Racial differences and an increased systemic inflammatory response are seen in patients with COVID-19 and ischemic stroke

The relationship of COVID-19 severity with laboratory findings and neutrophil-to-lymphocyte ratio in patients admitted to a large teaching hospital in Iran: A cross-sectional study

Background and Aims

COVID-19 patients might be admitted to the hospital based on their clinical manifestations or to the intensive care unit (ICU) due to the severity of their symptoms or critical situation. Our main objective was to investigate clinical and demographic factors influencing COVID-19 patients' admission to the ICU and length of stay (LOS) using extracted data from the hospital information systems in Iran.

Methods

The data of hospitalized patients with confirmed COVID-19 were retrieved from the health information system of Imam Khomeini Hospital Complex, Tehran, Iran between March 2020 and February 2022. The primary outcome was the ICU admission, and the secondary outcome was the LOS. The correlation analysis between laboratory findings and demographic data with ICU admission and LOS was done using SPSS 21.0, and p < 0.05 was considered significant.

Results

Of all the 4156 patients, 2391 (57.5%) were male and the mean age was 58.69 ± 8.19 years. Of these, 9.5% of patients were admitted to ICU at any time point during their hospital stay. Age and laboratory variables such as neutrophil-to-lymphocyte ratio (NLR), ALT (U/L), albumin (g/dL), plasma glucose (mg/dL), ferritin levels (ng/mL), and phosphorous levels (mg/dL) shown the significant relationship with ICU admission. Also, being a smoker and having hypoxemia had a significant relationship with longer stays in the hospital. In this study, we validated a cut-off value of 4.819 for NLR, calculated at hospitalization, as a useful predictor of disease progression and occurrence of serious clinical outcomes, such as ICU admission.

Conclusion

The study examined various clinical factors associated with ICU admission in COVID-19 patients. The findings suggest that certain factors can increase the risk of ICU admission and influence the length of hospital stay which should be focused in future studies.

Acute ischemic stroke outcomes in patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

Although patients with COVID-19 have a higher risk of acute ischemic stroke (AIS), the impact on stroke outcomes remains uncertain.

AIMS

To determine the clinical outcomes of patients with AIS and COVID-19 (AIS-COVID+).

METHODS

We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020211977). Systematic searches were last performed on June 3, 2021 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL Databases.

INCLUSION CRITERIA

(1) studies reporting outcomes on AIS-COVID+; (2) original articles published in 2020 or later; (3) study participants aged ≥18 years.

EXCLUSION CRITERIA

(1) case reports with <5 patients, abstracts, review articles; (2) studies analyzing novel interventions. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Random-effects models estimated the pooled OR and 95% confidence intervals (95% CI) for mortality, modified Rankin Scale (mRS) score, length of stay (LOS), and discharge disposition.

RESULTS

Of the 43 selected studies, 46.5% (20/43) reported patients with AIS without COVID-19 (AIS-COVID-) for comparison. Random-effects model included 7294 AIS-COVID+ and 158 401 AIS-COVID-. Compared with AIS-COVID-, AIS-COVID+ patients had higher in-hospital mortality (OR=3.87 (95% CI 2.75 to 5.45), P<0.001), less mRS scores 0-2 (OR=0.53 (95% CI 0.46 to 0.62), P<0.001), longer LOS (mean difference=4.21 days (95% CI 1.96 to 6.47), P<0.001), and less home discharge (OR=0.31 (95% CI 0.21 to 0.47), P<0.001).

CONCLUSIONS

Patients with AIS-COVID had worse outcomes, with almost fourfold increased mortality, half the odds of mRS scores 0-2, and one-third the odds of home discharge. These findings confirm the significant impact of COVID-19 on early stroke outcomes.

Exercise Intervention for Alzheimer's Disease: Unraveling Neurobiological Mechanisms and Assessing Effects

Alzheimer's disease (AD) is a progressive neurodegenerative disease and a major cause of age-related dementia, characterized by cognitive dysfunction and memory impairment. The underlying causes include the accumulation of beta-amyloid protein (Aβ) in the brain, abnormal phosphorylation, and aggregation of tau protein within nerve cells, as well as neuronal damage and death. Currently, there is no cure for AD with drug therapy. Non-pharmacological interventions such as exercise have been widely used to treat AD, but the specific molecular and biological mechanisms are not well understood. In this narrative review, we integrate the biology of AD and summarize the knowledge of the molecular, neural, and physiological mechanisms underlying exercise-induced improvements in AD progression. We discuss various exercise interventions used in AD and show that exercise directly or indirectly affects the brain by regulating crosstalk mechanisms between peripheral organs and the brain, including "bone-brain crosstalk", "muscle-brain crosstalk", and "gut-brain crosstalk". We also summarize the potential role of artificial intelligence and neuroimaging technologies in exercise interventions for AD. We emphasize that moderate-intensity, regular, long-term exercise may improve the progression of Alzheimer's disease through various molecular and biological pathways, with multimodal exercise providing greater benefits. Through in-depth exploration of the molecular and biological mechanisms and effects of exercise interventions in improving AD progression, this review aims to contribute to the existing knowledge base and provide insights into new therapeutic strategies for managing AD.

COVID-19 and Acute Ischemic Stroke Mortality and Clinical Outcomes among Hospitalized Patients in the United States: Insight from National Inpatient Sample

Coronavirus-19, primarily a respiratory virus, also affects the nervous system. Acute ischemic stroke (AIS) is a well-known complication among COVID-19 infections, but large-scale studies evaluating AIS outcomes related to COVID-19 infection remain limited. We used the National Inpatient Sample database to compare acute ischemic stroke patients with and without COVID-19. A total of 329,240 patients were included in the study: acute ischemic stroke with COVID-19 (n = 6665, 2.0%) and acute ischemic stroke without COVID-19 (n = 322,575, 98.0%). The primary outcome was in-hospital mortality. Secondary outcomes included mechanical ventilation, vasopressor use, mechanical thrombectomy, thrombolysis, seizure, acute venous thromboembolism, acute myocardial infarction, cardiac arrest, septic shock, acute kidney injury requiring hemodialysis, length of stay, mean total hospitalization charge, and disposition. Acute ischemic stroke patients who were COVID-19-positive had significantly increased in-hospital mortality compared to acute ischemic stroke patients without COVID-19 (16.9% vs. 4.1%, aOR: 2.5 [95% CI 1.7-3.6], p < 0.001). This cohort also had significantly increased mechanical ventilation use, acute venous thromboembolism, acute myocardial infarction, cardiac arrest, septic shock, acute kidney injury, length of stay, and mean total hospitalization charge. Further research regarding vaccination and therapies will be vital in reducing worse outcomes in patients with acute ischemic stroke and COVID-19.

Demographic and Social Patterns of the Mean Values of Inflammatory Markers in U.S. Adults: A 2009-2016 NHANES Analysis

Several studies have reported on the negative implications of elevated neutrophil-to-lymphocyte ratio (NLR) and elevated platelet-to-lymphocyte ratio (PLR) levels associated with outcomes in many surgical and medical conditions, including cancer. In order to use the inflammatory markers NLR and PLR as prognostic factors in disease, a normal value in disease-free individuals must be identified first. This study aims (1) to establish mean values of various inflammatory markers using a healthy and nationally representative U.S. adult population and (2) to explore heterogeneity in the mean values by sociodemographic and behavioral risk factors to better specify cutoff points accordingly. The National Health and Nutrition Examination Survey (NHANES) of aggregated cross-sectional data collected from 2009 to 2016 was analyzed; data extracted included markers of systemic inflammation and demographic variables. We excluded participants who were under 20 years old or had a history of an inflammatory disease such as arthritis or gout. Adjusted linear regression models were used to examine the associations between demographic/behavioral characteristics and neutrophil counts, platelet counts, lymphocyte counts, as well as NLR and PLR values. The national weighted average NLR value is 2.16 and the national weighted average PLR value is 121.31. The national weighted average PLR value for non-Hispanic Whites is 123.12 (121.13-125.11), for non-Hispanic Blacks it is 119.77 (117.49-122.06), for Hispanic people it is 116.33 (114.69-117.97), and for participants of other races it is 119.84 (116.88-122.81). Non-Hispanic Blacks and Blacks have significantly lower mean NLR values (1.78, 95% CI 1.74-1.83 and 2.10, 95% CI 2.04-2.16, respectively) as compared with that of non-Hispanic Whites (2.27, 95% CI 2.22-2.30, p < 0.0001). Subjects who reported a non-smoking history had significantly lower NLR values than subjects who reported any smoking history and higher PLR values than current smokers. This study provides preliminary data for demographic and behavioral effects on markers of inflammation, i.e., NLR and PLR, that have been associated with several chronic disease outcomes, suggesting that different cutoff points should be set according to social factors.

The landscape of disparities in obstetric neurocritical care and a path forward

Health disparities in the obstetric population affect maternal morbidity and mortality. In the past years, there has been no significant improvement in disparities in care in the obstetric population. Patients who are pregnant are known to have a higher risk of pregnancy-associated neurologic conditions such as stroke and intracerebral hemorrhage. They can also experience concomitant neurocritical care disease states such as status epilepticus and traumatic brain injury. Studies exploring the disparities of care among pregnant patients who are neurotically ill are lacking. We aim to provide the landscape of disparities of care among the obstetric neurocritically-ill population and provide potential actionable opportunities to address these disparities in care.

Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19

Background

The neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19.

Objective

We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke.

Methods

We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated.

Results

Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p  =  .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p  =  .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p  =  .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p  =  .043, TICI p  =  .070).

Conclusions

We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Neutrophil-lymphocyte ratio in acute ischemic stroke: Immunopathology, management, and prognosis

There is an ongoing need for accurate prognostic biomarkers in the milieu of acute ischemic stroke (AIS) receiving reperfusion therapy. Neutrophil-lymphocyte ratio (NLR) has been implicated in emergency medicine and acute stroke setting as an important biomarker in the prognosis of patients. However, there are ongoing questions around its accuracy and translation into clinical practice given suboptimal sensitivity and specificity results, as well as varying thresholds and lack of clarity around which NLR time points are most clinically indicative. This article provides a comprehensive overview of the role of NLR in AIS patients receiving reperfusion therapy and perspectives on areas of future research. NLR may be an important biomarker in risk stratifying patients in AIS to identify and select those who are more likely to benefit from reperfusion therapy. Appropriate clinical decision-making tools and models are required to harness the predictive value of NLR, which could be useful in identifying and monitoring high-risk patients to guide early treatment and achieve improved outcomes. Our understanding of the role of NLR in the immunopathogenesis of AIS is also suboptimal, which hinders the ability to translate this into clinical practice.

Prognostic utility of pretreatment neutrophil-lymphocyte ratio in survival outcomes in localized non-small cell lung cancer patients treated with stereotactic body radiotherapy: Selection of an ideal clinical cutoff point

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Neutrophil-lymphocyte ratio is a promising prognostic marker for several cancers.

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NLR is not useful as a marker of lung cancer survival in localized lung cancer.

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NLR has potential as a marker of competing mortality risk in localized lung cancer.

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NLR cutoff of 4.0 is proposed as a clinically useful cutoff point.

Background and purpose

Neutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs’ (VA) national database.

Materials and methods

In the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O’Quigley’s and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models.

Results

In 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39).

Conclusion

NLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.

Bioinformatic analyses hinted at augmented T helper 17 cell differentiation and cytokine response as the central mechanism of COVID-19-associated Guillain-Barré syndrome

Objectives

Guillain‐Barré syndrome (GBS) results from autoimmune attack on the peripheral nerves, causing sensory, motor and autonomic abnormalities. Emerging evidence suggests that there might be an association between COVID‐19 and GBS. Nevertheless, the underlying pathophysiological mechanism remains unclear.

Materials and Methods

We performed bioinformatic analyses to delineate the potential genetic crosstalk between COVID‐19 and GBS.

Results

COVID‐19 and GBS were associated with a similar subset of immune/inflammation regulatory genes, including TNF, CSF2, IL2RA, IL1B, IL4, IL6 and IL10. Protein‐protein interaction network analysis revealed that the combined gene set showed an increased connectivity as compared to COVID‐19 or GBS alone, particularly the potentiated interactions with CD86, IL23A, IL27, ISG20, PTGS2, HLA‐DRB1, HLA‐DQB1 and ITGAM, and these genes are related to Th17 cell differentiation. Transcriptome analysis of peripheral blood mononuclear cells from patients with COVID‐19 and GBS further demonstrated the activation of interleukin‐17 signalling in both conditions.

Conclusions

Augmented Th17 cell differentiation and cytokine response was identified in both COVID‐19 and GBS. PBMC transcriptome analysis also suggested the pivotal involvement of Th17 signalling pathway. In conclusion, our data suggested aberrant Th17 cell differentiation as a possible mechanism by which COVID‐19 can increase the risk of GBS.

Identification of Biomarkers in Patients with Thrombotic Thrombocytopenic Purpura Presenting with Large and Small Ischemic Stroke

Background

Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder resulting in organ damage including ischemic strokes. We sought to characterize the neuroimaging patterns of stroke in a large cohort of patients with immune-mediated TTP (iTTP) and determined their associations with clinical and laboratory parameters and outcomes.

Methods

We analyzed the Alabama TTP Registry who had laboratory confirmation of acute iTTP. We reviewed the neuroimaging patterns of those with ischemic stroke on MRI, clinical information, and laboratory results. Small ischemic strokes were ≤20 mm in their maximum diameter in the axial plane. Large ischemic strokes were >20 mm. Student t test, Mann-Whitney U test, and χ² test were all used for data analysis.

Results

Of 108 iTTP patients, 21 had ischemic stroke on neuroimaging. The median platelet count in these patients was 12 × 10⁹/L (interquartile range, IQR, 8.8–21 × 10⁹/L), plasma ADAMTS13 activity 1.8 U/dL (IQR 0–4.5 U/dL), and the mean plasma level of anti-ADAMTS13 IgG was 6,595.8 U/mL (SD 3,448.9 U/mL). Comparison between patients with large ischemic strokes (n = 10) and small ischemic strokes (n = 11) revealed that patients with small stroke were older (p = 0.043) and had higher plasma levels of citrullinated histone 3 (p = 0.006) and histone/DNA complex (p = 0.014) than those with large strokes. There were no significant differences between 2 stroke groups in mortality or exacerbation.

Conclusions

iTTP patients can present with large ischemic strokes and are usually younger. Further research should be performed in assessing different etiologies of iTTP-associated stroke based on neutrophil extracellular trap formation biomarkers (e.g., histone markers) seen in small ischemic stroke.

Review of the COVID-19 Risk in Multiple Sclerosis

The ongoing pandemic of the novel coronavirus of 2019 (COVID-19) has resulted in over 1 million deaths, primarily affecting older patients with chronic ailments. Multiple sclerosis (MS) patients have been deemed particularly vulnerable given their high rates of disability and increased susceptibility to infections. There have also been concerns regarding disease-modifying therapy (DMT) during the pandemic as many DMTs may increase the risk of infection due to some of their immunosuppressive properties. Furthermore, due to MS-related chronic inflammatory damage within the central nervous system, there have been concerns for worsening neurological injury by COVID-19. This has resulted in an alarmingly high level of anxiety and stress among the MS community leading to a lack of compliance with medications and routine check-ups, and even failure to obtain treatment for relapse. However, there is currently substantial evidence that MS and most DMT usage is not associated with increased COVID-19 severity. MS patients who suffer worse outcomes were more likely to be older and suffer from significant disabilities and comorbid conditions, which would also be expected from those in the general population. Likewise, there is little if any evidence demonstrating an increased susceptibility of MS patients to COVID-19-related neurological complications. Therefore, we aim to summarize the most recent findings related to COVID-19 and MS demonstrating that MS and most DMTs do not appear as risk factors for severe COVID-19.