Assessment of serum ferritin as a biomarker in COVID-19: bystander or participant? Insights by comparison with other infectious and non-infectious diseases

Post Covid telogen effluvium: the diagnostic value of serum ferritin biomarker and the preventive value of dietary supplements. a case control study

Telogen effluvium is characterized by excessive hair shedding usually following a stressful event. Ferritin has been used in clinical practice as a biomarker of nonanemic iron deficiency in cases of telogen effluvium. During the years of the COVID19 pandemic, telogen effluvium was reported as a part of post covid manifestations. As ferritin was also a biomarker for inflammation in cases with covid infection, this study was designed to evaluate the value of ferritin in cases with postcovid telogen effluvium one hundred patients recovering from covid 19 for 4-12 weeks were included in the study, detailed drug and laboratory history was obtained and serum ferritin level was measured. the mean serum level of ferritin among telogen effluvium patients was significantly lower than controls (68.52 ± 126 and 137 ± 137.597 ug/L respectively). Patients with telogen effluvium used significantly more azithromycin and ivermectin and significantly less vitamin C, D, lactoferrin and zinc than the controls Although serum ferritin is lower among telogen effluvium patients, it was still higher than the cutoff value for diagnosing nonanemic iron deficiency, we suggest that it will not be a good biomarkers in these cases. Our secondary outcomes showed that dietary supplements used during active infection such as vitamin C, D, lactoferrin and zinc might have a preventive value on postcovid hair loss, while azithromycin and ivermectin could have a negative long term effect on telogen effluvium.

Risk factors for the in‑hospital and 1‑year mortality of elderly patients hospitalized due to COVID‑19‑related pneumonia

Coronavirus disease 2019 (COVID-19) is characterized by poor outcomes and a high mortality rate, particularly among elderly patients. Since the beginning of the pandemic, an older age has been recognized as a critical risk factor for disease severity, with increasing mortality rates in each decade of life. This phenomenon may be a consequence of a poor previous health status, with a higher prevalence of pre-existing comorbidities and a higher degree of frailty. The majority of studies on the outcomes and risk factors of elderly patients refer to the first waves of the pandemic and the predictors of in-hospital mortality in these patients. The aim of the present study was to provide a detailed description of the clinical characteristics and management of a cohort of elderly patients (≥65 years of age) who were hospitalized with COVID-19-related pneumonia in all phases of the pandemic, presenting their outcomes, and investigating predictors of in-hospital and out-of-hospital mortality over a period of 1 year in this particularly vulnerable population. A total of 1,124 elderly patients (603 males, 53.7%) with a mean age of 78.51±7.42 years and a median Charlson comorbidity index (CCI) of 5 were included in the study. Of these patients, 104 (9.3%) were hospitalized during the period of prevalence of the original strain Wuhan, 385 (34.3%) were hospitalized during the period of prevalence of the Alpha variant, 221 (19.7%) were hospitalized during the period of prevalence of the Delta variant, and 414 (36.8%) were hospitalized during the period of prevalence of the Omicron variant. Overall, the in-hospital mortality rate was 33.4% (375 patients), and the 1-year mortality rate was 44.7% (502 patients). The majority of patients had not been vaccinated or had not completed full vaccination against severe acute respiratory syndrome coronavirus-2 (843 patients, 75%), given the period of infection. Age, immature granulocytes, lactate dehydrogenase (LDH) levels, ferritin levels, chest X-ray score, as well as the absence of full vaccination, cough and fatigue, were statistically significantly and independently associated with in-hospital mortality, while age, LDH levels, ferritin levels, alanine aminotransferase levels, CCI, chest X-ray score, the absence of cough and fatigue, and a history of dementia were statistically significantly and independently associated with 1-year mortality. On the whole, the present study demonstrates that both the in-hospital mortality and 1-year mortality rates of elderly patients hospitalized due to COVID-19-related pneumonia are high.

Adsorption of Ferritin at Nanofaceted Al2O3 Surfaces

The influence of nanoscale surface topography on protein adsorption is highly important for numerous applications in medicine and technology. Herein, ferritin adsorption at flat and nanofaceted, single-crystalline Al2O3 surfaces is investigated using atomic force microscopy and X-ray photoelectron spectroscopy. The nanofaceted surfaces are generated by the thermal annealing of Al2O3 wafers at temperatures above 1000 °C, which leads to the formation of faceted saw-tooth-like surface topographies with periodicities of about 160 nm and amplitudes of about 15 nm. Ferritin adsorption at these nanofaceted surfaces is notably suppressed compared to the flat surface at a concentration of 10 mg/mL, which is attributed to lower adsorption affinities of the newly formed facets. Consequently, adsorption is restricted mostly to the pattern grooves, where the proteins can maximize their contact area with the surface. However, this effect depends on the protein concentration, with an inverse trend being observed at 30 mg/mL. Furthermore, different ferritin adsorption behavior is observed at topographically similar nanofacet patterns fabricated at different annealing temperatures and attributed to different step and kink densities. These results demonstrate that while protein adsorption at solid surfaces can be notably affected by nanofacet patterns, fine-tuning protein adsorption in this way requires the precise control of facet properties.

Attenuation of ferroptosis as a potential therapeutic target for neuropsychiatric manifestations of post-COVID syndrome

Coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), is associated with the persistence of pre-existing or the emergence of new neurological and psychiatric manifestations as a part of a multi-system affection known collectively as "post-COVID syndrome." Cognitive decline is the most prominent feature among these manifestations. The underlying neurobiological mechanisms remain under intense investigation. Ferroptosis is a form of cell death that results from the excessive accumulation of intracellular reactive iron, which mediates lipid peroxidation. The accumulation of lipid-based reactive oxygen species (ROS) and the impairment of glutathione peroxidase 4 (GPX4) activity trigger ferroptosis. The COVID-19-associated cytokine storm enhances the levels of circulating pro-inflammatory cytokines and causes immune-cell hyper-activation that is tightly linked to iron dysregulation. Severe COVID-19 presents with iron overload as one of the main features of its pathogenesis. Iron overload promotes a state of inflammation and immune dysfunction. This is well demonstrated by the strong association between COVID-19 severity and high levels of ferritin, which is a well-known inflammatory and iron overload biomarker. The dysregulation of iron, the high levels of lipid peroxidation biomarkers, and the inactivation of GPX4 in COVID-19 patients make a strong case for ferroptosis as a potential mechanism behind post-COVID neuropsychiatric deficits. Therefore, here we review the characteristics of iron and the attenuation of ferroptosis as a potential therapeutic target for neuropsychiatric post-COVID syndrome.

A novel view of ferritin in cancer

Since its discovery more than 85 years ago, ferritin has principally been known as an iron storage protein. However, new roles, beyond iron storage, are being uncovered. Novel processes involving ferritin such as ferritinophagy and ferroptosis and as a cellular iron delivery protein not only expand our thinking on the range of contributions of this protein but present an opportunity to target these pathways in cancers. The key question we focus on within this review is whether ferritin modulation represents a useful approach for treating cancers. We discussed novel functions and processes of this protein in cancers. We are not limiting this review to cell intrinsic modulation of ferritin in cancers, but also focus on its utility in the trojan horse approach in cancer therapeutics. The novel functions of ferritin as discussed herein realize the multiple roles of ferritin in cell biology that can be probed for therapeutic opportunities and further research.

Ovarian Cancer Biomarkers in the COVID-19 Era

Ovarian Cancer (OC) diagnosis is entrusted to CA125 and HE4. Since the latter has been found increased in COVID-19 patients, in this study, we aimed to evaluate the influence of SARS-CoV-2 infection on OC biomarkers. HE4 values above the cut-off were observed in 65% of OC patients and in 48% of SARS-CoV-2-positive patients (not oncologic patients), whereas CA125 values above the cut-off were observed in 71% of OC patients and in 11% of SARS-CoV-2 patients. Hence, by dividing the HE4 levels into quartiles, we can state that altered levels of HE4 in COVID-19 patients were mostly detectable in quartile I (151-300 pmol/L), while altered levels in OC patients were mostly clustered in quartile III (>600, pmol/L). In light of these observations, in order to better discriminate women with ovarian cancer versus those with COVID-19, we established a possible HE4 cut-off of 328 pmol/L by means of a ROC curve. These results demonstrate that the reliability of HE4 as a biomarker in ovarian cancer remains unchanged, despite COVID-19 interference; moreover, it is important for a proper diagnosis that whether the patient has a recent history of SARS-CoV-2 infection is determined.

Comparing serum ferritin levels during COVID-19 infection and recovery period in pediatric patients with transfusion-dependent thalassemia, a single-center study

Background

Ferritin has been recognized as a predictor of severity among Coronavirus-19 disease (COVID-19) patients. Studies have shown higher levels of ferritin in patients with COVID-19 than in healthy children. Patients with transfusion-dependent thalassemia (TDT) basically have high ferritin level due to iron overload. It is uncertain whether serum ferritin level in these patients is associated with COVID-19 infection.

Objective

To evaluate ferritin levels in TDT with COVID-19 before, during, and after the course of infection.

Methods

This retrospective study enrolled all TDT children with COVID-19 infection that were hospitalized in Ulin General Hospital Banjarmasin during the COVID-19 pandemic (March 2020 to June 2022). Data were collected from medical records.

Results

There were 14 patients included in this study, 5 patients had mild symptoms and 9 patients were asymptomatic. The mean of hemoglobin level upon admission was 8.1 ± 3 g/dL and serum ferritin level were 5148.5 ± 2651.8 ng/mL. The average serum ferritin level during COVID-19 infection was 2373.2 ng/mL higher than before infection and then decreased by 952.4 ng/mL after infection. We found no association of increasing serum ferritin with patients' symptoms (p = 0.27). The severity of anemia also was not correlated with the presentation of COVID-19 infection (p = 0.902).

Conclusion

Serum ferritin levels in TDT children may not reflect disease severity or predict poor outcomes during COVID-19 infection. However, the presence of other co-morbid conditions/confounders warrants cautious interpretation.

EXPLORING THE INFLUENCE OF NEUTROPHIL-LYMPHOCYTE RATIO ON OUTCOME PREDICTION OF SEVERELY-ILL PATIENTS WITH COVID-19

OBJECTIVE

The aim: The study conducted to have a better understanding on the role of neutrophil-lymphocyte ratio in the determination of the prognosis of COVID-19 and to assist in predicting disease severity.

PATIENTS AND METHODS

Materials and methods: A total of 96 patients within age group 18-80 years who were verified positive for the COVID-19 by PCR, and admitted to (Al-Sader Medical City) in Al-Najaf City between (July to October 2020) were enrolled in a cohort retrospective study, Neutrophil to lymphocyte ratio was calculated via taking the absolute neutrophil count divided by the absolute lymphocyte count. Other parameters like (renal function tests, D-dimer, C-reactive protein, serum ferritin) also has been studied in relation to outcome of patients with COVID-19.

RESULTS

Results: The Neutrophil-lymphocyte ratio was significantly associated with low oxygen saturation and poor outcome. A significant difference was found between two clusters in CRP, serum ferritin, and D-dimer level. In addition, age and obstructive airway disease were important clinical predictors for poor outcome.

CONCLUSION

Conclusions: The study was a useful prognostic marker linked with poor outcome in patients admitted for COVID-19 pneumonia. Other inflammatory markers, such as ferritin, CRP, and D-dimer were also associated with critical illness and increased mortality from COVID-19 disease.

Predictors of pulmonary involvement in children with COVID-19: How strongly associated is viral load?

The purpose of this study was to identify risk factors for pulmonary involvement by examining the demographic, clinical, and laboratory characteristics of children with COVID-19. We performed a retrospective single-center study of COVID-19 in children treated at a tertiary care hospital in Turkey from December 2020 to June 2021. During the course of the study, 126 patients were evaluated, of whom 70/126 were male. The patients' ages ranged from 1 to 216 (mean, 4.73 ± 81.11) months. Fever (65.9%), cough (52.4%), and shortness of breath (18.3%) were the most common symptoms of COVID-19. Ten patients required noninvasive mechanical ventilation. Sixty-nine patients (54.8%) had pneumonia. Longer duration of fever, hospitalization, and the presence of cough were significantly associated with pulmonary involvement. Children with pneumonia had significantly higher levels of C-reactive protein (CRP), procalcitonin, erythrocyte sedimentation rate (ESR), and viral load, and significantly lower counts of lymphocytes and thrombocytes. The cutoff viral load, CRP, and procalcitonin values for predicting pulmonary involvement were 26.5 cycle threshold (Ct; 95% confidence interval [CI], 0.54-0.74; sensitivity, 0.65; specificity, 0.56; area under curve [AUC]: 0.647, p = 0.005), 7.85 mg/L (95% CI, 0.56-0.75; sensitivity, 0.66; specificity, 0.64; AUC = 0.656; p = 0.003) and 0.105 ng/ml (95% CI, 0.52-0.72; sensitivity, 0.55; specificity, 0.58; AUC = 0.626; p = 0.02), respectively. High CRP, procalcitonin levels, ESR, and viral load, and low lymphocyte and thrombocyte counts can predict pulmonary involvement in children with COVID-19, so better management may be provided for good prognosis.

An inexpensive and rapid diagnostic method for detection of SARS-CoV-2 RNA by loop-mediated isothermal amplification (LAMP)

SARS-CoV-2 is a public pandemic health concern globally. Nasopharyngeal and oropharyngeal swab samples are used for Covid-19 viral detection. Sample collection procedure was tedious and uncomfortable and unsuitable for biochemical and CBC analysis in swab samples. Biochemistry and CBC tests are key determinant in management of Covid-19 patients. We developed a LAMP test to detect viral RNA in blood samples. LAMP is required four specific primers targeting the internal transcribed S-region and loop primers for viral RNA amplification. RNA was extracted from blood samples by TRIzol method. LAMP reaction was performed at 60 °C for 1 hour and amplicons were visualized in HNB dye. No cross-reactivity was seen with HBV, HCV, and HIV infected sample. Out of 40 blood samples, 33 samples were positive for LAMP and Q-PCR analysis, one sample was positive for LAMP and negative for Q-PCR, two samples were negative for LAMP but positive for Q-PCR, and four blood samples were negative for LAMP and Q-PCR. LAMP method has an accuracy of 92.50%, with sensitivity and specificity of 94.28% and 80%, respectively. Thus, LAMP diagnostic test has proved reliable, fast, inexpensive and can be useful for detection where the limited resources available.•LAMP method is a potential tool for detection of SARS-CoV-2.•Blood samples are the key determinant for routine diagnostics as well as molecular diagnostics.•LAMP assay is an appropriate diagnostics method which offers greater simplicity, low cost, sensitivity, and specificity than other methods in molecular diagnostics.

Preoperative ferritin and hemoglobin levels are lower in patients with a history of COVID-19 but blood loss and transfusion requirements are not increased

INTRODUCTION

A history of COVID-19 (Coronavirus Disease 2019), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have an impact on hemoglobin and ferritin levels predisposing patients to increased blood transfusion requirements following total joint arthroplasty (TJA). The current study compares ferritin levels, hemoglobin levels, and transfusion rates between SARS-CoV-2 IgG positive and SARS-CoV-2 IgG negative TJA patients.

MATERIALS AND METHODS

Preoperative ferritin levels, pre- and postoperative hemoglobin levels, postoperative change in hemoglobin, and transfusion rates of 385 consecutive SARS-CoV-2 IgG positive patients undergoing TJA were compared to those of 5156 consecutive SARS-CoV-2 IgG negative patients undergoing TJA.

RESULTS

Preoperative hemoglobin levels were significantly lower in SARS-CoV-2 IgG positive patients [13.3 g/dL (range 8.9-17.7 g/dL)] compared to 13.5 g/dl (7.3-18.3 g/dL; p value 0.03). Ferritin levels were significantly lower in SARS-CoV-2 IgG positive patients (mean of 106.1 ng/ml (2.1-871.3.3 ng/ml) vs. 123.7 ng/ml (1.4-1985 ng/ml) (p value 0.02)). Hemoglobin on postoperative day (POD) one, after four-six weeks, and transfusion rates did not differ between the two groups.

CONCLUSION

Although preoperative hemoglobin and ferritin levels are lower in SARS-CoV2 IgG positive patients, there was no difference in hemoglobin on POD one, recovery of hemoglobin levels at four-six weeks postoperatively, and transfusion rates after surgery. Routine ferritin testing prior to TJA is not recommended in SARS-CoV-2 IgG positive patients.

Patients with severe coronavirus disease 2019 have high frequency of factor 5 Leiden and prothrombin gene mutations

We investigated the frequency of factor 5 Leiden (FVL) and prothrombin gene (PTG) mutations in patients with severe coronavirus disease 2019 (COVID-19). Our primary aim is to reveal whether these mutations are associated with severity of disease and mortality. A total of 249 patients were included in this cross-sectional study. Severe COVID-19 cases (with oxygen saturation of less than 90 mmHg and who received ventilation support invasively or noninvasively) were included. FVL and PTG mutations were identified by real time- PCR technique. Frequency of mutations for FVL was 11.7%, whereas for PTG was 3.5%. The frequency of FVL and PTG's mutations in our patient group was found to be significantly higher than the normal population ( P  < 0.0001, 0.004, respectively). There was no difference in the frequency of mutations of FVL and PTG between the patients ventilated - invasively and noninvasively. There was also no difference in D-dimer, ferritin, fibrinogen, ex status, and entubational status between the groups of FVL and PTG mutated and wild-type. To the best of our knowledge, it is the first time that we have examined the frequencies of FVL and PGM's mutations in severe COVID-19 disease on such a large scale. The frequencies of both mutations in severe COVID-19 patients were higher than in the healthy population. We believe that studies prospectively designed, including asymptomatic and mild COVID-19 patients, will provide more comprehensive information on the subject.

Biosensors based detection of novel biomarkers associated with COVID-19: Current progress and future promise

The pandemic situation of COVID-19 has caused global alarm in health care, devastating loss of lives, strangled economy, and paralysis of normal livelihood. The high inter-individual transmission rate created havoc in the global community. Although tremendous efforts are pitching in from across the globe to understand this disease, the clinical features seemed to have a wide range including fever, cough, and fatigue are the prominent features. Congestion, rhinorrhea, sore throat, and diarrhea are other less common features observed. The challenge of this disease lies in the difficulty in maneuvering the clinical course causing severe complications. One of the major causative factors for multi-organ failure in patients with severe COVID-19 complications is systemic vasculitis and cytokine-mediated coagulation disorders. Hence, effective markers trailing the disease severity and disease prognosis are urgently required for prompt medical treatment. In this review article, we have emphasized currently identified inflammatory, hematological, immunological, and biochemical biomarkers of COVID-19. We also discussed currently available biosensors for the detection of COVID-19-associated biomarkers & risk factors and the detection methods as well as their performances. These could be effective tools for rapid and more promising diagnoses in the current pandemic situation. Effective biomarkers and their rapid, scalable, & sensitive detection might be beneficial for the prevention of serious complications and the clinical management of the disease.

Establishment of the large-scale longitudinal multi-omics dataset in COVID-19 patients: data profile and biospecimen

Understanding and monitoring virus-mediated infections has gained importance since the global outbreak of the coronavirus disease 2019 (COVID-19) pandemic. Studies of high-throughput omics-based immune profiling of COVID-19 patients can help manage the current pandemic and future virus-mediated pandemics. Although COVID-19 is being studied since past 2 years, detailed mechanisms of the initial induction of dynamic immune responses or the molecular mechanisms that characterize disease progression remains unclear. This study involved comprehensively collected biospecimens and longitudinal multi-omics data of 300 COVID-19 patients and 120 healthy controls, including whole genome sequencing (WGS), single-cell RNA sequencing combined with T cell receptor (TCR) and B cell receptor (BCR) sequencing (scRNA(+scTCR/BCR)-seq), bulk BCR and TCR sequencing (bulk TCR/BCR-seq), and cytokine profiling. Clinical data were also collected from hospitalized COVID-19 patients, and HLA typing, laboratory characteristics, and COVID-19 viral genome sequencing were performed during the initial diagnosis. The entire set of biospecimens and multi-omics data generated in this project can be accessed by researchers from the National Biobank of Korea with prior approval. This distribution of largescale multi-omics data of COVID-19 patients can facilitate the understanding of biological crosstalk involved in COVID-19 infection and contribute to the development of potential methodologies for its diagnosis and treatment. [BMB Reports 2022; 55(9): 465-471].

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.

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.

Role of Serum Ferritin in Predicting Outcomes of COVID-19 Infection Among Sickle Cell Disease Patients: A Systematic Review and Meta-Analysis

Patients with sickle cell disease (SCD) are at higher risk of getting severe COVID-19 infection. This systematic review and meta-analysis aimed to determine the role of serum ferritin in predicting ICU admission and mortality among patients with SCD following COVID-19 infection. A systematic search was conducted in PubMed, Scopus, Web of Science, Embase, WHO COVID-19 database, ProQuest, and Cochrane Library for articles published between 1st December 2019 to 31st November 2021. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Eleven articles (7 cohorts and 4 case series) were included in this review. Pooled mean serum ferritin level on admission was 1581.62 ng/mL while pooled proportion of ICU admission and mortality were 0.10 (95% CI 0.06; 0.16, prediction interval 0.04; 0.23, p = 0.29, I² = 17%) and 0.07 (95% CI 0.05; 0.11, prediction interval 0.04; 0.12, p = 0.68, I² = 0%) respectively. Meta-regression showed that serum ferritin did not predict for both ICU admission (regression coefficient = 0.0001, p = 0.3523) and mortality (regression coefficient = 0.0001, p = 0.4029). Our analyses showed that serum ferritin may not be a useful marker to predict the outcomes of COVID-19 infection among patients with SCD. More data are required to identify a reliable tool to identify patients with SCD who are at risk of getting severe COVID-19 infection.

Clinical Characteristics and Predictors of Mortality in Elderly Patients Hospitalized with COVID-19 in Bangladesh: A Multicenter, Retrospective Study

Purpose

Elderly patients are at high risk of fatality from COVID-19. The present work aims to describe the clinical characteristics of elderly inpatients with COVID-19 and identify the predictors of in-hospital mortality at admission.

Materials and Methods

In this retrospective, multicenter cohort study, we included elderly COVID-19 inpatients (n = 245) from four hospitals in Sylhet, Bangladesh, who had been discharged between October 2020 and February 2021. Demographic, clinical, and laboratory data were extracted from hospital records and compared between survivors and nonsurvivors. We used univariable and multivariable logistic regression analysis to explore the risk factors associated with in-hospital death. Principal Results. Of the included patients, 202 (82.44%) were discharged and 43 (17.55%) died in hospital. Except hypertension, other comorbidities like diabetes, chronic kidney disease, ischemic heart disease, and chronic obstructive pulmonary disease were more prevalent in nonsurvivors. Nonsurvivors had a higher prevalence of leukocytosis (51.2 versus 30.7; p=0.01), lymphopenia (72.1 versus 55; p=0.05), and thrombocytopenia (20.9 versus 9.9; p=0.07). Multivariable regression analysis showed an increasing odds ratio of in-hospital death associated with older age (odds ratio 1.05, 95% CI 1.01–1.10, per year increase; p=0.009), thrombocytopenia (OR = 3.56; 95% CI 1.22–10.33, p=0.019), and admission SpO₂ (OR 0.91, 95% CI 0.88–0.95; p=0.001).

Conclusions

Higher age, thrombocytopenia, and lower initial level of SpO₂ at admission are predictors of in-hospital mortality in elderly patients with COVID-19.

Evaluation of Serum Ferritin, Procalcitonin, and C-Reactive Protein for the Prediction of Severity and Mortality in Hemorrhagic Fever With Renal Syndrome

This study aimed to analyze the clinical significance of serum ferritin, procalcitonin (PCT), and C-reactive protein (CRP) in patients with hemorrhagic fever with renal syndrome (HFRS). The demographical, clinical, and laboratory data of 373 patients with HFRS in northeastern China were retrospectively analyzed. The levels of serum ferritin and PCT in severe patients (n = 108) were significantly higher than those in mild patients (n = 265, p < 0.001) and associated with HFRS severity. The area under the receiver operating characteristic curve (AUC) values of serum ferritin and PCT for predicting the severity of HFRS were 0.732 (95% CI 0.678-0.786, p < 0.001) and 0.824 (95% CI 0.773-0.875, p < 0.001), respectively, showing sensitivity and specificity of 0.75 and 0.88 for serum ferritin, and 0.76 and 0.60 for PCT. The CRP level in HFRS with bacterial co-infection (n = 115) was higher than that without bacterial co-infection (n = 258, p < 0.001). The AUC value of CRP for predicting bacterial co-infection was 0.588 (95% CI 0.525-0.652, p < 0.001), showing sensitivity and specificity of 0.43 and 0.76, respectively. The serum ferritin level in non-survivors (n = 14) was significantly higher than in survivors (n = 359, p < 0.001). The AUC value of serum ferritin for predicting mortality was 0.853 (95% CI 0.774-0.933, p < 0.001), showing sensitivity and specificity of 0.933 and 0.739. Serum ferritin and PCT have a robust association with HFRS severity and mortality, which may be promising predictors, and CRP is an effective biomarker to assess bacterial co-infection in HFRS.

The Relationship Between Hepcidin-Mediated Iron Dysmetabolism and COVID-19 Severity: A Meta-Analysis

Backgrounds

Hepcidin has been identified as a systemic iron-regulatory hormone. Recent studies have suggested that iron metabolism disorders may be involved in the pathogenesis of acute respiratory distress syndrome and multiple organ dysfunction in coronavirus disease 2019 (COVID-19).

Objectives

To re-evaluate the hepcidin-related iron metabolism parameters and explore the relationship between hepcidin-mediated iron dysmetabolism and COVID-19 severity.

Methods

COVID-19 is classified as mild and moderate as non-severe, severe and critical as severe. A meta-analysis was conducted. Four bibliographic databases were comprehensively searched up to December 31st 2021.

Results

Six unique studies with data from 477 COVID-19 patients were included. Compared to non-severe cases, severe cases had higher hepcidin (standardized mean difference (SMD), -0.39; 95% Confidence Interval (CI) [-0.76, -0.03]; P = 0.03) and ferritin (SMD, -0.84; 95% CI [-1.30, -0.38]; P = 0.0004). In five out of six studies, a total of 427 patients were tested for serum iron, and there were significant differences in their levels between severe and non-severe cases (SMD, 0.22; 95% CI [0.02, 0.41]; P = 0.03). A total of 320 patients from four out of six studies were tested for transferrin saturation, and the statistical difference was not significant (SMD, 0.06; 95% CI [-0.17, 0.28]; P = 0.64).

Conclusion

Severe COVID-19 cases had higher serum levels of hepcidin and ferritin, and lower serum iron, without significant differences in transferrin saturation. Further studies are needed to verify whether targeting the hepcidin-mediated iron metabolism axis may influence the outcome and treatment of COVID-19.

Serum Ferritin Levels for the Prediction of Mortality among COVID-19 Patients in an Indonesia’s National Referral Hospital

BACKGROUND: Early identification of clinical outcomes is necessary for risk classification in COVID-19 patients. This study help in evaluating the progression of the disease and the patient’s therapy. AIM: This study aims to determine serum ferritin levels for the prediction of mortality among COVID-19 patients in an Indonesia’s National Referral Hospital. METHODS: A retrospective cohort study was conducted on 142 confirmed positive COVID-19 patients between March 2020 until March 2021 at Dr. M. Djamil General Hospital as a National Referral Hospital in Indonesia. Data obtained from medical record documents and examination of ferritin levels was carried out at the beginning of treatment. The Chi-square test and survival analysis with the log-rank test and Kaplan–Meier methods were used to analyze the data. The SPSS version 15 was used to analyze the data. RESULTS: The serum ferritin cutoff point for COVID-19 patients that can be used to predict poor outcomes was >651.02 ng/mL with sensitivity 79.3%, specificity 80.5%, and accuracy 85.0%. Age, comorbid diabetes mellitus, number of comorbidities, symptoms of trouble breathing, oxygen saturation, severity, and mortality outcome were all associated to ferritin levels >651.02 ng/mL. The Kaplan–Meier curve showed that ferritin levels >651.02 ng/mL were associated for risk of poor outcome COVID-19 patients (HR = 8.84, [95% CI 3.59–21.73]). CONCLUSION: The ferritin cutoff point for predicting poor prognosis in COVID-19 patients was 651.02 ng/mL. However, ferritin serum levels cannot be used as a single predictor in determining the poor outcome of COVID-19.

Comparison of Analytical Values D-Dimer, Glucose, Ferritin and C-Reactive Protein of Symptomatic and Asymptomatic COVID-19 Patients

Those infected by COVID-19 develop various kinds of complications with varying degrees of severity. For this reason, it is necessary to evaluate its analytical values to predict and reduce the risks and complications derived from this pathology. A cross-sectional study was carried out a population in Almeria (south-eastern Spain) who had a positive Polymerase Chain Reaction test result from 1 March 2020 to 30 November 2020. The study involved 4575 patients, with 1346 who were asymptomatic, 1653 mildly symptomatic (no hospitalisation needed) and 1576 severely symptomatic (symptomatic patients hospitalised). Laboratory values for D-dimer, glucose, serum ferritin, and C-reactive protein were analysed. The mean age of the participants in the study was 53.60 (16.89) years old. A total of 70.6% of the patients were symptomatic, of which 36.1% had mild symptoms. For all of the laboratory predictors analysed (D-dimer, glucose, serum ferritin, and C-reactive protein), it was found that severe alterations in the parameters were more frequent in severely symptomatic patients with statistically significant differences (p < 0.001), although these alterations also occurred in asymptomatic patients. Age correlated with analytical values (D-dimer, glucose, serum ferritin, and C-reactive protein) with statistically significant differences. Patients with severe symptoms presented alterations in the analytical values of D-dimer, glucose, serum ferritin, and C-reactive protein. Asymptomatic patients presented alterations in the analysed parameters, though with less frequency and severity than patients with severe symptoms.

Anakinra treatment efficacy in reduction of inflammatory biomarkers in COVID-19 patients: A meta-analysis

Introduction

Anakinra is being empirically considered for the treatment of COVID‐19 patients. The aim is to assess the efficacy of anakinra treatment on inflammatory marker reduction, including c‐reactive protein (CRP) concentrations, serum ferritin, and serum d‐dimer levels.

Methods

Adhering to PRISMA 2020 statement guidelines, a systematic search was conducted across the following databases from December 2019 until January 10, 2022: PubMed/MEDLINE, Cochrane Central, Web of Science, Scopus, and EMBASE. The following keywords were employed: Anakinra, COVID*, SARS‐CoV‐2, inflammatory, CRP, D‐dimer, Ferritin, hematological, laboratory, clinical, trials. The findings were collated and presented in a tabulated manner, and statistically analyzed using Review Manger 5.4 (Cochrane).

Results

In total, 2032 patients were included (881 in the anakinra and 1151 in the control/standard care group); 69.1% of them were males. Overall, the mean difference from admission until last follow‐up in CRP values was −9.66, where notable reductions were seen in the anakinra group (SMD = −0.46, p < 0.00001, N = 655). Serum ferritin mean values were reduced by 1467.16 in the anakinra group (SMD = −0.31, p = 0.004, N = 537). D‐dimer mean values were largely reduced by 4.04 in the anakinra group (SMD = −0.38, p = 0.0004, N = 375).

Conclusion

This study finds that anakinra is potentially a strong candidate as an anti‐inflammatory agent to reduce mortality in COVID‐19 patients, specifically in patients with elevated inflammatory biomarkers.

Laboratory medicine in pandemic of COVID-19

After the outbreak in China in the year 2019, severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) quickly spread around the world causing a protracted pandemic. Approximately one-third of infections appear to be asymptomatic. Symptomatic disease is characterized primarily by symptoms of respiratory tract infection of varying severity. But Coronavirus Disease 2019 (COVID-19) is much more than an acute respiratory disease because SARS-CoV-2 affects many organs inducing a vast number of symptoms such as cardiovascular, neurological, gastrointestinal, dermatological, with numerous complications. Short and long-term effects of infection, severe ones, and especially mild forms of the disease which affect a huge number of patients need to be further investigated. Laboratory medicine has a crucial role in early diagnosis of the disease, recognition of the patients who need hospital care, and close monitoring of hospitalized patients to timely identify associated clinical complications as well as follow-up of patients with long-term COVID-19.

Immunotherapy of COVID-19: Inside and Beyond IL-6 Signalling

Acting on the cytokine cascade is key to preventing disease progression and death in hospitalised patients with COVID-19. Among anti-cytokine therapies, interleukin (IL)-6 inhibitors have been the most used and studied since the beginning of the pandemic. Going through previous observational studies, subsequent randomised controlled trials, and meta-analyses, we focused on the baseline characteristics of the patients recruited, identifying the most favourable features in the light of positive or negative study outcomes; taking into account the biological significance and predictivity of IL-6 and other biomarkers according to specific thresholds, we ultimately attempted to delineate precise windows for therapeutic intervention. By stimulating scavenger macrophages and T-cell responsivity, IL-6 seems protective against viral replication during asymptomatic infection; still protective on early tissue damage by modulating the release of granzymes and lymphokines in mild-moderate disease; importantly pathogenic in severe disease by inducing the proinflammatory activation of immune and endothelial cells (through trans-signalling and trans-presentation); and again protective in critical disease by exerting homeostatic roles for tissue repair (through cis-signalling), while IL-1 still drives hyperinflammation. IL-6 inhibitors, particularly anti-IL-6R monoclonal antibodies (e.g., tocilizumab, sarilumab), are effective in severe disease, characterised by baseline IL-6 concentrations ranging from 35 to 90 ng/mL (reached in the circulation within 6 days of hospital admission), a ratio of partial pressure arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2) between 100 and 200 mmHg, requirement of high-flow oxygen or non-invasive ventilation, C-reactive protein levels between 120 and 160 mg/L, ferritin levels between 800 and 1600 ng/mL, D-dimer levels between 750 and 3000 ng/mL, and lactate dehydrogenase levels between 350 and 500 U/L. Granulocyte-macrophage colony-stimulating factor inhibitors might have similar windows of opportunity but different age preferences compared to IL-6 inhibitors (over or under 70 years old, respectively). Janus kinase inhibitors (e.g., baricitinib) may also be effective in moderate disease, whereas IL-1 inhibitors (e.g., anakinra) may also be effective in critical disease. Correct use of biologics based on therapeutic windows is essential for successful outcomes and could inform future new trials with more appropriate recruiting criteria.

Therapeutic potential of induced iron depletion using iron chelators in Covid-19

Ferritin, which includes twenty-four light and heavy chains in varying proportions in different tissues, is primarily responsible for maintaining the body's iron metabolism. Its normal value is between 10 and 200 ngmL^-1 in men and between 30 and 300 ngmL^-1 in women. Iron is delivered to the tissue via them, and they act as immunomodulators, signaling molecules, and inflammatory markers. When ferritin level exceeds 1000 µgL^-1, the patient is categorized as having hyperferritinemia. Iron chelators such as deferiprone, deferirox, and deferoxamine are currently FDA approved to treat iron overload. The inflammation cascade and poor prognosis of COVID-19 may be attributed to high ferritin levels. Critically ill patients can benefit from deferasirox, an iron chelator administered orally at 20-40 mgkg^-1 once daily, as well as intravenous deferoxamine at 1000 mg initially followed by 500 mg every 4 to 12 h. It can be combined with monoclonal antibodies, antioxidants, corticosteroids, and lactoferrin to make iron chelation therapy effective for COVID-19 victims. In this article, we analyze the antiviral and antifibrotic activity of iron chelators, thereby promoting iron depletion therapy as a potentially innovative treatment strategy for COVID-19.

Association of renalase with clinical outcomes in hospitalized patients with COVID-19

Renalase is a secreted flavoprotein with anti-inflammatory and pro-cell survival properties. COVID-19 is associated with disordered inflammation and apoptosis. We hypothesized that blood renalase levels would correspond to severe COVID-19 and survival. In this retrospective cohort study, clinicopathologic data and blood samples were collected from hospitalized COVID-19 subjects (March—June 2020) at a single institution tertiary hospital. Plasma renalase and cytokine levels were measured and clinical data abstracted from health records. Of 3,450 COVID-19 patients, 458 patients were enrolled. Patients were excluded if <18 years, or opted out of research. The primary composite outcome was intubation or death within 180 days. Secondary outcomes included mortality alone, intensive care unit admission, use of vasopressors, and CPR. Enrolled patients had mean age 64 years (SD±17), were 53% males, and 48% non-whites. Mean renalase levels was 14,108·4 ng/ml (SD±8,137 ng/ml). Compared to patients with high renalase, those with low renalase (< 8,922 ng/ml) were more likely to present with hypoxia, increased ICU admission (54% vs. 33%, p < 0.001), and cardiopulmonary resuscitation (10% vs. 4%, p = 0·023). In Cox proportional hazard model, every 1000 ng/ml increase in renalase decreased the risk of death or intubation by 5% (HR 0·95; 95% CI 0·91–0·98) and increased survival alone by 6% (HR 0·95; CI 0·90–0·98), after adjusting for socio-demographics, initial disease severity, comorbidities and inflammation. Patients with high renalase-low IL-6 levels had the best survival compared to other groups (p = 0·04). Renalase was independently associated with reduced intubation and mortality in hospitalized COVID-19 patients. Future studies should assess the pathophysiological relevance of renalase in COVID-19 disease.

Prognostic and Predictive Biomarkers in Patients With Coronavirus Disease 2019 Treated With Tocilizumab in a Randomized Controlled Trial

OBJECTIVES

To explore candidate prognostic and predictive biomarkers identified in retrospective observational studies (interleukin-6, C-reactive protein, lactate dehydrogenase, ferritin, lymphocytes, monocytes, neutrophils, d-dimer, and platelets) in patients with coronavirus disease 2019 pneumonia after treatment with tocilizumab, an anti-interleukin-6 receptor antibody, using data from the COVACTA trial in patients hospitalized with severe coronavirus disease 2019 pneumonia.

DESIGN

Exploratory analysis from a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial.

SETTING

Hospitals in North America and Europe.

PATIENTS

Adults hospitalized with severe coronavirus disease 2019 pneumonia receiving standard care.

INTERVENTION

Randomly assigned 2:1 to IV tocilizumab 8 mg/kg or placebo.

MEASUREMENTS AND MAIN RESULTS

Candidate biomarkers were measured in 295 patients in the tocilizumab arm and 142 patients in the placebo arm. Efficacy outcomes assessed were clinical status on a seven-category ordinal scale (1, discharge; 7, death), mortality, time to hospital discharge, and mechanical ventilation (if not receiving it at randomization) through day 28. Prognostic and predictive biomarkers were evaluated continuously with proportional odds, binomial or Fine-Gray models, and additional sensitivity analyses. Modeling in the placebo arm showed all candidate biomarkers except lactate dehydrogenase and d-dimer were strongly prognostic for day 28 clinical outcomes of mortality, mechanical ventilation, clinical status, and time to hospital discharge. Modeling in the tocilizumab arm showed a predictive value of ferritin for day 28 clinical outcomes of mortality (predictive interaction, p = 0.03), mechanical ventilation (predictive interaction, p = 0.01), and clinical status (predictive interaction, p = 0.02) compared with placebo.

CONCLUSIONS

Multiple biomarkers prognostic for clinical outcomes were confirmed in COVACTA. Ferritin was identified as a predictive biomarker for the effects of tocilizumab in the COVACTA patient population; high ferritin levels were associated with better clinical outcomes for tocilizumab compared with placebo at day 28.

Extracellular Oxidative Stress Markers in COVID-19 Patients with Diabetes as Co-Morbidity

COVID-19 patients have a higher risk of developing inflammatory responses associated with serious and even fatal respiratory diseases. The role of oxidative stress in exacerbating manifestations in COVID-19 pathogenesis is under-reported.This study aimed touseserum levels of superoxide dismutase (SOD3) and glutathione-S-transferase (GSTp1) by ELISA, zinc (ErbaChem5), ferritin and free iron (VitrosChemistry, Ortho Clinical Diagnosis, Raritan, NJ, USA) at the first encounter of randomly selected RT-PCR-positive COVID-19 patients, for assessing disease severity. The parameters which helped in identifying the severity, leading to poor prognosis, were neutrophil:lymphocyte higher than 4, high CRP, low SOD3 values and high GSTp1 values, and diabetes mellitus as a co-morbidity. Higher zinc levels correlated with high GSTp1 and low SOD3, indicating the protective effect of zinc on ROS. The increased high GSTp1 shows an anticipated protective biochemical response, to mitigate the low SOD3 values due to ROS consumption. Decreased SOD3 levels indicate a state of high oxidative stress at cellular levels, and an anticipated increase in GSTp1 levels points to the pathophysiological bases of increasing severity with age, sex, and co-morbidities, such asdiabetes. High levels of initial GSTp1 and zinc levels possibly offer protection to redox reactions at the cellular level in severe COVID-19 infection, preventing deterioration.

Significance of Cardiac Troponins as an Identification Tool in COVID-19 Patients Using Biosensors: An Update

Coronavirus disease 2019 (COVID-19) has rapidly developed as a global health emergency. Respiratory diseases are significant causes of morbidity and mortality in these patients with a spectrum of different diseases, from asymptomatic subclinical infection to the progression of severe pneumonia and subsequent acute respiratory distress syndrome. Individuals with cardiovascular disease are more likely to become infected with SARS-CoV-2 and develop severe symptoms. Hence, patients with underlying cardiovascular disease mortality rate are over three times. Furthermore, note that patients with a history of cardiovascular disease are more likely to have higher cardiac biomarkers, especially cardiac troponins, than infected patients, especially those with severe disease, making these patients more susceptible to cardiac damage caused by SARS-2-CoV. Biomarkers are important in decision-making to facilitate the efficient allocation of resources. Viral replication in the heart muscle can lead to a cascade of inflammatory processes that lead to fibrosis and, ultimately, cardiac necrosis. Elevated troponin may indicate damage to the heart muscle and may predict death. After the first Chinese analysis, increased cardiac troponin value was observed in a significant proportion of patients, suggesting that myocardial damage is a possible pathogenic mechanism leading to severe disease and death. However, the prognostic performance of troponin and whether its value is affected by different comorbidities present in COVID-19 patients are not known. This review aimed to assess the diagnostic value of troponin to offer insight into pathophysiological mechanisms and reported new assessment methods, including new biosensors for troponin in patients with COVID-19.

Criteria and potential predictors of severity in patients with COVID-19

Background

The challenge in treating severe COVID-19 in the absence of targeted medication is enforcing physicians to search carefully for clinical predictors of severity.

Aim

To define the profile of patients at risk of severe COVID-19 and to assess for certain predictors.

Methods

Confirmed COVID-19 cases were classified into the following: group A: mild/moderate cases and group B: severe/critical cases according to the selected criteria. History, radiological assessment, complete blood count, lactate dehydrogenase (LDH), myocardial enzymes, serum ferritin, and D dimer were assessed. Patients were followed for the need of ICU and mechanical ventilation. Duration till conversion, length of stay, and mortality were recorded.

Results

A total of 202 patients were analyzed. Group B had higher age (53.2 ± 12.6 vs 40.3 ± 10.3, P < 0.001), more prevalence of DM (60.61% vs 16.57% P < 0.001), hypertension (51.52% vs 20.12%, P < 0.001), ischemic heart (27.27% vs 3.55%, P < 0.001), bronchial asthma (36.36% vs 3.55%, P < 0.001), COPD (9.09% vs 1.18%, P = 0.03), higher mean platelet volume (MPV) (12.76 ± 7.13 vs 10.51 ± 7.78 (fL), P < 0.001), higher serum ferritin (954 ± 138 vs 447 ± 166 ng/ml, P < 0.001), higher LDH (604 ± 220 vs 384 ± 183 U/L, P-value < 0.001), higher creatine phosphokinase (24.27 ± 5.82 vs 16.4 ± 4.87 IU/L, P < 0.001), and higher mortality (30.3% vs 0.6%, P < 0.001). Multivariate regression of predictors of severity identified three predictors; age, MPV, serum ferritin, and IHD.

Conclusions

The current study places of interest the characteristic host-related features of severe COVID-19 and draws attention to potential predictors.

Biomarkers during COVID-19: Mechanisms of Change and Implications for Patient Outcomes

As the COVID-19 (Coronavirus disease 19) pandemic spreads worldwide, the massive numbers of COVID-19 patients have created a considerable healthcare burden for every country. The clinical spectrum of SARS-CoV-2 infection is broad, ranging from asymptomatic to mild, moderate, severe, and critical. Most COVID-19 patients present with no or mild symptoms, but nearly one-fifth of all patients develop severe or life-threatening complications. In addition to localized respiratory manifestations, severe COVID-19 cases also show extra-pulmonary complications or induce multiorgan failure. Identifying, triaging, and treating patients at risk early is essential and urgent. This article reviews the potential prognostic value of various biomarkers at different clinical spectrum stages of COVID-19 infection and includes information on fundamental prognostic mechanisms as well as potential clinical implications. Biomarkers are measurable biochemical substances used to recognize and indicate disease severity or response to therapeutic interventions. The information they provide is objective and suitable for delivering healthcare providers with a means of stratifying disease state in COVID-19 patients. This, in turn, can be used to help select and guide intervention efforts as well as gauge the efficacy of therapeutic approaches. Here, we review a number of potential biomarkers that may be used to guide treatment, monitor treatment efficacy, and form individualized therapeutic guidance based on patient response. Implementation of the COVID-19 biomarkers discussed here may lead to significantly improved quality of care and patient outcomes for those infected with SARS-CoV-2 worldwide.

Health of the Newborn and Breastfeeding during the COVID-19 Pandemic: A Literature Review

OBJECTIVE

 The present article presents a literature review concerning the microbiota of breast milk and the influence of epigenetics in the susceptibility to COVID-19.

METHODS

 A literature review.

RESULTS

 Breastfeeding transfers microbiota, nutrients, diverse white blood cells, prebiotics, hormones, and antibodies to the baby, which provide short- and long-term immunological protection against several infectious, gastrointestinal, and respiratory illnesses. The little evidence available shows that breast milk very rarely carries the SARS-CoV-2 virus, and even in those cases, it has been discarded as the source of contagion.

CONCLUSION

 The reviewed studies show evidence of a beneficial effect of breastfeeding and highlights its importance on the current pandemic due to the immune reinforcement that it provides. Breastfed individuals showed better clinical response due to the influence on the microbiota and to the nutritional and immune contribution provided by breast milk, compared with those who were not breastfed.

Development and validation of prognostic scoring system for COVID-19 severity in South India

Background

Development of a prediction model using baseline characteristics of COVID-19 patients at the time of diagnosis will aid us in early identification of the high-risk groups and devise pertinent strategies accordingly. Hence, we did this study to develop a prognostic-scoring system for predicting the COVID-19 severity in South India.

Methods

We undertook this retrospective cohort study among COVID-19 patients reporting to Hindu Mission Hospital, India. Multivariable logistic regression using the LASSO procedure was used to select variables for the model building, and the nomogram scoring system was developed with the final selected model. Model discrimination, calibration, and decision curve analysis (DCA) was performed.

Results

In total, 35.1% of the patients in the training set developed severe COVID-19 during their follow-up period. In the basic model, nine variables (age group, sex, education, chronic kidney disease, tobacco, cough, dyspnea, olfactory-gustatory dysfunction [OGD], and gastrointestinal symptoms) were selected and a nomogram was built using these variables. In the advanced model, in addition to these variables (except OGD), C-reactive protein, lactate dehydrogenase, ferritin, d-dimer, and CT severity score were selected. The discriminatory power (c-index) for basic model was 0.78 (95%CI: 0.74–0.82) and advanced model was 0.83 (95%CI: 0.79–0.87). DCA showed that both the models are beneficial at a threshold probability around 10–95% than treat-none or treat-all strategies.

Conclusion

The present study has developed two separate prognostic-scoring systems to predict the COVID-19 severity. This scoring system could help the clinicians and policymakers to devise targeted interventions and in turn reduce the COVID-19 mortality in India.

Supplementary information

The online version contains supplementary material available at 10.1007/s11845-021-02876-w.

PaO 2 / FiO 2 ratio responsiveness to prone positioning in intubated patients with severe COVID ‐19: a retrospective observational study

Aim

Prone positioning of coronavirus disease 2019 (COVID‐19) patients could improve oxygenation. However, clinical data on prone positioning of intubated COVID‐19 patients are limited. We investigated trends of PaO₂ / FiO₂ ratio values in patients during prone positioning to identify a predictive factor for early detection of patients requiring advanced therapeutic intervention such as extracorporeal membrane oxygenation (ECMO).

Methods

This retrospective, observational cohort study was undertaken between April 2020 and May 2021 in a tertiary referral hospital for COVID‐19 in Osaka, Japan. We included intubated adult COVID‐19 patients treated with prone positioning within the first 72 h of admission to the intensive care unit and followed them until hospital discharge or death. Primary outcomes were in‐hospital mortality and escalation of care to ECMO. We used unsupervised k‐means clustering modeling to categorize COVID‐19 patients by PaO₂ / FiO₂ ratio responsiveness to prone positioning.

Results

The final study cohort comprised 54 of 155 consecutive severe COVID‐19 patients. Three clusters were generated according to trends in PaO₂ / FiO₂ ratios during prone positioning (cluster A, n = 16; cluster B, n = 24; cluster C, n = 14). Baseline characteristics of all clusters were almost similar. Cluster A (no increase in PaO₂ / FiO₂ ratio during prone positioning) had a significantly higher proportion of patients placed on ECMO or who died (6/16, 37.5%). Numbers of patients with ECMO and with in‐hospital death were significantly different between the three groups (p = 0.017).

Conclusion

In Japanese patients intubated due to COVID‐19, clinicians should consider earlier escalation of treatment, such as facility transfer or ECMO, if the PaO₂ / FiO₂ ratio does not increase during initial prone positioning.

Ferritin - from iron, through inflammation and autoimmunity, to COVID-19

While it took decades to arrive to a conclusion that ferritin is more than an indicator of iron storage level, it took a short period of time through the COVID-19 pandemic to wonder what the reason behind high levels of ferritin in patients with severe COVID-19 might be. Unsurprisingly, acute phase reactant was not a satisfactory explanation. Moreover, the behavior of ferritin in patients with severe COVID-19 and the subsequent high mortality rates in patients with high ferritin levels necessitated further investigations to understand the role of ferritin in the diseases. Ferritin was initially described to accompany various acute infections, both viral and bacterial, indicating an acute response to inflammation. However, with the introduction of the hyperferritinemic syndrome connecting four severe pathological conditions such as adult-onset Still's disease, macrophage activation syndrome, catastrophic antiphospholipid syndrome, and septic shock added another aspect of ferritin where it could have a pathogenetic role rather than an extremely elevated protein only. In fact, suggesting that COVID-19 is a new member in the spectrum of hyperferritinemic syndrome besides the four mentioned conditions could hopefully direct further search on the pathogenetic role of ferritin. Doubtlessly, improving our understanding of those aspects of ferritin would enormously contribute to better coping with severe diseases in terms of treatment and prevention of complications. The origin, history, importance, and the advances of searching the role of ferritin in various pathological and clinical processes are presented hereby in our article. In addition, the implications of ferritin in COVID-19 are addressed.

ESCAPE: An Open-Label Trial of Personalized Immunotherapy in Critically lll COVID-19 Patients

Background

Macrophage activation-like syndrome (MALS) and complex immune dysregulation (CID) often underlie acute respiratory distress (ARDS) in COVID-19. We aimed to investigate the effect of personalized immunotherapy on clinical improvement of critical COVID-19.

Methods

In this open-label prospective trial, 102 patients with ARDS by SARS-CoV-2 were screened for MALS (ferritin >4,420 ng/mL) and CID (ferritin ≤4,420 ng/mL and low human leukocyte antigen (HLA)-DR expression on CD14-monocytes). Patients with MALS or CID with increased aminotransferases received intravenous anakinra; those with CID and normal aminotransferases received tocilizumab. The primary outcome was ≥25% decrease in the Sequential Organ Failure Assessment (SOFA) score and/or 50% increase in the respiratory ratio by day 8; 28-day mortality, change of SOFA score by day 28, serum biomarkers, and cytokine production by mononuclear cells were secondary endpoints.

Results

The primary study endpoint was met in 58.3% of anakinra-treated patients and in 33.3% of tocilizumab-treated patients (p: 0.01). Most patients in both groups received dexamethasone as standard of care. No differences were found in secondary outcomes, mortality, and SOFA score changes. Ferritin decreased among anakinra-treated patients; interleukin-6, soluble urokinase plasminogen activator receptor, and HLA-DR expression increased among tocilizumab-treated patients. Survivors by day 28 who received anakinra were distributed to lower severity levels of the WHO clinical progression scale. Greater incidence of secondary infections was found with tocilizumab treatment.

Conclusion

Immune assessment resulted in favorable anakinra responses among critically ill patients with COVID-19 and features of MALS.

Proteinaceous Lung With COVID-19: The Mimicker

Pulmonary alveolar proteinosis (PAP) is a syndrome, in which surfactants get deposited slowly in alveoli, blocking the airway exchange. PAP severity also varies from mild to severe, presenting with dyspnea, cough, hemoptysis with or without fever. The radiological findings are ground-glass opacities along with septal thickening (Crazy Paving), consolidations, and less commonly air bronchograms. COVID-19 is a viral infection caused by SARS COV2 primarily affecting the lungs and causing atypical viral pneumonia. The clinical picture of the disease varies from a milder form of fever, dry cough with or without expectoration, to severe disease-causing respiratory distress, pneumonia, acute respiratory distress syndrome (ARDS), and even death. Radiologically, the findings of COVID-19 are similar to PAP. So, PAP mimics the COVID-19, posing a differential challenge, though our patient was a known case of PAP. Therefore, for proper management of the disease, it is important to differentiate it from other pathologies. In this case report, we describe a patient who was a known case of autoimmune pulmonary alveolar proteinosis. She presented with acute exacerbation in the emergency department and tested positive for COVID-19. We followed a systematic approach consisting of clinical, laboratory, radiologic parameters to differentiate the cause of this exacerbation.

Lactoferrin as Antiviral Treatment in COVID-19 Management: Preliminary Evidence

Lactoferrin (Lf), a multifunctional cationic glycoprotein synthesized by exocrine glands and neutrophils, possesses an in vitro antiviral activity against SARS-CoV-2. Thus, we conducted an in vivo preliminary study to investigate the antiviral effect of oral and intranasal liposomal bovine Lf (bLf) in asymptomatic and mild-to-moderate COVID-19 patients. From April 2020 to June 2020, a total of 92 mild-to-moderate (67/92) and asymptomatic (25/92) COVID-19 patients were recruited and divided into three groups. Thirty-two patients (14 hospitalized and 18 in home-based isolation) received only oral and intranasal liposomal bLf; 32 hospitalized patients were treated only with standard of care (SOC) treatment; and 28, in home-based isolation, did not take any medication. Furthermore, 32 COVID-19 negative, untreated, healthy subjects were added for ancillary analysis. Liposomal bLf-treated COVID-19 patients obtained an earlier and significant (p < 0.0001) SARS-CoV-2 RNA negative conversion compared to the SOC-treated and untreated COVID-19 patients (14.25 vs. 27.13 vs. 32.61 days, respectively). Liposomal bLf-treated COVID-19 patients showed fast clinical symptoms recovery compared to the SOC-treated COVID-19 patients. In bLf-treated patients, a significant decrease in serum ferritin, IL-6, and D-dimers levels was observed. No adverse events were reported. These observations led us to speculate a potential role of bLf in the management of mild-to-moderate and asymptomatic COVID-19 patients.

Increased serum catalytic iron may mediate tissue injury and death in patients with COVID-19

The pathophysiology and the factors determining disease severity in COVID-19 are not yet clear, with current data indicating a possible role of altered iron metabolism. Previous studies of iron parameters in COVID-19 are cross-sectional and have not studied catalytic iron, the biologically most active form of iron. The study was done to determine the role of catalytic iron in the adverse outcomes in COVID-19. We enrolled adult patients hospitalized with a clinical diagnosis of COVID-19 and measured serum iron, transferrin saturation, ferritin, hepcidin and serum catalytic iron daily. Primary outcome was a composite of in-hospital mortality, need for mechanical ventilation, and kidney replacement therapy. Associations between longitudinal iron parameter measurements and time-to-event outcomes were examined using a joint model. We enrolled 120 patients (70 males) with median age 50 years. The primary composite outcome was observed in 25 (20.8%) patients-mechanical ventilation was needed in 21 (17.5%) patients and in-hospital mortality occurred in 21 (17.5%) patients. Baseline levels of ferritin and hepcidin were significantly associated with the primary composite outcome. The joint model analysis showed that ferritin levels were significantly associated with primary composite outcome [HR (95% CI) = 2.63 (1.62, 4.24) after adjusting for age and gender]. Both ferritin and serum catalytic iron levels were positively associated with in-hospital mortality [HR (95% CI) = 3.22 (2.05, 5.07) and 1.73 (1.21, 2.47), respectively], after adjusting for age and gender. The study shows an association of ferritin and catalytic iron with adverse outcomes in COVID-19. This suggests new pathophysiologic pathways in this disease, also raising the possibility of considering iron chelation therapy.

Obesity, inflammatory and thrombotic markers, and major clinical outcomes in critically ill patients with COVID-19 in the US

OBJECTIVE

This study aimed to determine whether obesity is independently associated with major adverse clinical outcomes and inflammatory and thrombotic markers in critically ill patients with COVID-19.

METHODS

The primary outcome was in-hospital mortality in adults with COVID-19 admitted to intensive care units across the US. Secondary outcomes were acute respiratory distress syndrome (ARDS), acute kidney injury requiring renal replacement therapy (AKI-RRT), thrombotic events, and seven blood markers of inflammation and thrombosis. Unadjusted and multivariable-adjusted models were used.

RESULTS

Among the 4,908 study patients, mean (SD) age was 60.9 (14.7) years, 3,095 (62.8%) were male, and 2,552 (52.0%) had obesity. In multivariable models, BMI was not associated with mortality. Higher BMI beginning at 25 kg/m² was associated with a greater risk of ARDS and AKI-RRT but not thrombosis. There was no clinically significant association between BMI and inflammatory or thrombotic markers.

CONCLUSIONS

In critically ill patients with COVID-19, higher BMI was not associated with death or thrombotic events but was associated with a greater risk of ARDS and AKI-RRT. The lack of an association between BMI and circulating biomarkers calls into question the paradigm that obesity contributes to poor outcomes in critically ill patients with COVID-19 by upregulating systemic inflammatory and prothrombotic pathways.

Redox imbalance links COVID-19 and myalgic encephalomyelitis/chronic fatigue syndrome

Although most patients recover from acute COVID-19, some experience postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC). One subgroup of PASC is a syndrome called "long COVID-19," reminiscent of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). ME/CFS is a debilitating condition, often triggered by viral and bacterial infections, leading to years-long debilitating symptoms including profound fatigue, postexertional malaise, unrefreshing sleep, cognitive deficits, and orthostatic intolerance. Some are skeptical that either ME/CFS or long COVID-19 involves underlying biological abnormalities. However, in this review, we summarize the evidence that people with acute COVID-19 and with ME/CFS have biological abnormalities including redox imbalance, systemic inflammation and neuroinflammation, an impaired ability to generate adenosine triphosphate, and a general hypometabolic state. These phenomena have not yet been well studied in people with long COVID-19, and each of them has been reported in other diseases as well, particularly neurological diseases. We also examine the bidirectional relationship between redox imbalance, inflammation, energy metabolic deficits, and a hypometabolic state. We speculate as to what may be causing these abnormalities. Thus, understanding the molecular underpinnings of both PASC and ME/CFS may lead to the development of novel therapeutics.

Biochemical role of serum ferratin and d-dimer parameters in COVID 19 diagnosis

One and one only most unforgettable pandemic is coronavirus 2019 (COVID 19) which is the most memorable pandemic of the twenty-first century. The diagnosis of COVID19 is based on purely clinical symptoms and real time reverse transcription polymerase chain reaction (RT-PCR) test. The role of COVID19 during this pandemic was horrible in diagnosing the disease with RT-PCR as this disease was documented to be a symptomatic disease. Serum ferratin and D-dimer tests plays a major role in identifying the infections in the human body specifically, patients diagnosed with COVID19. Serum ferritin levels are important for an immune response mediator that rises in severe COVID-19 instances, and elevated ferritin levels may trigger a cytokine storm by exerting direct immunosuppressive and pro-inflammatory effects. d-dimer is used to identify the clots in the blood. COVID-19 patients were found to be clotting of blood and d-dimer is recommended. The blood of the COVID-19 patients were found to clotted than the patients were prescribed the anticoagulant Injections are prescribed. d-dimer can be used as a biomarker in the COVID-19 patients by measuring the d-dimer levels and analyse the mortality and severity. Pulmonary complication risk can also be identified. d-dimer is a mandatory and an essential test in the COVID-19. Numerous COVID-19 vaccines have been shown to have great efficacy levels through clinical trials. COVID-19 vaccines are not 100% effective, although the condition is mild or moderate and can be controlled if COVID-19 is affected. In this review, I have only included serum ferritin and d-dimer; however, C-reactive protein, vitamin D levels, and prolactin were also attributed to COVID-19. This review concludes the importance of RT-PCR, serum ferratin, and d-dimer testing in identifying COVID-19 infection in humans.

Chronic kidney disease linked to SARS-CoV-2 infection: a case report

Background

The recent COVID-19 pandemic has raised concerns about patient diagnosis and follow-up of chronically ill patients. Patients suffering from chronic illnesses, concomitantly infected by SARS-CoV-2, globally tend to have a worse prognosis and poor outcomes. Renal tropism and acute kidney injury following SARS-CoV-2 infection has recently been described in the literature, with elevated mortality rates. Furthermore, patients with pre-existing chronic kidney disease, infected by SARS-CoV-2, should be monitored carefully. Here, we report the case of a 69-year-old patient with splenic marginal zone lymphoma, suffering from longstanding chronic kidney disease following SARS-CoV-2 infection.

Case presentation

A 69-year-old male patient previously diagnosed with pulmonary embolism and splenic marginal zone lymphoma (Splenomegaly, Matutes 2/5, CD5 negative and CD23 positive), was admitted to the hospital with shortness of breath, fever and asthenia. A nasopharyngeal swab test was performed in addition to a CT-scan, which confirmed SARS-CoV-2 infection. Blood creatinine increased following SARS-CoV-2 infection at 130 μmol/l, with usual values at 95 μmol/l. The patient was discharged at home with rest and symptomatic medical treatment (paracetamol and hydration), then readmitted to the hospital in August 2020. A kidney biopsy was therefore conducted as blood creatinine levels were abnormally elevated. Immunodetection performed in a renal biopsy specimen confirmed co-localization of SARS-CoV2 nucleocapsid and protease 3C proteins with ACE2, Lewis x and sialyl-Lewis x antigens in proximal convoluted tubules and podocytes. Co-localization of structural and non-structural viral proteins clearly demonstrated viral replication in proximal convoluted tubules in this chronically ill patient. Additionally, we observed the co-localization of sialyl-Lewis x and ACE2 receptors in the same proximal convoluted tubules. Reverse Transcriptase-Polymerase Chain Reaction test performed on the kidney biopsy was negative, with very low Ct levels (above 40). The patient was finally readmitted to the haematology department for initiation of chemotherapy, including CHOP protocol and Rituximab.

Conclusions

Our case emphasizes on the importance of monitoring kidney function in immunosuppressed patients and patients suffering from cancer following SARS-CoV-2 infection, through histological screening. Further studies will be required to decipher the mechanisms underlying chronic kidney disease and the putative role of sialyl-Lewis x and HBGA during SARS-CoV-2 infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02490-z.

Association between HLA genotype and ferritin levels in COVID-19 infection: a study of a Saudi cohort

BACKGROUND

An elevation in serum ferritin levels through an unknown mechanism was observed in COVID-19 infected patients. This study examined the association between patients' HLA genotype and serum ferritin level modulation and also assessed the effect of serum ferritin levels on infection severity/mortality.

MATERIALS AND METHODS

One hundred and thirty-six COVID-19 Saudi patients were divided into two groups according to their ferritin levels: group 1 (<500 ng/mL, N = 67) and group 2 (>500 ng/mL, N = 69). HLA genotyping (class I and II) was carried out through the rPCR-SSO method.

RESULTS

High serum ferritin levels were associated with a significant increase in infection severity, as 75% of ICU patients showed high levels of ferritin compared to 43% of patients with moderate symptoms, p = .002. This elevation indicated a gender skew in that 56% of the infected male patients displayed high ferritin levels compared to 36.6% of the female patients, p = .03. In terms of mortality, 74% of patients with fatal outcomes had a high level of serum ferritin compared to 47% of recovered patients, p = .039. There was a significant difference in the HLA frequency between the two groups, with a predominance of HLA-A*01 in the low-ferritin group (19.4 vs. 6.5%, p = .002, p_c = .016) and predominance of C*03 in the high ferritin group (10.9 vs. 3%, p = .047, p_c = .27).

CONCLUSION

High serum ferritin levels are associated with an increase in COVID-19 severity, which may be affected by HLA polymorphism.

Case Report: Reinfection of COVID-19, with second infection less severe

There is concern that an individual may contract COVID-19 twice, either as a result of being a viral carrier that was not entirely cleared from the body in the first instance or as a result of reinfection. The recurrent infection may be qRT-PCR positive, which must be distinguished from post-COVID-19 symptoms that are qRT-PCR negative. Although it is known that recovered patients of viral diseases can be immune for the next infection, recurrent infections of COVID-19 have been recorded in Brazilian healthcare workers. We report a case of recurrent COVID-19 infection in a 34-year-old man working in the Gynecology and Children Hospital in Al-Muthanna Province, south of Iraq. The patient suffered from a sharp and noticeable rise in the body temperature at 39 ºC and cough on the 16th of July 2020. Then, the patient was symptomized with another course of COVID-19 on the 27th of August 2020, which was contracted from the patient’s workmate. Nose swab PCR test and CT scan were performed to confirm the second infection. The clinical signs of repeated infection with coronavirus were obviously less than the first infection of the same patient. It is clear that the first infection symptoms of COVID-19 are more severe than the signs of recurrent disease.

Clinical and Biomarker Profiles and Prognosis of Elderly Patients With Coronavirus Disease 2019 (COVID-19) With Cardiovascular Diseases and/or Risk Factors

BACKGROUND

This study investigated the effects of age on the outcomes of coronavirus disease 2019 (COVID-19) and on cardiac biomarker profiles, especially in patients with cardiovascular diseases and/or risk factors (CVDRF).Methods and Results:A nationwide multicenter retrospective study included 1,518 patients with COVID-19. Of these patients, 693 with underlying CVDRF were analyzed; patients were divided into age groups (<55, 55-64, 65-79, and ≥80 years) and in-hospital mortality and age-specific clinical and cardiac biomarker profiles on admission evaluated. Overall, the mean age of patients was 68 years, 449 (64.8%) were male, and 693 (45.7%) had underlying CVDRF. Elderly (≥80 years) patients had a significantly higher risk of in-hospital mortality regardless of concomitant CVDRF than younger patients (P<0.001). Typical characteristics related to COVID-19, including symptoms and abnormal findings on baseline chest X-ray and computed tomography scans, were significantly less prevalent in the elderly group than in the younger groups. However, a significantly (P<0.001) higher proportion of elderly patients were positive for cardiac troponin (cTn), and B-type natriuretic peptide (BNP) and N-terminal pro BNP (NT-proBNP) levels on admission were significantly higher among elderly than younger patients (P<0.001 and P=0.001, respectively).

CONCLUSIONS

Elderly patients with COVID-19 had a higher risk of mortality during the hospital course, regardless of their history of CVDRF, were more likely to be cTn positive, and had significantly higher BNP/NT-proBNP levels than younger patients.