higher proportion of respiratory failure, intensive care treatment, and ventilator use. COVID-19 patients with bacterial infection had a worse prognosis than those without bacterial infection (p<0.04). The empirical antibiotic was given to 75.2% of the patients. Gram-negative bacteria were commonly found as causative agents in this study (n = 39; 70.37%).

Conclusion: COVID-19 patients with bacterial infection have a longer length of stay and worse outcomes. Healthcare-associated infections during intensive care treatment for COVID-19 patients must be carefully prevented.

The clinical impact of bacterial co-infection among moderate, severe and critically ill COVID-19 patients in the second referral hospital in Surabaya

Background: Data on the prevalence of bacterial co-infections among COVID-19 patients are limited, especially in our country, Indonesia. We aimed to assess the rate of bacterial co-infections in hospitalized COVID-19 patients and report the most common microorganisms involved and the antibiotic use in these patients. Methods: This study is a retrospective cohort study, among COVID-19 adult patients admitted to Universitas Airlangga Hospital Surabaya from 14 March-30 September 2020. The bacterial infection is defined based on clinical assessment, laboratory parameters, and microbiology results. Results: A total of 218 patients with moderate to critical illness and confirmed COVID-19 were included in this study. Bacterial infection was confirmed in 43 patients (19.7%). COVID-19 patients with bacterial infections had longer hospital length of stay (17.6 ± 6.62 vs 13.31±7.12), a higher proportion of respiratory failure, intensive care treatment, and ventilator use. COVID-19 patients with bacterial infection had a worse prognosis than those without bacterial infection (p<0.04). The empirical antibiotic was given to 75.2% of the patients. Gram-negative bacteria were commonly found as causative agents in this study (n = 39; 70.37%). Conclusion: COVID-19 patients with bacterial infection have a longer length of stay and worse outcomes. Healthcare-associated infections during intensive care treatment for COVID-19 patients must be carefully prevented.

Clinical characteristics and outcomes in women and men hospitalized for coronavirus disease 2019 in New Orleans

OBJECTIVES

Determine if sex differences exist in clinical characteristics and outcomes of adults hospitalized for coronavirus disease 2019 (COVID-19) in a US healthcare system.

DESIGN

Case series study.

SETTING AND PARTICIPANTS

Sequentially hospitalized adults admitted for COVID-19 at two tertiary care academic hospitals in New Orleans, LA, between 27 February and 15 July 2020.

MEASURES AND OUTCOMES

Measures included demographics, comorbidities, presenting symptoms, and laboratory results. Outcomes included intensive care unit admission (ICU), invasive mechanical ventilation (IMV), and in-hospital death.

RESULTS

We included 776 patients (median age 60.5 years; 61.4% women, 75% non-Hispanic Black). Rates of ICU, IMV, and death were similar in both sexes. In women versus men, obesity (63.8 vs 41.6%, P < 0.0001), hypertension (77.6 vs 70.1%, P = 0.02), diabetes (38.2 vs 31.8%, P = 0.06), chronic obstructive pulmonary disease (COPD, 22.1 vs 15.1%, P = 0.015), and asthma (14.3 vs 6.9%, P = 0.001) were more prevalent. More women exhibited dyspnea (61.2 vs 53.7%, P = 0.04), fatigue (35.7 vs 28.5%, P = 0.03), and digestive symptoms (39.3 vs 32.8%, P = 0.06) than men. Obesity was associated with IMV at a lower BMI (> 35) in women, but the magnitude of the effect of morbid obesity (BMI ≥ 40) was similar in both sexes. COPD was associated with ICU (adjusted OR (aOR), 2.6; 95%CI, 1.5-4.3) and IMV (aOR, 1.8; 95%CI, 1.2-3.1) in women only. Diabetes (aOR, 2.6; 95%CI, 1.2-2.9), chronic kidney disease (aOR, 2.2; 95%CI, 1.3-5.2), elevated neutrophil-to-lymphocyte ratio (aOR, 2.5; 95%CI, 1.4-4.3), and elevated ferritin (aOR, 3.6; 95%CI, 1.7-7.3) were independent predictors of death in women only. In contrast, elevated D-dimer was an independent predictor of ICU (aOR, 7.3; 95%CI, 2.7-19.5), IMV (aOR, 6.5; 95%CI, 2.1-20.4), and death (aOR, 4.5; 95%CI, 1.2-16.4) in men only.

CONCLUSIONS

This study highlights sex disparities in clinical determinants of severe outcomes in COVID-19 patients that may inform management and prevention strategies to ensure gender equity.