Evaluation of variation in D-dimer levels among COVID-19 and bacterial pneumonia: a retrospective analysis

Platelet and Monocyte Microvesicles as Potential Biomarkers of COVID-19 Severity: A Cross-Sectional Analysis

Background

Coronavirus disease (COVID-19) induces inflammation, coagulopathy following platelet and monocyte activation, and fibrinolysis, resulting in elevated D-dimer levels. Activated platelets and monocytes produce microvesicles (MVs). We analyzed the differences in platelet and monocyte MV counts in mild, moderate, and severe COVID-19, as well as their correlation with D-dimer levels.

Methods

In this cross-sectional study, blood specimens were collected from 90 COVID-19 patients and analyzed for D-dimers using SYSMEX CS-2500. Platelet MVs (PMVs; PMVCD42b+ and PMVCD41a+), monocyte MVs (MMVs; MMVCD14+), and phosphatidylserine-binding annexin V (PS, AnnV+) were analyzed using a BD FACSCalibur instrument.

Results

PMV and MMV counts were significantly increased in COVID-19 patients. AnnV+ PMVCD42b+ and AnnV+ PMVCD41a+ cell counts were higher in patients with severe COVID-19 than in those with moderate clinical symptoms. The median (range) of AnnV+ PMVCD42b+ (MV/μL) in mild, moderate, and severe COVID-19 was 1,118.3 (328.1-1,910.5), 937.4 (311.4-2,909.5), and 1,298.8 (458.2-9,703.5), respectively (P =0.009). The median (range) for AnnV+ PMVCD41a+ (MV/μL) in mild, moderate, and severe disease was 885.5 (346.3-1,682.7), 663.5 (233.8-2,081.5), and 1,146.3 (333.3-10,296.6), respectively (P =0.007). D-dimer levels (ng/mL) weak correlated with AnnV+ PMVCD41a+ (P =0.047, r=0.258).

Conclusions

PMV PMVCD42b+ and PMVCD41a+ counts were significantly increased in patients with severe clinical symptoms, and PMVCD41a+ counts correlated with D-dimer levels. Therefore, MV counts can be used as a potential biomarker of COVID-19 severity.

Advances in D-dimer testing: progress in harmonization of clinical assays and innovative detection methods

The D-dimer is a sensitive indicator of coagulation and fibrinolysis activation, especially valuable as a biomarker of intravascular thrombosis. Measurement of plasma D-dimer levels plays a crucial role in the diagnosis and monitoring of conditions such as deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. A variety of immunoassays, including enzyme-linked immunosorbent assays, latex-enhanced immunoturbidimetric assays, whole-blood aggregation analysis, and immunochromatography assays, are widely used in clinical settings to determine D-dimer levels. However, the results obtained from different D-dimer assays vary significantly. These assays exhibit intra-method coefficients of variation ranging from 6.4% to 17.7%, and the measurement discrepancies among different assays can be as high as 20-fold. The accuracy and reliability of D-dimer testing cannot be guaranteed due to the lack of an internationally endorsed reference measurement system (including reference materials and reference measurement procedures), which may lead to misdiagnosis and underdiagnosis, limiting its full clinical application. In this review, we present an in-depth analysis of clinical D-dimer testing, summarizing the existing challenges, the current state of metrology, and progress towards harmonization. We also review the latest advancements in D-dimer detection techniques, which include mass spectrometry and electrochemical and optical immunoassays. By comparing the basic principles, the definition of the measurand, and analytical performance of these methods, we provide an outlook on the potential improvements in D-dimer clinical testing.

SARS-CoV-2 Infection-Dependent Modulation in Vital Components of the Serum Profile of Severely SARS-CoV-2 Infected Patients

Background

COVID-19 modulates many serological biomarkers during the progress of disease severity. The study aimed to determine COVID-19 severity-associated perturbance in the serum profile.

Methods

A retrospective study including COVID-19-positive individuals (n = 405) was accomplished. The serum profile of COVID-19 participants was mined from laboratory records. Severity-associated alteration in the serum profile was evaluated using Pearson correlation, regression, VCramer, Bayesian posterior VCramer, and bias factor using R-base-RStudio-version-3.3.0 with a significant cut-off of p < 0.05.

Results

Significantly different mean ± standard deviation (SD) (highly versus moderately severe) of C-reactive protein (CRP), ferritin, neutrophil-lymphocyte ratio (NLR), D-dimer, platelets, prothrombin time (PT), partial prothrombin time (PTT), troponin 1, lactate dehydrogenase (LDH), aspartate-aminotransferase (AST), alanine aminotransferase (ALT), and AST/ALT ratio was observed (p < 0.001). Highly severe COVID-19 associated with CRP, ferritin, NLR, in D-dimer, PT, PTT, troponin 1, AST/ALT ratio, AST and ALT (adjusted odds ratio (AOR): 1.346, 1.05, 1.46, 1.33, 1.42, 1.23, 4.07, 3.9, 1.24, 1.45, p < 0.001). CRP with ferritin (r = 0.743), NLR (r = 0.77), white blood cells (WBC) (r = 0.8), troponin1 with LDH (r = 0.757), and D-dimer with platelets (r = -0.81) were highly correlated. X2pearson (p < 0.001), VCramer (0.71), Bayesian-VCramer (0.7), and bias-factor (-125) for troponin 1 indicate the strong association of troponin 1 level and with COVID-19 severity. X2pearson (p < 0.001), VCramer (1), Bayesian-VCramer (0.98), and bias-factor (-266.3) for NLR exhibited a very strong association of pathologic conditions with the high severity of the disease.

Conclusion

These biomarkers of inflammation (CRP, Ferritin, NLR), coagulation disorders (D-dimer, PT, and PTT) cardiac abnormality (troponin 1), and liver injury (AST/ALT) could be crucial in low-medical resource settings as potential prognosticator/predictors of the COVID-19 severity and clinical outcomes. Moreover, the outcome of this study could be leveraged for the early prediction of disease severity during SARS-CoV or Middle East Respiratory Coronavirus (MERS-CoV) infection.

Association of Coagulopathy and Inflammatory Biomarkers with Severity in SARS-CoV-2-Infected Individuals of the Al-Qunfudhah Region of Saudi Arabia

BACKGROUND

Identifying prognosticators/predictors of COVID-19 severity is the principal focus for early prediction and effective management of the disease in a time-bound and cost-effective manner. We aimed to evaluate COVID-19 severity-dependent alteration in inflammatory and coagulopathy biomarkers.

METHODS

A hospital-dependent retrospective observational study (total: n = 377; male, n = 213; and female, n = 164 participants) was undertaken. COVID-19 exposure was assessed by performing real-time PCR on nasopharyngeal (NP) swabs. Descriptive and inferential statistics were applied for both continuous and categorical variables using Rstudio-version-4.0.2. Pearson correlation and regression were executed with a cut-off of p < 0.05 for evaluating significance. Data representation by R-packages and ggplot2.

RESULTS

A significant variation in the mean ± SD (highly-sever (HS)/moderately severe (MS)) of CRP (HS/MS: 102.4 ± 22.9/21.3 ± 6.9, p-value < 0.001), D-dimer (HS/MS: 661.1 ± 80.6/348.7 ± 42.9, p-value < 0.001), and ferritin (HS/MS: 875.8 ± 126.8/593.4 ± 67.3, p-value < 0.001) were observed. Thrombocytopenia, high PT, and PTT exhibited an association with the HS individuals (p < 0.001). CRP was correlated with neutrophil (r = 0.77), ferritin (r = 0.74), and WBC (r = 0.8). D-dimer correlated with platelets (r = -0.82), PT (r = 0.22), and PTT (r = 0.37). The adjusted odds ratios (Ad-OR) of CRP, ferritin, D-dimer, platelet, PT, and PTT for HS compared to MS were 1.30 (95% CI -1.137, 1.50; p < 0.001), 1.048 (95% CI -1.03, 1.066; p < 0.001), 1.3 (95% CI -1.24, 1.49, p > 0.05), -0.813 (95% CI -0.734, 0.899, p < 0.001), 1.347 (95% CI -1.15, 1.57, p < 0.001), and 1.234 (95% CI -1.16, 1.314, p < 0.001), respectively.

CONCLUSION

SARS-CoV-2 caused alterations in vital laboratory parameters and raised ferritin, CRP, and D-dimer presented an association with disease severity at a significant level.

Serial laboratory biomarkers are associated with ICU outcomes in patients hospitalized with COVID-19

BACKGROUND

Clinical utility of routinely measured serial biomarkers in predicting escalation of inpatient care intensity and mortality among hospitalized patients with COVID-19 remains unknown.

METHODS

This retrospective cohort study included patients with COVID-19 who admitted to the Massachusetts General Hospital between March and June 2020 and January to March 2021. White blood cell (WBC) count, platelet count, C-reactive protein (CRP), and D-dimer values were measured on days 1, 3, and 7 of admission. Clinical outcomes include 30- and 60-day morality, ICU transfer, and overall survival (OS) over a follow-up period of 90 days. The association between serial biomarkers and outcomes were assessed using multivariable logistic regression and Cox proportional hazards models.

MEASUREMENTS AND MAIN RESULTS

Of the 456 patients hospitalized with COVID-19, 199 (43.6%) were ICU, 179 (39.3%) were medical floor, and 78 (17.1%) were initially admitted to the medical floor and then transferred to the ICU. In adjusted analyses, each unit increase in the slope of CRP was associated with a 42% higher odds of ICU transfer after controlling for the initial admission level (OR = 1.42, 95% CI: 1.25-1.65, P < 0.001). Including serial change in CRP levels from initial level on admission achieved the greatest predictive accuracy for ICU transfer (AUC = 0.72, 95% CI: 0.64-0.79).

CONCLUSIONS

Serial change in CRP levels from admission is associated with escalations of inpatient care intensity and mortality among hospitalized patients with COVID-19.

Analysis of altered level of blood-based biomarkers in prognosis of COVID-19 patients

INTRODUCTION

Immune and inflammatory responses developed by the patients with Coronavirus Disease 2019 (COVID-19) during rapid disease progression result in an altered level of biomarkers. Therefore, this study aimed to analyze levels of blood-based biomarkers that are significantly altered in patients with COVID-19.

METHODS

A cross-sectional study was conducted among COVID-19 diagnosed patients admitted to the tertiary care hospital. Several biomarkers-biochemical, hematological, inflammatory, cardiac, and coagulatory-were analyzed and subsequently tested for statistical significance at P<0.01 by using SPSS version 17.0.

RESULTS

A total of 1,780 samples were analyzed from 1,232 COVID-19 patients (median age 45 years [IQR 33-57]; 788 [63.96%] male). The COVID-19 patients had significantly (99% Confidence Interval, P<0.01) elevated levels of glucose, urea, alanine transaminase (ALT), aspartate aminotransaminase (AST), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), white blood cell (WBC), C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), ferritin, D-Dimer, and creatinine phosphokinase-MB (CPK-MB) compared to the control group. However, the levels of total protein, albumin, and platelets were significantly (P<0.01) lowered in COVID-19 patients compared to the control group. The elevated levels of glucose, urea, WBC, CRP, D-Dimer, and LDH were significantly (P<0.01) associated with in-hospital mortality in COVID-19 patients.

CONCLUSIONS

Assessing and monitoring the elevated levels of glucose, urea, ALT, AST, ALP, WBC, CRP, PCT, IL-6, ferritin, LDH, D-Dimer, and CPK-MB and the lowered levels of total protein, albumin, and platelet could provide a basis for evaluation of improved prognosis and effective treatment in patients with COVID-19.

The added value of lung perfusion scintigraphy semiquantitative measures in post-COVID patients with persistent dyspnea without pulmonary embolism

BACKGROUND

Persistent dyspnea is frequent in post-COVID patients, even in the absence of pulmonary embolism (PE). In this scenario, the role of lung perfusion scintigraphy is unclear. The present study correlated scintigraphy-based semiquantitative perfusion parameters with chest high-resolution computed tomography (hrCT) volumetric indexes and clinical data in post-COVID patients with persistent dyspnea.

RESEARCH DESIGN AND METHODS

Sixty patients (30 post-COVID and 30 not previously affected by COVID-19) with persistent dyspnea submitted to lung perfusion scintigraphy and hrCT were retrospectively recruited. Perfusion rates of the pulmonary fields and hrCT-based normalized inflated, emphysematous, infiltrated, collapsed, and vascular lung volumes were calculated. Inflammatory and coagulation biomarkers were collected. PE at imaging was an exclusion criterion.

RESULTS

Compared to controls, reduced perfusion rates of the lower pulmonary fields and higher perfusion rates of the middle ones were observed in post-COVID patients, while hrCT findings were superimposable between the two groups. Perfusion rates of lower pulmonary fields were significantly associated only with abnormal lung volumes at hrCT.

CONCLUSIONS

In post-COVID dyspnea without PE, lung perfusion scintigraphy may reveal a pulmonary involvement not detectable by hrCT. Post-COVID patients may show decreased perfusion rates of lower pulmonary fields in the presence of normal vascular density and markers of inflammation/coagulation.

Study to Determine a Prognostic Cutoff Values of the Coagulation Analyte D-dimer for ICU Admission among COVID-19 Patients

Introduction

The measured D-dimer levels in coronavirus disease-2019 (COVID-19) patients have no specific cutoff to find the progression of coagulopathy and severity.

Aim

This study aimed to determine prognostic cutoff values of D-dimer for intensive care unit (ICU) admission among COVID-19 patients.

Materials and methods

This cross-sectional study was conducted in Sree Balaji Medical College and Hospital, Chennai, during a period of 6 months. This study included 460 COVID-19-positive individuals.

Results

The mean age was 52.2 ± 12.53 years. Patients with mild illness have D-dimer value 461.8 ± 221, whereas moderate and severe COVID illness patients have D-dimer values of 1915.2 ± 699.9 and 7937.6 ± 2045.2, respectively. D-dimer cutoff value of 1036.9 is shown to be a prognostic cutoff value for COVID-19 patients admitted in the ICU with 99% sensitivity and 17% specificity. The area under curve (AUC) was considered excellent (AUC = 0.827, 95% Cl: 0.78-0.86, p-value < 0.0001) indicative of high sensitivity.

Conclusion

The D-dimer value of 1036.9 ng/mL was found to be the optimum cutoff for the patients to predict the severity of the COVID-19-positive patients admitted in the ICU.

How to cite this article

Anton MC, Shanthi B, Vasudevan E. Study to Determine a Prognostic Cutoff Values of the Coagulation Analyte D-dimer for ICU Admission among COVID-19 Patients. Indian J Crit Care Med 2023;27(2):135-138.

Development of aptamer-based ELISA method for d-dimer detection

This study developed an aptamer-based enzyme-linked immunosorbent assay (ELISA) system for sensitive detection of the d -dimer molecule, which is significantly elevated in several severe diseases. Aptamers are known to have advantages, such as longer stability and usability at different temperatures and in different complex samples, over antibodies, which are generally used in traditional ELISA methods. In the present work, the aptamer-based ELISA system was capable of quantitatively determining in a wide range (100 ng/ml─10 μg/ml) and remain stable for a couple of months even under ordinary room conditions. Validation of the developed system was evaluated by spiked human serum samples with high accuracy. With more comprehensive project steps, the developed aptamer-based ELISA system could be transformed into a platform that offers a sensitive, portable, and easy-to-use tool for analyzing d -dimer molecules.

Better safe than sorry-Whole-genome sequencing indicates that missense variants are significant in susceptibility to COVID-19

Undoubtedly, genetic factors play an important role in susceptibility and resistance to COVID-19. In this study, we conducted the GWAS analysis. Out of 15,489,173 SNPs, we identified 18,191 significant SNPs for severe and 11,799 SNPs for resistant phenotype, showing that a great number of loci were significant in different COVID-19 representations. The majority of variants were synonymous (60.56% for severe, 58.46% for resistant phenotype) or located in introns (55.77% for severe, 59.83% for resistant phenotype). We identified the most significant SNPs for a severe outcome (in AJAP1 intron) and for COVID resistance (in FIG4 intron). We found no missense variants with a potential causal function on resistance to COVID-19; however, two missense variants were determined as significant a severe phenotype (in PM20D1 and LRP4 exons). None of the aforementioned SNPs and missense variants found in this study have been previously associated with COVID-19.

Diagnosis and Stratification of COVID-19 Infections Using Differential Plasma Levels of D-Dimer: A Two-Center Study from Saudi Arabia

Background: D-dimer, generated upon the degradation of fibrin, is extensively used to detect thrombosis in various diseases. It is also explored as a marker for thrombosis in cases with COVID-19 disease. Few studies have confirmed its utility as a marker for assessing disease severity. Objectives: The current research was undertaken to determine the role of D-dimer in patients with COVID-19 and to investigate any association with the progression and severity of the disease in the Saudi population. Methods: Clinical indices in confirmed COVID-19 patients were collected from tertiary care hospitals in Aljouf and Qassim regions. The plasma D-dimer levels were quantified directly in the samples collected from COVID-19 patients (n = 148) using an immunofluorescence assay, and the data were presented in Fibrinogen Equivalent Units (mg/L). The collected data of D-dimer were analyzed based on COVID-19 severity, age, and the gender of patients. Results: The findings show that the plasma D-dimer concentrations were significantly (p = 0.0027) elevated in COVID-19 cases (n = 148), compared to in the normal healthy uninfected controls (n = 309). Moreover, the D-dimer levels were analyzed according to the severity of the disease in the patients. The data revealed that D-dimer concentrations were significantly increased in patients with mild infection to moderate disease, and the levels were the highest in patients with severe COVID-19 disease (p < 0.05). Our analysis demonstrates that the D-dimer levels have no association with the age or gender of COVID-19 patients (p > 0.05) in the study population. Conclusions: D-dimer can serve as a biomarker not only for the detection of COVID-19 infection, but also for determining the severity of infection of COVID-19 disease.

D-dimer and HbA1c levels findings in COVID-19 Iraqi patients

On March 11, 2020, the World Health Organization (WHO) declared a new coronavirus infection caused by the SARS-CoV-2 virus as a pandemic, making it the 11th pandemic of the 20th and 21st centuries. This study investigated the clinical and laboratory results (D-dimer, conventional coagulation, and HbA1c biomarker concentrations) of 150 patients (75 male and 75 female) with confirmed COVID-19 pneumonia and 50 controls (25 male and 25 female). For disease diagnosis, all COVID-19 patients were given a Real-Time Reverse Transcription Polymerase Chain Reaction Assay (RT-PCR). The findings revealed that D-dimer and HbA1c levels in COVID-19 patients were significantly higher (P 0.001) at the time of admission; In COVID-19 patients, there was also a strong correlation between D-dimer levels and HbA1c levels (P 0.001). In conclusion, COVID-19 patients are more likely to have a poor prognosis if their D-dimer and HbA1c levels remain uncontrolled over a lengthy period. To lower the likelihood of a bad prognosis in COVID-19, patients with higher levels of D-dimer and HbA1c should be continuously monitored.

Post-discharge Thromboembolic Events in COVID-19 Patients: A Review on the Necessity for Prophylaxis

Coronavirus disease 2019 (COVID-19) affects the respiratory system of patients and is characterized by pneumonia with hypoxemia. Hospitalized patients and particularly those admitted to intensive care unit (ICU) may encounter a cascade of coagulopathies, which may lead to macrovessel thrombotic events such as pulmonary embolism (PE), deep vein thrombosis (DVT), or arterial thromboembolism (ATE). These events can result in serious life-threatening diseases including cerebrovascular stroke and myocardial infarction. Despite all available information about the incidence, prevention, and treatment of venous thromboembolism (VTE) among hospitalized patients, few data are available on the incidence of both symptomatic and subclinical VTE after discharge. Therefore, there is no precise suggestion or guideline for prophylaxis against VTE in post-discharge period, and some controversies exist over the current guidelines. In the present study, we aimed to review and summarize available literature upon incidence, prevention, diagnosis, and therapeutic approaches for VTE in COVID-19 patients. Also, the pathogenic mechanisms of VTE in infected individuals with COVID-19 were discussed.

Arterial and venous thrombosis in a patient with Covid-19: A unique presentation

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) infection not only affects the respiratory system but also induces coagulation abnormalities and thrombosis. We report a middle-aged woman who presented during the Covid-19 pandemic with sudden-onset acute left upper limb ischaemia of short duration, with no history of dry cough, breathlessness or fever, and tested positive on TrueNAT for SARS-CoV-2. Later, she developed deep venous thrombosis of the right lower limb during isolation in the hospital.

Early Changes in Clinical and Laboratory Parameters in Patients Died of COVID-19

261,435,768 COVID-19 infections were detected worldwide, of them 5,207,634 deaths were registered. Identifying markers of the patient severity early in the course of the disease can facilitate the assessment of the risk of adverse outcome.

The objective: To compare values of laboratory parameters and their changes during treatment of patients with a complicated course of COVID-19 infection.

Subjects and Methods. 56 patients were included in the study, all of them were hospitalized to COVID Hospital of the Clinic of Bashkir State Medical University, Russian Ministry of Health, from September 30, 2021 to November 15, 2021, and their complicated course of the disease necessitated transfer to the intensive care unit (ICU). The laboratory evaluation included the following: a general blood and urine counts, blood chemistry including urea and creatinine, liver transaminases, and blood coagulogram (prothrombin time (PTT), prothrombin index (PTI), thrombin time, fibrinogen, and blood clotting time).

Results. In the group of patients with a fatal outcome on the day of transfer to ICU, lymphocytopenia, eosinopenia, elevated values of creatinine, total bilirubin, transaminases, C-reactive protein, D-dimer, and ferritin were noted. Also on this day, microscopic hematuria, proteinuria and cylindruria were detected in the urine tests of most patients in this group during treatment.

Conclusion. Critical deviations in the results of hematological and biochemical tests were revealed. Particular attention should be paid to such parameters as the level of erythrocytes, lymphocytes, eosinophils, glucose, urea, creatinine, total bilirubin, aspartate aminotransferase, alanine aminotransferase, creatine kinase, C-reactive protein, D-dimer, and ferritin.

Exploration of prognostic factors for prediction of mortality in elderly CAP population using a nomogram model

Background

The incidence and mortality rate of community-acquired pneumonia (CAP) in elderly patients were higher than the younger population. The assessment tools including CURB-65 and qSOFA have been applied in early detection of high-risk patients with CAP. However, several disadvantages exist to limit the efficiency of these tools for accurate assessment in elderly CAP. Therefore, we aimed to explore a more comprehensive tool to predict mortality in elderly CAP population by establishing a nomogram model.

Methods

We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University. The least absolute shrinkage and selection operator (LASSO) logistic regression combined with multivariate analyses were used to select independent predictive factors and established nomogram models via R software. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance.

Results

LASSO and multiple logistic regression analyses showed the age, pulse, NLR, albumin, BUN, and D-dimer were independent risk predictors. A nomogram model (NB-DAPA model) was established for predicting mortality of CAP in elderly patients. In both training and validation set, the area under the curve (AUC) of the NB-DAPA model showed superiority than CURB-65 and qSOFA. Meanwhile, DCA revealed that the predictive model had significant net benefits for most threshold probabilities.

Conclusion

Our established NB-DAPA nomogram model is a simple and accurate tool for predicting in-hospital mortality of CAP, adapted for patients aged 65 years and above. The predictive performance of the NB-DAPA model was better than PSI, CURB-65 and qSOFA.

D-Dimer as a Sensitive Biomarker of Survival Rate in Patients with COVID-19

OBJECTIVE

The global case fatality rate of coronavirus disease 2019 is 2.16% as announced by the World Health Organization. In Indonesia, according to the Ministry of Health, the number is even higher, reaching a 2.8% case fatality rate. D-dimer levels were found to affect coronavirus disease 2019 patient's survival in several studies. The study aimed to determine whether the amount of D-dimer predicted survival in coronavirus disease 2019 patients.

MATERIALS AND METHODS

This research was performed in a retrospective cohort design and used survival analysis. From March 1, 2020, to August 31, 2020, the samples were collected from polymerase chain reaction-confirmed coronavirus disease 2019 patients at Mohammad Hoesin General Hospital in Palembang, South Sumatera, Indonesia. We used electronic medical records to obtain demographic (age and gender), coexisting condition, laboratory (coagulation and hematologic test), and outcome (non-survivors or survivors) data. The chi-square and Mann-Whitney tests were used to evaluate the results. The Kaplan-Meier method and the Mantel-Haenszel log-rank test were used to examine D-dimer levels and patient outcomes. Youden index was calculated to determine the optimal cut-off value of D-dimer.

RESULTS

There were 52 non-survivors and 235 survivors among the 287 patients who met the inclusion criterion. Non-survivors had D-dimer levels of more than 1.49 mg/L in 82.69%of cases. Males had lower cut-off compared to females (>1.49 mg/L vs. >2.2 mg/L). The researchers discovered a highly significant correlation between D-dimer levels and coronavirus disease 2019 mortality (P=.001). The c-index analysis showed that D-dimer (0.79, 95% CI: 0.73-0.83) ability for mortality prediction was the second-best compared with other laboratory markers.

CONCLUSION

D-dimer can be used as a predictor of coronavirus disease 2019 in-hospital mortality for early identification of coagulopathy.

Hemostatic system and COVID-19 crosstalk: A review of the available evidence

Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its resultant coronavirus disease 2019 (COVID-19) pandemic, respiratory manifestations have been the mainstay of clinical diagnosis, laboratory evaluations, and radiological investigations. As time passed, other pathological aspects of SARS-CoV-2 have been revealed. Various hemostatic abnormalities have been reported since the rise of the pandemic, which was sometimes superficial, transient, or fatal. Mild thrombocytopenia, thrombocytosis, venous, arterial thromboembolism, and disseminated intravascular coagulation are among the many hemostatic events associated with COVID-19. Venous thromboembolism necessitating therapeutic doses of anticoagulants is more frequently seen in severe cases of COVID-19, especially in patients admitted to intensive care units. Hemorrhagic complications rarely arise in COVID-19 patients either due to a hemostatic imbalance resulting from severe disease or as a complication of over anticoagulation. Although the pathogenesis of coagulation disturbance in SARS-CoV-2 infection is not yet understood, professional societies recommend prophylactic antithrombotic therapy in severe cases, especially in the presence of abnormal coagulation indices. The review article discusses the various available evidence on coagulation disorders, management strategies, outcomes, and prognosis associated with COVID-19 coagulopathy, which raises awareness about the importance of anticoagulation therapy for COVID-19 patients to guard against possible thromboembolic events.

Management of COVID-19: A comprehensive and practical approach

Since the beginning of Corona Virus Disease (COVID) pandemic, there has been lack of clarity about the management protocols in spite of frequently updated national and international guidelines. Irrational use of unproven therapies has not been helpful in improving treatment outcomes. Early use of high-dose steroids or late use of antiviral medicines might have caused more harm than the benefit. There is also lot of fear about post-COVID fibrosis leading to extended use of steroids and antifibrotics. We reviewed the available COVID guidelines and treatment protocols in the light of scientific evidence generated over last 2 years by a systematic literature search using various databases (PubMed, Google Scholar, MEDLINE, UpToDate, Embase, and Web of Science). This article presents a comprehensive approach to the diagnosis, appropriate investigations, their interpretations, and use of specific therapies according to the stage of disease.

A systematic review of biomarkers among hospitalized patients with COVID-19 predictive of venous thromboembolism: A communication from the Predictive and Diagnostic Variables Scientific and Standardization Committee of the ISTH

Background

Thrombosis is reported to occur more often among patients with COVID-19 than otherwise expected in the setting of viral pneumonia and sepsis. Systemic inflammatory biomarkers may be associated with venous thromboembolism (VTE) risk. The ISTH subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease aimed to report the evidence on prognostic biomarkers for VTE in hospitalized patients with COVID-19.

Methods

Using a standardized Preferred Reporting Items for Systematic Reviews and Meta-analysis methodology, we conducted a systematic literature review to identify studies reporting prognostic biomarkers for VTE among hospitalized patients with COVID-19. Eligible studies included adults hospitalized with COVID-19 and reported the prognostic associations between any biomarker measured on admission, and the subsequent diagnosis of deep vein thrombosis or pulmonary embolism. Two authors reviewed titles and abstracts, and three authors extracted study data and performed review of bias. Results were displayed descriptively. Meta-analysis was not possible.

Results

From the initial 196 identified studies, full-text review was performed for 72 studies. Admission D-dimer levels were associated with VTE during hospitalization in five studies, and elevated platelet count was associated with VTE during hospitalization in one study. The risk of bias ranged from low to high for included studies. Overall, there was a paucity of high-quality prognostic studies. Studies on other biomarkers did not meet the systematic review inclusion criteria.

Conclusions

Admission D-dimer was associated with VTE diagnosis during hospitalization for COVID-19; however, prospective validation of this finding is needed to identify optimal D-dimer thresholds to guide VTE prophylaxis measures.

Thromboprophylaxis and clinical outcomes in moderate COVID-19 patients: A comparative study

Background

Many thrombotic complications are linked to coronavirus disease 2019 (COVID-19). Antithrombotic treatments are important for prophylaxis against these thrombotic events.

Objectives

This study was designed to compare enoxaparin and rivaroxaban as prophylactic anticoagulants in moderate cases of COVID-19 in terms of efficacy, safety, and clinical outcomes.

Methods

The study involved 124 patients with moderate COVID-19 (pneumonia without hypoxia) divided into two groups. The first group (G1) comprised 66 patients who received enoxaparin subcutaneously at a dose of 0.5 mg/kg every 12 h until discharge from the hospital. The second group (G2) comprised 58 patients who received oral rivaroxaban at a dose of 10 mg once daily until discharge from the hospital. The outcomes evaluated in this study were as follows: intermediate care unit (IMCU) duration, the number of patients transferred from the IMCU to the intensive care unit (ICU), ICU duration, the total length of hospital stay, in-hospital mortality, and thrombotic and bleeding complications.

Results

No significant differences in IMCU duration (p = 0.39), ICU duration (p = 0.96), and total length of hospital stay (p = 0.73) were observed between the two groups. The percentage of patients requiring ICU admission after hospitalization was 21.2% in G1 and 22.4% in G2 (p = 0.87). The mortality rate was 12.1% in G1 and 10.3% in G2 (p = 0.76). The proportion of patients who had thrombotic complications was 9.1% in G1 and 12.1% in G2 (p = 0.59). The incidence of mild bleeding was 3% in G1 and 1.7% in G2 (p = 0.64).

Conclusion

Either enoxaparin or rivaroxaban may be used as thromboprophylaxis agents in managing patients with moderate COVID-19. Either medication has no clear advantage over the other.

An overview of the neurological aspects in COVID-19 infection

The Crown-shaped, severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) triggered the globally fatal illness of Coronavirus disease-2019 (COVID-19). This infection is known to be initially reported in bats and has been causing major respiratory challenges. The primary symptoms of COVID-19 include fever, fatigue and dry cough. As progressed the complications may lead to acute respiratory distress syndrome (ADRS), arrhythmia and shock. This review illustrates the neurological and neuropsychiatric impairments due to COVID-19 infection. The SARS-CoV-2 virus enters via the hematogenous or neural route, spreads to the Central Nervous System (CNS), causing a blood-brain barrier (BBB) dysfunction. Recent scientific articles have reported that SARS-CoV-2 causes several neurological issues such as encephalitis, seizures, acute stroke, delirium, meningoencephalitis and Guillain-Barré Syndrome (GBS). As a long-term effect of this disease certain neuropsychiatric conditions are witnessed such as depression and anxiety. Invasion into followed by degeneration takes place causing an uncontrolled immune response. Transcription factors like NF-κB (nuclear factor kappa light chain enhancer of activated B cells), which modulate genes responsible for inflammatory response gets over expressed. Nrf2 (nuclear factor erythroid 2- related factor 2) counterpoises the inflammation by antioxidant response towards COVID-19 infection. Like every other infection, the severity of this infection leads to deterioration of major organ systems and even leads to death. By the columns of this review, we elaborate on the neurological aspects of this life-threatening infection.

The host response in different aetiologies of community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) can be caused by a variety of pathogens, of which Streptococcus pneumoniae, Influenza and currently SARS-CoV-2 are the most common. We sought to identify shared and pathogen-specific host response features by directly comparing different aetiologies of CAP.

METHODS

We measured 72 plasma biomarkers in a cohort of 265 patients hospitalized for CAP, all sampled within 48 hours of admission, and 28 age-and sex matched non-infectious controls. We stratified the biomarkers into several pathophysiological domains- antiviral response, vascular response and function, coagulation, systemic inflammation, and immune checkpoint markers. We directly compared CAP caused by SARS-CoV-2 (COVID-19, n=39), Streptococcus pneumoniae (CAP-strep, n=27), Influenza (CAP-flu, n=22) and other or unknown pathogens (CAP-other, n=177). We adjusted the comparisons for age, sex and disease severity scores.

FINDINGS

Biomarkers reflective of a stronger cell-mediated antiviral response clearly separated COVID-19 from other CAPs (most notably granzyme B). Biomarkers reflecting activation and function of the vasculature showed endothelial barrier integrity was least affected in COVID-19, while glycocalyx degradation and angiogenesis were enhanced relative to other CAPs. Notably, markers of coagulation activation, including D-dimer, were not different between the CAP groups. Ferritin was most increased in COVID-19, while other systemic inflammation biomarkers such as IL-6 and procalcitonin were highest in CAP-strep. Immune checkpoint markers showed distinctive patterns in viral and non-viral CAP, with highly elevated levels of Galectin-9 in COVID-19.

INTERPRETATION

Our investigation provides insight into shared and distinct pathophysiological mechanisms in different aetiologies of CAP, which may help guide new pathogen-specific therapeutic strategies.

FUNDING

This study was financially supported by the Dutch Research Council, the European Commission and the Netherlands Organization for Health Research and Development.

Changes in laboratory value improvement and mortality rates over the course of the pandemic: an international retrospective cohort study of hospitalised patients infected with SARS-CoV-2

OBJECTIVE

To assess changes in international mortality rates and laboratory recovery rates during hospitalisation for patients hospitalised with SARS-CoV-2 between the first wave (1 March to 30 June 2020) and the second wave (1 July 2020 to 31 January 2021) of the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

This is a retrospective cohort study of 83 178 hospitalised patients admitted between 7 days before or 14 days after PCR-confirmed SARS-CoV-2 infection within the Consortium for Clinical Characterization of COVID-19 by Electronic Health Record, an international multihealthcare system collaborative of 288 hospitals in the USA and Europe. The laboratory recovery rates and mortality rates over time were compared between the two waves of the pandemic.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause mortality rate within 28 days after hospitalisation stratified by predicted low, medium and high mortality risk at baseline. The secondary outcome was the average rate of change in laboratory values during the first week of hospitalisation.

RESULTS

Baseline Charlson Comorbidity Index and laboratory values at admission were not significantly different between the first and second waves. The improvement in laboratory values over time was faster in the second wave compared with the first. The average C reactive protein rate of change was -4.72 mg/dL vs -4.14 mg/dL per day (p=0.05). The mortality rates within each risk category significantly decreased over time, with the most substantial decrease in the high-risk group (42.3% in March-April 2020 vs 30.8% in November 2020 to January 2021, p<0.001) and a moderate decrease in the intermediate-risk group (21.5% in March-April 2020 vs 14.3% in November 2020 to January 2021, p<0.001).

CONCLUSIONS

Admission profiles of patients hospitalised with SARS-CoV-2 infection did not differ greatly between the first and second waves of the pandemic, but there were notable differences in laboratory improvement rates during hospitalisation. Mortality risks among patients with similar risk profiles decreased over the course of the pandemic. The improvement in laboratory values and mortality risk was consistent across multiple countries.

A Pilot Study on COVID-19 Positive Subjects: An Excerpt of Post-Infection-Pro-Diabetic Disposition & Related Consequences in Correlation to Hepato-Pancreatic Bio-Markers, Pro-Inflammatory Cytokines and Other Risk Factors

COVID-19, a global pandemic that led to increased morbidity and mortality worldwide since its outcome at the end of the year 2019. A newly discovered variant of severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) was the arbitrator for spreading the syndrome by droplet transmission causing multi-organ failure in many occasions. A post-infection-pro-diabetic disposition was found evident in this study with the persistence of hepato-pancreatic aberrations in respect of reference range of tissue specific bio-markers in hospital admitted COVID-19 cases. The results of this study show that hyperglycemia is a risk factor in precipitating disease oriented complications to the patients with COVID-19 disease. A post-infection follow- up on glycemic-index and related complexities is a vital need to the COVID-19 infected convalescent subjects. Implementation of guidelines on social measure and awareness of anti-viral interventions may be the only way to prevent COVID-19 transmission.

Inaccurate recording of routinely collected data items influences identification of COVID-19 patients

Background

During the Coronavirus disease 2019 (COVID-19) pandemic it became apparent that it is difficult to extract standardized Electronic Health Record (EHR) data for secondary purposes like public health decision-making. Accurate recording of, for example, standardized diagnosis codes and test results is required to identify all COVID-19 patients. This study aimed to investigate if specific combinations of routinely collected data items for COVID-19 can be used to identify an accurate set of intensive care unit (ICU)-admitted COVID-19 patients.

Methods

The following routinely collected EHR data items to identify COVID-19 patients were evaluated: positive reverse transcription polymerase chain reaction (RT-PCR) test results; problem list codes for COVID-19 registered by healthcare professionals and COVID-19 infection labels. COVID-19 codes registered by clinical coders retrospectively after discharge were also evaluated. A gold standard dataset was created by evaluating two datasets of suspected and confirmed COVID-19-patients admitted to the ICU at a Dutch university hospital between February 2020 and December 2020, of which one set was manually maintained by intensivists and one set was extracted from the EHR by a research data management department. Patients were labeled ‘COVID-19′ if their EHR record showed diagnosing COVID-19 during or right before an ICU-admission. Patients were labeled ‘non-COVID-19′ if the record indicated no COVID-19, exclusion or only suspicion during or right before an ICU-admission or if COVID-19 was diagnosed and cured during non-ICU episodes of the hospitalization in which an ICU-admission took place. Performance was determined for 37 queries including real-time and retrospective data items. We used the F₁ score, which is the harmonic mean between precision and recall. The gold standard dataset was split into one subset including admissions between February and April and one subset including admissions between May and December to determine accuracy differences.

Results

The total dataset consisted of 402 patients: 196 ‘COVID-19′ and 206 ‘non-COVID-19′ patients. F₁ scores of search queries including EHR data items that can be extracted real-time ranged between 0.68 and 0.97 and for search queries including the data item that was retrospectively registered by clinical coders F₁ scores ranged between 0.73 and 0.99. F₁ scores showed no clear pattern in variability between the two time periods.

Conclusions

Our study showed that one cannot rely on individual routinely collected data items such as coded COVID-19 on problem lists to identify all COVID-19 patients. If information is not required real-time, medical coding from clinical coders is most reliable. Researchers should be transparent about their methods used to extract data. To maximize the ability to completely identify all COVID-19 cases alerts for inconsistent data and policies for standardized data capture could enable reliable data reuse.

Symptomatic Venous Thromboembolic Events in COVID-19 Patients after Hospital Discharge: Aspects to Consider

Venous thromboembolic (VTE) events have been increasingly reported in patients with coronavirus disease 2019 (COVID-19) after hospital discharge. Acute pulmonary embolism (PE) is the most frequent type of post-discharge VTE complication. Levels of procoagulants (fibrinogen, factor VIII, von Willebrand factor), and D-dimer are higher during the SARS-CoV-2 infection. Patients with more severe inflammatory and procoagulant response experience higher VTE rates during hospitalization, while the risk after hospital discharge have not been well characterized. The incidence of VTE events following hospitalization is heterogeneous, ranging from low (3.1 per 1000 discharges), to 1.8%, which appears higher than for other medical condition. This discrepancy was partially explained by the differences in VTE screening and follow-up strategies, and by the period when the information about the VTE was collected. These data were based mainly on observational and retrospective studies; however, evolving data are to come after the completion of the prospective trials. The current guidelines do not recommend routine post-hospital VTE prophylaxis for COVID-19 patients but recommend it for all hospitalized adults. A careful risk-benefit assessment of VTE probability should be performed, to determine whether an individual patient may merit post-discharge thromboprophylaxis. A score such IMPROVE DD can help identify the patient who will potentially benefit but is also important to consider the bleeding risk and the feasibility. The optimal duration and the type of extended thromboprophylaxis is still under debate (from a minimum of 14 days to a maximum of 42 days), and future studies will help to validate these protocols in different populations. Direct oral anticoagulants (DOACs), warfarin and low molecular weight heparin (LMWH) are recommended, but low doses of DOACs rather than LMVH or warfarin were predominantly used in most patients. Finally, the COVID-19 patients should be educated to recognize and advised to seek urgent medical care should VTE events occur after hospital discharge.

Current strategies in diagnostics and therapeutics against novel coronavirus disease (COVID-19)

The epidemic of COVID-19 spread quickly through China and engulfed all of the countries across the globe. Several advances have been made in understanding the novel coronavirus's pathophysiology and in the development of newer diagnostics with pinpoint accuracy. Several newer therapeutic methods have either been accepted or are awaiting acceptance. In many countries, vaccination programs have been rolled out. Despite all these efforts, coronavirus still exists, though with lesser propensity. Multiple new forms of the novel coronavirus unexpectedly appeared in various areas of the world, undermining previously existing diagnosis and care protocols. This article highlights our understanding of the novel coronavirus's symptoms in brief, pathogenesis, diagnostics, and therapeutic strategies to contain COVID-19. The clinical findings, including serological, radiological, and other advanced diagnostic strategies, contributed much to control the disease. To date, supportive interventions have been used in tandem with potent antiviral therapies such as remdesivir, lopinavir/ritonavir, or corticosteroids with a level of trust in the care of COVID-19 patients. However, in several areas of the world, vaccination initiatives took place; the vaccines' safety and efficacy to control the outbreak is yet to be identified. This review concludes that improvement in therapies and diagnostics for COVID-19 must continually be explored as new variants constantly emerge.

COVID-19 related thrombosis: A mini-review

Introduction

COVID-19 associated VTE is a new disease entity with high morbidity and mortality. The aim of this paper is to review contemporary emerging literature on the incidence, pathophysiology, predictive prognostic indicators, and management consensus for Covid-19 related thrombotic complications, in particular DVT and PE.

Methods

A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed. References of review articles were further screened according to the exclusion criteria.

Results

In total, 154 records were identified and 20 duplicates were removed. A final 68 articles were included in the qualitative analysis. COVID-19 related thrombosis can affect multiple organs of the body, presenting in the form of arterial or venous thrombosis such as ischemic stroke, myocardial infarction, mesenteric ischemia, limb ischemia, DVT, or PE. DVT and PE has an overall incidence of 6–26%, and severely ill COVID-19 patients have even higher incidence of thromboembolism. On the other hand, incidence of arterial thromboembolism is much lower with incidence of 0.7%–3.7%. D-dimer is found to be an independent risk factor, and IMPROVE score, Caprini score, and Padua score have all been used as predictors. International guidelines suggest the use of low molecular weight heparin (LMWH) or fondaparinux for prophylaxis of VTE, and therapeutic dosage of weight adjusted LMWH for treatment if confirmed diagnosis.

Conclusions

Contemporary rapidly evolving evidence shows that COVID-19 associated thrombosis was a novel clinical entity, especially in severely ill COVID-19 patients. There are multiple society-driven guidelines only, but without any level 1 evidence for management regimen. The ideal dose for prophylaxis is not established and may vary depending on balance of bleeding and thrombosis risk. The risk of bleeding may be increased in patients in intensive care unit.

Differences in inflammatory markers between coronavirus disease 2019 and sepsis in hospitalised patients

Background

Inflammatory markers are pivotal for the diagnosis of coronavirus disease 2019 (COVID-19) and sepsis. This study compared markers between hospitalised patients with COVID-19 and those with bacterial sepsis.

Methods

This retrospective single-centre cohort study included 50 patients with COVID-19 clinical stages II and III and 24 patients with bacterial sepsis. Both groups were treated according to the country's official standards. Leukocytes, C-reactive protein (CRP), ferritin, and D-dimer were registered at the time of patient's admission and 24, 48, and 72 h after initiating intrahospital treatment.

Results

Upon admission, marker levels were high, with a significant decrease at 72 h after antibiotic therapy in the sepsis group. The leukocyte count was higher in deceased patients with sepsis. The mean ferritin levels were 1105 mcg/dl for COVID-19 and 525 mcg/dL for sepsis. Higher ferritin levels in COVID-19 (P = 0.001) seemed to be a predictor of higher mortality. Upon admission, the median D-dimer level was 0.68 mg/L for COVID-19 and 3 mg/L for patients with sepsis, whether recovered or deceased. As D-dimer, procalcitonin levels were higher in patients with sepsis (P = 0.001). CRP levels were equally elevated in both entities but higher in deceased patients with COVID-19.

Conclusion

Ferritin was the main inflammatory marker for COVID-19, and leukocytes, procalcitonin, and D-dimer were the main markers of sepsis. Markers that were most affected in deceased patients were CRP for COVID-19 and leukocyte for sepsis. The therapeutic implications of these differences require further study.

Correlation of D-dimer and Outcomes in COVID-19 Patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) global pandemic has impacted daily life and medical practices around the world. Hospitals are continually making observations about this unique population as it relates to laboratory data and outcomes. Plasma D-dimer levels have been shown to be promising as a prognostic factor for outcomes in COVID-19 patients. This single institution retrospective study investigates the correlation between D-dimer and patient outcomes in our inpatient COVID-19 patient population.

METHODS

COVID-19 confirmed positive patients who were admitted between March 2020 and May 2020 at our hospital were identified. Admission and peak D-dimer values and patient outcomes, including intubation and mortality, were retrospectively analyzed.

RESULTS

Ninety-seven patients met criteria for inclusion in the study Mean age was 63.2 years, median admission D-dimer 2.35ug/mL, and median peak D-dimer 2.74ug/mL. Average time to peak D-dimer was 3.2 days. Patient's requiring intubation had higher admission D-dimers (3.79ug/mL vs. 1.62 ug/mL).

DISCUSSION

Higher admission and peak D-dimer values were associated with worsening clinical outcomes, specifically with higher rates of intubation and mortality. Noting D-dimer trends early in a patients' COVID course, regardless of patients' clinical condition, may allow opportunities for physicians to provide early intervention to prevent these outcomes.

Examining the utility of extended laboratory panel testing in the emergency department for risk stratification of patients with COVID-19: a single-centre retrospective service evaluation

BACKGROUND

The role of specific blood tests to predict poor prognosis in patients admitted with infection from SARS-CoV-2 remains uncertain. During the first wave of the global pandemic, an extended laboratory testing panel was integrated into the local pathway to guide triage and healthcare resource utilisation for emergency admissions. We conducted a retrospective service evaluation to determine the utility of extended tests (D-dimer, ferritin, high-sensitivity troponin I, lactate dehydrogenase and procalcitonin) compared with the core panel (full blood count, urea and electrolytes, liver function tests and C reactive protein).

METHODS

Clinical outcomes for adult patients with laboratory-confirmed COVID-19 admitted between 17 March and 30 June 2020 were extracted, alongside costs estimates for individual tests. Prognostic performance was assessed using multivariable logistic regression analysis with 28-day mortality used as the primary endpoint and a composite of 28-day intensive care escalation or mortality for secondary analysis.

RESULTS

From 13 500 emergency attendances, we identified 391 unique adults admitted with COVID-19. Of these, 113 died (29%) and 151 (39%) reached the composite endpoint. 'Core' test variables adjusted for age, gender and index of deprivation had a prognostic area under the curve of 0.79 (95% CI 0.67 to 0.91) for mortality and 0.70 (95% CI 0.56 to 0.84) for the composite endpoint. Addition of 'extended' test components did not improve on this.

CONCLUSION

Our findings suggest use of the extended laboratory testing panel to risk stratify community-acquired COVID-19 positive patients on admission adds limited prognostic value. We suggest laboratory requesting should be targeted to patients with specific clinical indications.

Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19

OBJECTIVES

COVID-19 predisposes patients to thrombotic disease. The aim of this guidance document is to provide Belgian health-care workers with recommendations on anticoagulation management in COVID-19 positive patients.

METHODS

These recommendations were based on current knowledge and a limited level of evidence.

RESULTS

We formulated recommendations for the prophylaxis and treatment of COVID-related venous thromboembolism in ambulatory and hospitalised patients, as well as recommendations for the use of antithrombotic drugs in patients with prior indication for anticoagulation who develop COVID-19.

CONCLUSIONS

These recommendations represent an easy-to-use practical guidance that can be implemented in every Belgian hospital and be used by primary care physicians and gynaecologists. Of note, they are likely to evolve with increased knowledge of the disease and availability of data from ongoing clinical trials.

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism

Introduction

D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE.

Patients and methods

Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance.

Results

Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165 ng/mL, with a sensitivity of 57.9% and specificity of 98.7%.

Conclusion

It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.

Plasma D-dimer value corrected by inflammatory markers in patients with SARS-CoV-2 infection: Its prognostic value in the diagnosis of venous thromboembolism

INTRODUCTION

D-dimer levels are elevated in COVID 19 and they correlate to the levels of other inflammatory markers such us ferritin, fibrinogen and C-reactive protein. It may be possible to correct D-dimer value in function of inflammatory markers, thus identifying patients at higher risk of venous thromboembolism (VTE). Our objectives are estimating a corrected value of plasma D-dimer as a linear function of ferritin, C-reactive protein and fibrinogen and stablishing a cut-off point of high probability of VTE.

PATIENTS AND METHODS

Age and sex matched case-control study of all patients diagnosed with COVID 19 and VTE between March and May 2020 in a tertiary hospital in Madrid (Spain). Using linear regression, the best predictive model will be estimated and residual D-dimer values will be obtained and analyzed using ROC curves to determine its discriminative performance.

RESULTS

Thirty-eight cases and seventy-six controls were included. There was 63.2% of men and mean age was 68.2. D-dimer was best predicted by a linear model including fibrinogen, ferritin and C-reactive protein. Using residual values, the optimal cutoff point was 2165ng/mL, with a sensitivity of 57.9% and specificity of 98.7%.

CONCLUSION

It is possible to estimate a D-dimer corrected value in function of ferritin, C-reactive protein and fibrinogen. Using the observed and estimated value we can obtain a residual value that performs well as a screening method to detect patients who would benefit for further VTE diagnostic testing.

Elucidating the Correlation of D-Dimer Levels with COVID-19 Severity: A Scoping Review

Aims. The review explores the findings of previous studies to elucidate the association between levels of D-dimer and COVID-19 severity and prognosis. In addition, we assessed the efficiency of anticoagulant therapies in reducing COVID-19 severity and improving the prognosis of the patients. Materials and Methods. A comprehensive literature review was conducted using MEDLINE/PubMed databases, Scopus, and Web of Science with the help of keywords “COVID-19,” “D-Dimer,” “Thrombosis,” “Fibrin network,” “Anticoagulant therapy,” “Inflammation,” and “disease severity.” Based on all these articles and clinical experience, a scoping review was constructed and the full texts of the articles that were retrieved were accessed. Results. A D-dimer is a complex protein molecule that is formed during plasmin-mediated degradation of the fibrin network. Thus, it serves as a marker of thrombotic activity. On the other hand, in addition to severe respiratory distress and reduction in pulmonary gas exchange, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also triggers prothrombotic changes in the infected individuals. The levels of D-dimer have been postulated to be positively associated with the degree of disease severity among COVID-19 patients. Conclusions. It has been postulated that D-dimer could potentially be used as a biomarker to predict the prognosis and outcome of COVID-19 patients at the time of admission to hospitals and facilitate more personalized and efficient clinical management that could significantly reduce the mortality rate of such patients and allow more rapid recovery.

Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week

Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban. (FREEDOM COVID-19 Anticoagulation Strategy [FREEDOM COVID]; NCT04512079)

Insight into prognostics, diagnostics, and management strategies for SARS CoV-2

The foremost challenge in countering infectious diseases is the shortage of effective therapeutics. The emergence of coronavirus disease (COVID-19) outbreak has posed a great menace to the public health system globally, prompting unprecedented endeavors to contain the virus. Many countries have organized research programs for therapeutics and management development. However, the longstanding process has forced authorities to implement widespread infrastructures for detailed prognostic and diagnostics study of severe acute respiratory syndrome (SARS CoV-2). This review discussed nearly all the globally developed diagnostic methodologies reported for SARS CoV-2 detection. We have highlighted in detail the approaches for evaluating COVID-19 biomarkers along with the most employed nucleic acid- and protein-based detection methodologies and the causes of their severe downfall and rejection. As the variable variants of SARS CoV-2 came into the picture, we captured the breadth of newly integrated digital sensing prototypes comprised of plasmonic and field-effect transistor-based sensors along with commercially available food and drug administration (FDA) approved detection kits. However, more efforts are required to exploit the available resources to manufacture cheap and robust diagnostic methodologies. Likewise, the visualization and characterization tools along with the current challenges associated with waste-water surveillance, food security, contact tracing, and their role during this intense period of the pandemic have also been discussed. We expect that the integrated data will be supportive and aid in the evaluation of sensing technologies not only in current but also future pandemics.

Is it possible to make a common reference standard for D-dimer measurements? Communication from the ISTH SSC Subcommittee on Fibrinolysis

BACKGROUND

D-dimer antigen is a heterogeneous mixture of fibrin degradation products that when present at high levels in plasma indicate ongoing coagulation and fibrinolysis. The heterogeneous nature of the target D-dimer antigen and the variety of assay systems means that it is difficult to compare results from different methods.

OBJECTIVES

To identify a universally agreed D-dimer standard that could help harmonize results from different methods.

METHODS

A pool of patient plasma with high D-dimer levels was freeze-dried and investigated as a long-term World Health Organization international standard for D-dimer. Fibrin degradation products from clot lysis reactions were also freeze-dried in various formulations and investigated in commutability studies with patient plasma.

RESULTS

Problems of instability of D-dimer plasma emerged suggesting loss of reactivity after freeze-drying and storage at -20°C of 10%-18% per year. Freeze-dried fibrin degradation products added to plasma were also unstable, but the sugar trehalose was found to improve stability. However, this preparation was not suitable as a standard in widely used assay platforms. Previous studies suggest fibrin degradation products are prone to structural rearrangements and amyloid formation, which may explain the instability of candidate D-dimer standards.

CONCLUSIONS

The known difficulties of D-dimer standardization are compounded by instability of D-dimer antigen after freeze-drying, described in this report. Fibrin degradation products added to plasma and stabilized by trehalose are not suitable as a standard for D-dimer measurement harmonization. Trehalose stabilization of pooled patient plasma containing high D-dimer levels may produce a useful standard, but this requires confirmation.

Overview of Clinical Outcome and Therapeutic Effectiveness of Favipiravir in Patients with COVID-19 Admitted to Intensive Care Unit, Riyadh, Saudi Arabia

Background

Prior to the availability of the current COVID-19 vaccine, the need to control the pandemic worldwide was focused on management of the disease using previously approved antivirals, including Favipiravir which inhibits viral replication through the RNA dependent RNA polymerase enzyme. Favipiravir’s efficacy against different viral infections has made it a potential treatment for COVID-19. We are aiming in this study to assess the therapeutic efficacy and safety of Favipiravir in treating critically ill patients admitted with COVID-19 to Intensive Care Units (ICUs).

Methods

This is a retrospective cohort study was conducted in five tertiary hospitals in Riyadh, Kingdom of Saudi Arabia (KSA). The studied sample was randomized from a huge pool of data collected primarily for critically ill COVID-19 patients admitted to (ICUs) during the period between April 2020 to March 2021. Two groups of patients matched 1: 1 for age and body mass index (BMI) was enrolled in the study; one group received Favipiravir and another comparison group received other antimicrobial medications, not including Favipiravir.

Results

A total data of 538 COVID-19 patients were analyzed, 269 (50.%) received Favipiravir and 269 (50%) the control group received different treatments. More than two-thirds 201 (74.7%) were Saudi citizens, the majority 177 (65.8%) were males and the mean age and (BMI) were; (57.23 ± 15.16) years and (31.61 ± 7.33) kg/m2 respectively. The most frequent symptoms of presentation were shortness of breath (SOB), fever, and cough, and the most frequent comorbidity was diabetes mellitus, hypertension, and ischemic heart disease.

In the supplemental therapy, corticosteroid, tocilizumab and chloroquine were statistically significant (P = 0.001) when combined in the FVP group more than in the comparison group. Severe acute respiratory distress syndrome (ARDS) was more frequent among Favipiravir group, while the overall mortality rate among the Favipiravir group was not statistically significant (p-value 0.4).

Conclusion

According to the study’s results revealing FVP is not superior to other antivirals, patients who received Favipiravir presented with more severe symptoms, more comorbidities, more complications, and is not effective in controlling the cytokine storm which negatively impact the efficacy of Favipiravir.

FVP therapy had no influence on ICU and hospital length of stay in comparison with the control group as well as in the overall mortality rate among the FVP group was not statistically significant. further research is needed to understand how FVP along with other treatments can improve the length of stay among COVID-19 patients admitted to the ICU.

D-Dimer Level Among COVID-19 Patients as Biological Mediator for Hyper Coagulation State

&lt;b&gt;Background and Objective:&lt;/b&gt; Viremia due to SARS-CoV-2 lead variety of biochemical change in the human body, which play a crucial role in the activation of the coagulation cascade causing thrombotic complications and coagulopathies. The study aimed&lt;i&gt; &lt;/i&gt;to ascertain the D-dimer level as a biological mediator in COVID-19 patients in Khartoum state and compare the results to the control group. &lt;b&gt;Materials and Methods:&lt;/b&gt; A cross-sectional study was conducted during the period of August to December, 2021, including 50 healthy patients and 50 COVID-19 patients, blood samples were collected from study groups for measurement of D-dimer level using an I Chroma device. Statistical analysis was conducted using SSPS version 21. &lt;b&gt;Results:&lt;/b&gt; This study revealed a statistically increased D-dimer level among COVID-19 patients compared with the control group (2000-10000 vs. up to 500 ng mL&lt;sup&gt;&lt;/sup&gt;&lt;sup&gt;1&lt;/sup&gt;), respectively. &lt;b&gt;Conclusion:&lt;/b&gt; Viremia induced by COVID-19 infection can cause a high D-dimer level which can lead to thrombosis event or bleeding tendency.

Imaging of COVID-19

The novel coronavirus disease 2019 (COVID-19) emerged as the source of a global pandemic in late 2019 and early 2020 and quickly spread throughout the world becoming one of the worst pandemics in recent history. This chapter reviews the most up to date radiological literature and outlines the utility of thoracic imaging in COVID-19, defining both the common and the less typical imaging appearances during the acute and subacute phases of COVID-19. The short term complications and the long term sequela will also be discussed in the context of radiology, including pulmonary emboli, acute respiratory distress syndrome, superimposed infections, barotrauma, cardiac manifestations, pulmonary parenchymal scarring and fibrosis.

A Simple Scoring Model Predicting the Outcome of COVID-19 Patients: Tanta COVID score

BACKGROUND & AIM

COVID-19 is a worldwide pandemic with high rates of morbidity and mortality, and an uncertain prognosis leading to an increased risk of infection in health providers and limited hospital care capacities. In this study, we have proposed a predictive, interpretable prognosis scoring system with the use of readily obtained clinical, radiological and laboratory characteristics to accurately predict worsening of the condition and overall survival of patients with COVID -19.

METHODS

This is a single-center, observational, prospective, cohort study. A total of 347 patients infected with COVID-19 presenting to the Tanta university hospital, Egypt, were enrolled in the study, and clinical, radiological and laboratory data were analyzed. Top-ranked variables were identified and selected to be integrated into a Cox regression model, building the scoring system for accurate prediction of the prognosis of patients with COVID-19.

RESULTS

The six variables that were finally selected in the scoring system were lymphopenia, serum CRP, ferritin, D-Dimer, radiological CT lung findings and associated chronic debilitating disease. The scoring system discriminated risk groups with either mild disease or severe illness characterized by respiratory distress (and also those with hypoxia and in need for oxygen therapy or mechanical ventilation) or death. The area under the curve to estimate the discrimination performance of the scoring system was more than 90%.

CONCLUSION

We proposed a simple and clinically useful predictive scoring model for COVID-19 patients. However, additional independent validation will be required before the scoring model can be used commonly.

The Optimal Cutoff Value of D-dimer Levels to Predict in Hospital Mortality in Severe Cases of Coronavirus Disease 2019

Introduction: Coronavirus disease 2019 (Covid-19) can cause coagulation parameters abnormalities such as an increase of D-dimer levels especially in severe cases. The purpose of this study is to determine the differences of D-dimer levels in severe cases of Covid-19 who survived and non-survived and determine the optimal cut-off value of D-dimer levels to predict in-hospital mortality. Method: Data were obtained from confirmed Covid-19 patients who were treated from June to September 2020. The Mann-Whitney U test was used to determine differences of D-dimer levels in surviving and non-surviving patients. The optimal cut-off value and area under the curve (AUC) of the D-dimer level in predicting mortality were obtained by the receiver operating characteristic curve (ROC) method. Results: A total of 80 patients were recruited in this study. Levels of D-dimer were significantly higher in non-surviving patients (median 3.346 mg/ml; minimum – maximum: 0.939 – 50.000 mg/ml) compared to surviving patients (median 1.201 mg/ml; minimum – maximum: 0.302 – 29.425 mg/ml), p = 0.012. D-dimer levels higher than 1.500 mg/ml are the optimal cut-off value for predicting mortality in severe cases of Covid-19 with a sensitivity of 80.0%; specificity of 64.3%; and area under the curve of 0.754 (95% CI 0.586 - 0.921; p = 0.010). Conclusions: D-dimer levels can be used as a predictor of mortality in severe cases of Covid-19.

Thromboembolic and bleeding events in intensive care unit patients with COVID-19: results from a Brazilian tertiary hospital

Objectives

To describe the incidence of thromboembolic events in adult patients with severe COVID-19 and identify clinical and laboratory factors associated with these events.

Design

Observational retrospective cohort study of 243 adult patients with severe COVID-19 admitted to an intensive care unit (ICU) at a Brazilian tertiary hospital.

Results

The incidence of all thromboembolic events was 14.8%, in which 3.8% developed deep vein thrombosis, 7.8% pulmonary embolism, 2.5% acute myocardial infarction, 1.2% stroke, and 1.2% peripheral artery occlusion. Risk factors identified were D-dimer at admission >3000 ng/mL (P=<0.0013) and major bleeding (P=0.001). The cumulative risk of developing thromboembolic events at day 28 after ICU admission was 16.0%. The rate of major bleeding was 4.1%. After receiver operating characteristic curve analysis, the D-dimer cut-off at admission correlating with thromboembolic events was 1140.5 ng/mL.

Conclusions

The rate of thromboembolic events in our study was lower than previously described. High D-dimer level at admission was the leading risk factor; the optimal cut-off was 1140.5 ng/mL. The occurrence of thromboembolic events did not have an impact on the median overall survival rate. The optimal anticoagulant strategy in this context still needs to be established.

COVID-19 patient plasma demonstrates resistance to tPA-induced fibrinolysis as measured by thromboelastography

Patients critically ill with COVID-19 are at risk for thrombotic events despite prophylactic anticoagulation. Impaired fibrinolysis has been proposed as an underlying mechanism. Our objective was to determine if fibrinolysis stimulated by tissue plasminogen activator (tPA) differed between COVID patients and controls. Plasma from 14 COVID patients on prophylactic heparin therapy was obtained and compared with heparinized plasma from 14 different healthy donors to act as controls. Kaolin activated thromboelastography with heparinase was utilized to obtain baseline measurements and then repeated with the addition of 4 nM tPA. Baseline fibrinogen levels were higher in COVID plasma as measured by maximum clot amplitude (43.6 ± 6.9 mm vs. 23.2 ± 5.5 mm, p < 0.0001) and Clauss assay (595 ± 135 mg/dL vs. 278 ± 44 mg/dL, p < 0.0001). With the addition of tPA, fibrinolysis at 30 min after MA (LY30%) was lower (37.9 ± 16.5% vs. 58.9 ± 18.3%, p = 0.0035) and time to 50% lysis was longer (48.8 ± 16.3 vs. 30.5 ± 15.4 min, p = 0.0053) in the COVID-19 samples. Clotting times and rate of fibrin polymerization ('R' or 'α' parameters) were largely the same in both groups. Clot from COVID patients contains a higher fibrin content compared to standard controls and shows resistance to fibrinolysis induced by tPA. These findings suggest the clinical efficacy of thrombolytics may be reduced in COVID-19 patients.