The role of hemogram parameters and C-reactive protein in predicting mortality in COVID-19 infection

Predictivity of the Prognostic Nutritional Index and Systemic Inflammation Index for All-Cause In-Hospital Mortality in Geriatric and Adult COVID-19 Inpatients

Background: The prognostic nutritional index (PNI) and the systemic immune inflammation index (SII) have been used as simple risk-stratification predictors for COVID-19 severity and mortality in the general population. However, the associations between these indices and mortality might differ due to age-related changes such as inflammaging and several comorbid conditions in older patients. Therefore, we aimed to compare the predictivity of the PNI and SII for mortality among hospitalized older patients and patients under 65 years old. Methods: Patients hospitalized with COVID-19 from March 2020 to December 2020 were retrospectively included. The PNI and SII were calculated from hospital records within the first 48 h after admission. Data were evaluated in the whole group and according to age groups (≥65 < years). Receiver operating characteristic curves were drawn to evaluate the predictivity of the PNI and SII. Results: Out of 407 patients included in this study, 48.4% (n = 197) were older patients, and 51.6% (n = 210) were under 65 years old. For mortality, the area under the curve (AUC) of the PNI and SII in the adult group (<65 years) was 0.706 (95% CI 0.583-0.828) (p = 0.003) and 0.697 (95% CI 0.567-0.827) (p < 0.005), respectively. The AUC of the PNI and SII in the older group was 0.515 (95% CI 0.427-0.604) (p = 0.739) and 0.500 (95% CI 0.411-0.590) (p = 0.993). Conclusions: The accuracy of the PNI and SII in predicting mortality in adult COVID-19 patients seemed to be fair, but no association was found in geriatric patients in this study. The predictivity of the PNI and SII for mortality varies according to age groups.

Meta-analysis of the systemic immune-inflammatory index and in-hospital mortality of COVID-19 patients

Background

The potential significance of immunoinflammatory factors in the prognosis of individuals afflicted with coronavirus disease 2019 (COVID-19) is worthy of examination. The systemic immune-inflammatory index (SII), a recently developed immunoinflammatory metric based on the enumeration of neutrophils, platelets, and lymphocytes in blood samples, holds promise for elucidating this relationship. Consequently, in order to explore any possible correlation between the SII levels at admission and the in-hospital mortality of patients with COVID-19, we undertook a thorough systematic review and meta-analysis.

Methods

In pursuit of accomplishing the aim of this meta-analysis, an extensive search was conducted to seek out pertinent observational studies featuring longitudinal follow-up across PubMed, Cochrane Library, Embase and the Web of Science databases. The I2 statistic was utilized to estimate the extent of heterogeneity and the Cochrane Q test was employed to evaluate heterogeneity between studies. The synthesis of outcomes involved the use of random-effects models, accounting for the possible influence of heterogeneity.

Results

Our analysis included sixteen studies, encompassing 10,007 hospitalized COVID-19 patients. Among them, 1801 patients (18.0 %) succumbed during hospitalization. The pooled results indicated that a high SII at admission was substantially linked to a higher risk of all-cause mortality (risk ratio [RR]: 2.41, 95 % confidence interval: 1.78 to 3.24, p < 0.001; I2 = 86 %). Meta-regression analysis demonstrated a negative correlation between mean SII at baseline and patient mortality in individual studies (coefficients = -0.00023 and -0.030, p < 0.05), effectively explaining the observed heterogeneity. Furthermore, in patients with lower baseline SII (<1300) and a lower risk of mortality (<20 %), we observed a more pronounced association between high SII levels and the risk of all-cause mortality.

Conclusion

The results of our study indicate that a high SII upon admission could potentially function as a prognostic indicator for mortality during hospitalization in patients diagnosed with COVID-19, particularly in individuals categorized as low risk.

Pentraxins in invertebrates and vertebrates: From structure, function and evolution to clinical applications

The immune system is divided into two broad categories, consisting of innate and adaptive immunity. As recognition and effector factors of innate immunity and regulators of adaptive immune responses, lectins are considered to be important defense chemicals against microbial pathogens, cell trafficking, immune regulation, and prevention of autoimmunity. Pentraxins, important members of animal lectins, play a significant role in protecting the body from pathogen infection and regulating inflammatory reactions. They can recognize and bind to a variety of ligands, including carbohydrates, lipids, proteins, nucleic acids and their complexes, and protect the host from pathogen invasion by activating the complement cascade and Fcγ receptor pathways. Based on the primary structure of the subunit, pentraxins are divided into short and long pentraxins. The short pentraxins are comprised of C-reactive protein (CRP) and serum amyloid P (SAP), and the most important member of the long pentraxins is pentraxin 3 (PTX3). The CRP and SAP exist in both vertebrates and invertebrates, while the PTX3 may be present only in vertebrates. The major ligands and functions of CRP, SAP and PTX3 and three activation pathways involved in the complement system are summarized in this review. Their different characteristics in various animals including humans, and their evolutionary trees are analyzed. The clinical applications of CRP, SAP and PTX3 in human are reviewed. Some questions that remain to be understood are also highlighted.

Serum C-reactive protein greater than 75 mg/dL as an early available laboratory predictor of severe COVID-19: A systematic review

INTRODUCTION

Severe COVID-19 management is still challenging. Having a laboratory factor to predict the severity of a patient's condition can be very useful in how to approach each patient. There have been studies concentrating on the correlation between serum C-reactive protein (CRP) level and COVID-19 severity but we aim to reach a threshold for CRP in disease severity determination.

METHODS

We conducted a thorough search on PubMed, Web of Science and Google Scholar databases from early 2019 to October 2021, and 323 studies were assessed for eligibility in three phases. We used the Newcastle-Ottawa Scale to examine the validity of the studies. The t-test was applied for the CRP level cutoffs.

RESULTS

Eventually, 11 articles and 1615 patients were included in this systematic review. Our analysis evaluated combined mean, median, and standard deviation of severe patients' CRP to be respectively 73.37, 53.80, and 47.936. Based on the combined mean, 75 mg/dL was suggested as an initial threshold for baseline CRP in hospitalized patients for developing severe conditions.

CONCLUSION

This study recommends that COVID-19 patients with on-admission serum CRP levels of 75 mg/dL and more are likely associated with severe conditions. Thus, anti-inflammatory agents and further following may be helpful in these patients.

The Role of Procalcitonin/Albumin Ratio and CRP/Albumin Ratio in Predicting In-hospital Mortality in COVID-19 Patients

Background

Hospitalized coronavirus disease 2019 (COVID-19) patients have higher mortality rates. Parameters to predict mortality are needed. Therefore, we investigated the power of procalcitonin/albumin ratio (PAR) and C-reactive protein/albumin ratio (CAR) to predict in-hospital mortality in hospitalized COVID-19 patients.

Methods

In this study, 855 patients were included. Patients' PAR and CAR values were recorded from the hospital information management system. The patients were evaluated in two groups according to their in-hospital mortality status.

Results

In-hospital mortality was observed in 163 patients (19.1%). The median PAR and CAR values of patients in the non-survivor group were statistically significantly higher than those of patients in the survivor group, PAR (median: 0.07, interquartile range [IQR]: 0.03-0.33 vs. median: 0.02, IQR: 0.01-0.04, respectively; p < 0.001); CAR (median: 27.60, IQR: 12.49-44.91 vs. median: 7.47, IQR: 2.66-18.93, respectively; p < 0.001). The area under the curve (AUC) and odds ratio (OR) values obtained by PAR to predict in-hospital mortality were higher than the values obtained by procalcitonin, CAR, albumin, and CRP (AUCs of PAR, procalcitonin, CAR, albumin, and CRP: 0.804, 0.792, 0.762, 0.755, and 0.748, respectively; OR: PAR > 0.04, procalcitonin > 0.14, CAR > 20.59, albumin < 4.02, and CRP > 63; 8.215, 7.134, 5.842, 6.073, and 5.07, respectively). Patients with concurrent PAR > 0.04 and CAR > 20.59 had an OR of 15.681 compared to patients with concurrent PAR < 0.04 and CAR < 20.59.

Conclusions

In this study, PAR was found to be more valuable for predicting in-hospital COVID-19 mortality than all other parameters. In addition, concurrent high levels of PAR and CAR were found to be more valuable than a high level of PAR or CAR alone.

Association of C-reactive protein with mortality in Covid-19 patients: a secondary analysis of a cohort study

Our study aimed to explore the association between serum C-reactive protein (CRP) and COVID-19 mortality. This is a retrospective cohort study of all patients admitted to 4 hospitals within the Montefiore Health System between March 1 and April 16, 2020, with SARS-CoV-2 infection. All-cause mortality were collected in 7 May 2020. The mortality risk was estimated using Cox proportional hazards models. Of the 3545 patients with a median age of 63.7 years, 918 (25.9%) died within the time of cohort data collection after admission. When the CRP was < 15.6 mg/L, the mortality rate increased with an adjusted HR of 1.57 (95% CI 1.30-1.91, P < 0.0001) for every 10 mg/L increment in the CRP. When the CRP was ≥ 15.6 mg/L, the mortality rate increased with an adjusted HR of 1.11 (95% CI 0.99-1.24, P = 0.0819) for every 10 mg/L increment in the CRP. For patients with COVID-19, the association between the CRP and the mortality risk was curve and had a saturation effect. When the CRP was small, the mortality rate increased significantly with the increase of CRP. When CRP > 15.6 mg/L, with the increase of CRP, the mortality rate increases relatively flat.

The effects of antihypertensive medications on severity and outcomes of hypertensive patients with COVID-19

In Covid-19 pandemic, specific comorbidities are associated with the increased risk of worse outcomes and increased severity of lung injury and mortality. the aim of this study was to investigate the effects of antihypertensive medications on the severity and outcomes of hypertensive patients with COVID-19. This retrospective observational study conducted on patients with COVID-19 who referred to Afzalipour Hospital, Kerman, Iran during the six months from 19 February 2020 to 20 July 2020. The data were collected through medical chart reviews. We assessed 265 patients with Covid-19 and they stratified based on hypertension and type of antihypertension medications. The data were described and Student's t-test, Mann-Whitney U and Fisher exact test were run to compare the patients 'demographical and clinical information. The qualitative variables were compared using the by SPSS software version 23. The results of the present study showed that hypertension was a prevalent comorbidity among patients with COVID-19 and hypertensive patients compared to other patients without any comorbidity who were older (P-value: 0.03). The oxygen saturation was higher for the patients in the control group than hypertensive patients (P-value: 0.01). The severity of COVID-19 and its outcome were not different between the patients who took or did not take antihypertensive medications and also the type of antihypertensive medications. Hypertensive patients did not show any significant difference in survival, hospital stay, ICU admission, disease severity, and invasive medical ventilation in other normotensive patients with COVID-19.

Point-of-care pancreatic stone protein measurement in critically ill COVID-19 patients

INTRODUCTION

Pancreatic stone protein (PSP) is a novel biomarker that is reported to be increased in pneumonia and acute conditions. The primary aim of this study was to prospectively study plasma levels of PSP in a COVID-19 intensive care unit (ICU) population to determine how well PSP performed as a marker of mortality in comparison to other plasma biomarkers, such as C reactive protein (CRP) and procalcitonin (PCT).

METHODS

We collected clinical data and blood samples from COVID-19 ICU patients at the time of admission (T0), 72 h later (T1), five days later (T2), and finally, seven days later. The PSP plasma level was measured with a point-of-care system; PCT and CRP levels were measured simultaneously with laboratory tests. The inclusion criteria were being a critical COVID-19 ICU patient requiring ventilatory mechanical assistance.

RESULTS

We enrolled 21 patients and evaluated 80 blood samples; we found an increase in PSP plasma levels according to mixed model analysis over time (p < 0.001), with higher levels found in the nonsurvivor population (p < 0.001). Plasma PSP levels achieved a statistically significant result in terms of the AUROC, with a value higher than 0.7 at T0, T1, T2, and T3. The overall AUROC of PSP was 0.8271 (CI (0.73-0.93), p < 0.001). These results were not observed for CRP and PCT.

CONCLUSION

These first results suggest the potential advantages of monitoring PSP plasma levels through point-of-care technology, which could be useful in the absence of a specific COVID-19 biomarker. Additional data are needed to confirm these results.

Correlation of systemic inflammation biomarkers and disease severity in pregnant women with COVID-19

OBJECTIVE

The aim of this study was to evaluate the prognostic value of whole blood parameters, systemic inflammatory indices, and systemic inflammatory markers in pregnant women with COVID-19.

METHODS

In this cross-sectional study, the demographic, clinical, and laboratory data (i.e., whole blood parameters, C-reactive protein, procalcitonin, ferritin, and D-dimer) of 464 pregnant women with COVID-19 who attended a tertiary hospital between January and April 2021 were reviewed. Systemic inflammatory indices (i.e., neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, platelet/neutrophil ratio, and systemic immune inflammation index) were calculated. Asymptomatic and mildly symptomatic pregnant women were classified as Group 1 (n=413), and those with severe disease were classified as Group 2 (n=51).

RESULTS

Lymphocyte count and lymphocyte percentage in whole blood parameters were significantly lower (p<0.05), and C-reactive protein, ferritin, and procalcitonin values were higher in Group 2 (p<0.05). Systemic inflammatory indices [neutrophil/lymphocyte ratio (4.7±2.9 (1.1-21.2) vs 7.5±4.7 (2.13-23.2)), platelet/lymphocyte ratio (191.1±104.3 (53.0-807.1) vs 269.5±118.9 (105.0-756.0)), systemic immune inflammation index (1,000±663 (209-5,231) vs 1,630±1,314 (345-7,006))] were found statistically significantly higher in severe disease group (p<0.001).

CONCLUSION

Evidence in this study indicates that neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and systemic immune inflammation index at first admission are simple, rapid, and inexpensive indices in predicting the prognosis of COVID-19 in pregnant women.

Systemic inflammation index, disease severity, and mortality in patients with COVID-19: a systematic review and meta-analysis

Introduction

An excessive systemic pro-inflammatory state increases the risk of severe disease and mortality in patients with coronavirus disease 2019 (COVID-19). However, there is uncertainty regarding whether specific biomarkers of inflammation can enhance risk stratification in this group. We conducted a systematic review and meta-analysis to investigate an emerging biomarker of systemic inflammation derived from routine hematological parameters, the systemic inflammation index (SII), in COVID-19 patients with different disease severity and survival status.

Methods

A systematic literature search was conducted in PubMed, Web of Science, and Scopus, between the 1st of December 2019 and the 15th of March 2023. Risk of bias and certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and the Grades of Recommendation, Assessment, Development and Evaluation, respectively (PROSPERO registration number: CRD42023420517).

Results

In 39 studies, patients with a severe disease or non-survivor status had significantly higher SII values on admission compared to patients with a non-severe disease or survivor status (standard mean difference (SMD)=0.91, 95% CI 0.75 to 1.06, p<0.001; moderate certainty of evidence). The SII was also significantly associated with the risk of severe disease or death in 10 studies reporting odds ratios (1.007, 95% CI 1.001 to 1.014, p=0.032; very low certainty of evidence) and in six studies reporting hazard ratios (1.99, 95% CI 1.01 to 3.92, p=0.047; very low certainty of evidence). Pooled sensitivity, specificity, and area under the curve for severe disease or mortality were 0.71 (95% CI 0.67 to 0.75), 0.71 (95% CI 0.64 to 0.77), and 0.77 (95% CI 0.73 to 0.80), respectively. In meta-regression, significant correlations were observed between the SMD and albumin, lactate dehydrogenase, creatinine, and D-dimer.

Discussion

Our systematic review and meta-analysis has shown that the SII on admission is significantly associated with severe disease and mortality in patients with COVID-19. Therefore, this inflammatory biomarker derived from routine haematological parameters can be helpful for early risk stratification in this group.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023420517.

How to diagnose COVID-19 in family practice? Usability of complete blood count as a COVID-19 diagnostic tool: a cross-sectional study in Turkey

OBJECTIVE

COVID-19 is currently diagnosed in hospital settings. An easy and practical diagnosis of COVID-19 is needed in primary care. For this purpose, the usability of complete blood count in the diagnosis of COVID-19 was investigated.

DESIGN

Retrospective, cross-sectional study.

SETTING

Single-centre study in a tertiary university hospital in Erzurum, Turkey.

PARTICIPANTS

Between March 2020 and February 2021, patients aged 18-70 years who applied to the hospital and underwent both complete blood count and reverse-transcription-PCR tests for COVID-19 were included and compared. Conditions affecting the test parameters (oncological-haematological conditions, chronic diseases, drug usage) were excluded.

OUTCOME MEASURE

The complete blood count and COVID-19 results of eligible patients identified using diagnostic codes [U07.3 (COVID-19) or Z03.8 (observation for other suspected diseases and conditions)] were investigated.

RESULTS

Of the 978 patients included, 39.4% (n=385) were positive for COVID-19 and 60.6% (n=593) were negative. The mean age was 41.5±14.5 years, and 53.9% (n=527) were male. COVID-19-positive patients were found to have significantly lower leucocyte, neutrophil, lymphocyte, monocyte, basophil, platelet and immature granulocyte (IG) values (p<0.001). Neutrophil/lymphocyte, neutrophil/monocyte and IG/lymphocyte ratios were also found to be significantly decreased (p<0.001). With logistic regression analysis, low lymphocyte count (OR 0.695; 95% CI 0.597 to 0.809) and low red cell distribution width-coefficient of variation (RDW-CV) (OR 0.887; 95% CI 0.818 to 0.962) were significantly associated with COVID-19 positivity. In receiver operating characteristic analysis, the cut-off values of lymphocyte and RDW-CV were 0.745 and 12.35, respectively.

CONCLUSION

Although our study was designed retrospectively and reflects regional data, it is important to determine that low lymphocyte count and RDW-CV can be used in the diagnosis of COVID-19 in primary care.

Correlation of Lymphocyte Subpopulations, Clinical Features and Inflammatory Markers during Severe COVID-19 Onset

Background: Dysregulation of the immune response in the course of COVID-19 has been implicated in critical outcomes. Lymphopenia is evident in severe cases and has been associated with worse outcomes since the early phases of the pandemic. In addition, cytokine storm has been associated with excessive lung injury and concomitant respiratory failure. However, it has also been hypothesized that specific lymphocyte subpopulations (CD4 and CD8 T cells, B cells, and NK cells) may serve as prognostic markers for disease severity. The aim of this study was to investigate possible associations of lymphocyte subpopulations alterations with markers of disease severity and outcomes in patients hospitalized with COVID-19. Materials/Methods: A total of 42 adult hospitalized patients were included in this study, from June to July 2021. Flow-cytometry was used to calculate specific lymphocyte subpopulations on day 1 (admission) and on day 5 of hospitalization (CD45, CD3, CD3CD8, CD3CD4, CD3CD4CD8, CD19, CD16CD56, CD34RA, CD45RO). Markers of disease severity and outcomes included: burden of disease on CT (% of affected lung parenchyma injury), C-reactive protein and interleukin-6 levels. PO2/FiO2 ratio and differences in lymphocytes subsets between two timepoints were also calculated. Logistic and linear regressions were used for the analyses. All analyses were performed using Stata (version 13.1; Stata Corp, College Station, TX, USA). Results: Higher levels of CD16CD56 cells (Natural Killer cells) were associated with higher risk of lung injury (>50% of lung parenchyma). An increase in CD3CD4 and CD4RO cell count difference between day 5 and day 1 resulted in a decrease of CRP difference between these timepoints. On the other hand, CD45RARO difference was associated with an increase in the difference of CRP levels between the two timepoints. No other significant differences were found in the rest of the lymphocyte subpopulations. Conclusions: Despite a low patient number, this study showed that alterations in lymphocyte subpopulations are associated with COVID-19 severity markers. It was observed that an increase in lymphocytes (CD4 and transiently CD45RARO) resulted in lower CRP levels, perhaps leading to COVID-19 recovery and immune response homeostasis. However, these findings need further evaluation in larger scale trials.

Clinical Significance and Diagnostic Utility of NLR, LMR, PLR and SII in the Course of COVID-19: A Literature Review

Nowadays, society is increasingly struggling with infectious diseases that are characterized by severe course and even death. Recently, the whole world has faced the greatest epidemiological threat, which is COVID-19 caused by SARS CoV-2 virus. SARS CoV-2 infection is often accompanied by severe inflammation, which can lead to the development of different complications. Consequently, clinicians need easily interpreted and effective markers of inflammation that can predict the efficacy of the treatment and patient prognosis. Inflammation is associated with changes in many biochemical and hematological parameters, including leukocyte counts and their populations. In COVID-19, changes in leukocytes count populations such as neutrophils, lymphocytes or monocytes are observed. The numerous research confirm that indicators like neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelets-to-lymphocyte ratio (PLR) and systemic inflammatory index (SII) may prove effective in assessment patient prognosis and choosing optimal therapy. Therefore, in this review, we would like to summarize the latest knowledge about the diagnostic utility of systemic inflammatory ratios - NLR, LMR, PLR and SII in patients with COVID-19. We focused on the papers evaluating the diagnostic utility of inflammatory ratios using ROC curve published in the recent 3 years. Identification of biomarkers associated with inflammation would help the selection of patients with severe course of COVID-19 and high risk of death.

The role of indices in predicting disease severity and outcomes of multisystem inflammatory syndrome in children

BACKGROUND

The aim of this study was to evaluate the role of the systemic immune inflammation index (SII), C-reactive protein/albumin ratio (CAR), the monocyte/lymphocyte ratio (MLR), and the neutrophil/lymphocyte ratio (NLR) in predicting disease severity, treatment, and prognosis in multisystem inflammatory syndrome in children (MIS-C).

METHODS

This medical record review retrospectively evaluated the clinical and laboratory findings of 191 MIS-C patients followed in the Department of Pediatric Rheumatology at Ankara City Hospital, Turkey. The patients were grouped by disease severity: mild, moderate, and severe. SII, CAR, MLR, and NLR were calculated for each group.

RESULTS

All patients had fever at the time of admission; 153 (80.1%) had gastrointestinal tract involvement, 74 (38.7%) had rash, 63 (33%) had conjunctivitis, 107 (56%) had cardiac involvement, 32 (15.6%) had renal involvement, and 143 (74.9%) had hematological involvement. According to logistic regression analysis, SII, NLR, MLR, and CAR were found to be predictive indexes for disease severity, need for intensive care, need for inotropes, and anakinra treatment in MIS-C. The cut-off values of ≥1605.3 for SII, ≥9.1 for NLR, and ≥3.9 for CAR increased the risk of severe disease by 3.4, 7.1, and 5.7 times, respectively.

CONCLUSION

NLR, SII, MLR, and CAR are effective and useful for predicting the severity of MIS-C, the need for intensive care, and the need for anakinra treatment.

The systemic immune-inflammation index in predicting sepsis mortality

BACKGROUND

The systemic immune-inflammation index (SII) is a novel parameter and its role in the prognosis of sepsis has never been explored previously.

METHODS

We retrospectively assessed 267 patients with blood-culture confirmed sepsis. Clinical and laboratory data recorded at intensive care unit (ICU) admission were analyzed. Outcomes of interest included in-hospital mortality and length-of-stay (LOS) in the ICU. Sequential Organ Failure Assessment (SOFA) scores, SII, neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) were calculated. Multivariable regression analysis was used to identify independent predictors of LOS and mortality. Area under receiver operator characteristic (AUROC) curves were used to determine optimum cutoffs, and the incremental effect of SII on the SOFA score was assessed using model discrimination and calibration properties.

RESULTS

There were 76 (28.5%) non-survivors. SII, NLR, and PLR were independent predictors of sepsis mortality, with adjusted odds ratios of 1.51 (1.24-1.84), 1.67 (1.30-2.13) and 1.24 (1.11-1.39). SII and SOFA score were independent predictors of LOS. SII had an AUROC of 0.848, and the optimum cutoff was 564 with a sensitivity and specificity of 85.5% and 71.2%. The addition of SII to the model had a significant incremental effect on the predictive ability of SOFA score (Net Reclassification Index = 0.084, P = 0.025; Integrated Discrimination Index = 0.056, P = 0.001).

CONCLUSION

The SII is an inexpensive parameter that can be used in addition to clinical sepsis scores to improve the accuracy of patient assessment.

THE IMPORTANCE OF INFLAMMATORY MARKERS IN PREDICTION OF MORTALITY IN COVID-19 PATIENTS

ÖZET GİRİŞ: Çin’de 2019 Aralık ayı sonunda ortaya çıkan COVID-19 kısa sürede tüm dünyaya yayılarak Dünya Sağlık Örgütü tarafından 11 Mart 2020’de pandemi olarak kabul edilmiştir. Pandemi hala değişen varyantlarıyla ve vaka sayılarıyla güncelliğini korumaktadır. Bu çalışmada COVID-19 tanılı yatan hastalarda 1. ve 5. gün bakılan hematolojik, inflamatuvar ve biyokimyasal belirteçlerin mortaliteyi öngörmede önemini belirlemeyi amaçladık. GEREÇ ve YÖNTEM: Araştırma retrospektif ve kesitsel çalışma olarak tasarlanmıştır. Çalışmaya 1 Kasım 2020-30 Nisan 2021 tarihleri arasında Kahramanmaraş Sütçü İmam Üniversitesi Hastanesi’ne COVID-19 şüpheli semptomları ile başvuran COVID-19 RT-PCR testi ile tanısı doğrulanarak yatışı yapılan 18 yaş üstü 200 hasta dahil edilmiştir. Hastaların yaş, cinsiyet, eşlik eden komorbid hastalıkları, 1. ve 5. gün laboratuvar parametreleri ve sonlanım durumları kaydedildi. Hastalar taburcu ve ölen şeklinde iki gruba ayrıldı. BULGULAR: Çalışmaya alınan 200 hastanın %75’i (n=150) taburcu olan, %25’i ise (n=50) 28 gün içinde ölen hastalardan oluşmaktaydı. Hastaların %63.5 (n=127) erkek, %36.5’i (n=73) kadındı. Hastaların yaş ortalaması 63±17.2 yıldı. Hastaların %50.5’i hafif, %31’i orta, %18.5’i ise ağır klinik tabloya sahipti. COVID-19 hastalarının prognozunu etkileyen faktörleri belirlemek amacıyla lojistik regresyon analizi yapıldı. Prognoz ile ilişkili faktörler erkek cinsiyet, diyabetes mellitus, KOAH, hipertansiyon varlığı, ateş, nefes darlığı ve öksürük olarak bulundu. Hastaların 1. ve 5.gün bakılan lenfosit (lenfopeni), C-Reaktif Protein (CRP), Prokalsitonin (PCT),nötrofil7lenfosit oranı (NLO), platelet /lenfosit oranı (PLO), D-Dimer değerleri tanı anında ve takiplerde mortalite öngörücüsü olarak tespit edildi (p

The Role of Neutrophil-to-Lymphocyte Ratio in Risk Stratification and Prognostication of COVID-19: A Systematic Review and Meta-Analysis

Several studies have proposed that the neutrophil−lymphocyte ratio (NLR) is one of the various biomarkers that can be useful in assessing COVID-19 disease-related outcomes. Our systematic review analyzes the relationship between on-admission NLR values and COVID-19 severity and mortality. Six different severity criteria were used. A search of the literature in various databases was conducted from 1 January 2020 to 1 May 2021. We calculated the pooled standardized mean difference (SMD) for the collected NLR values. A meta-regression analysis was performed, looking at the length of hospitalization and other probable confounders, such as age, gender, and comorbidities. A total of sixty-four studies were considered, which included a total of 15,683 patients. The meta-analysis showed an SMD of 3.12 (95% CI: 2.64−3.59) in NLR values between severe and non-severe patients. A difference of 3.93 (95% CI: 2.35−5.50) was found between survivors and non-survivors of the disease. Upon summary receiver operating characteristics analysis, NLR showed 80.2% (95% CI: 74.0−85.2%) sensitivity and 75.8% (95% CI: 71.3−79.9%) specificity for the prediction of severity and 78.8% (95% CI: 73.5−83.2%) sensitivity and 73.0% (95% CI: 68.4−77.1%) specificity for mortality, and was not influenced by age, gender, or co-morbid conditions. Conclusion: On admission, NLR predicts both severity and mortality in COVID-19 patients, and an NLR > 6.5 is associated with significantly greater the odds of mortality.

Hematological profile of COVID-19 patients in Ramanagar district, Karnataka - A cross sectional study

Introduction and Aim: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which rapidly evolved into a pandemic infecting humans all over the world. Whether hematologic and immunologic responses play a crucial role in progression of COVID-19 is still not clear. Increasing scientific evidence has shown that abnormalities in routine hematological tests, have the potential to diagnose SARS-CoV-2 infection in an economical way. Major laboratory changes indicating systemic inflammation and multi-organ impairment including hematopoietic system leading to lymphocytopenia, neutrophilia, eosinopenia, mild thrombocytopenia and ratios derived from these hematological parameters indicated severe disease and/or fatal outcomes. The aim was to study the hematological profile of Covid-19 patients admitted at a tertiary care hospital at Ramanagar district.   Materials and Methods: This retrospective study included 260 confirmed cases of Covid-19 diagnosed at a tertiary health care centre. Demographic, clinical, laboratory, treatment, and outcome data were extracted from the institutional electronic medical records after obtaining permission from the concerned authorities. From CBC test results obtained neutrophil lymphocyte ratio was derived.   Results: The present study revealed that majority of Covid positive patients   presented with lymphopenia. While a  significant association was observed between N/L ratio and disease severity, no significant association was seen between platelet count and severity of the disease.   Conclusion: Since the results of the present study features lymphopenia among large proportion of patients and elevated N/L ratio among critically ill patients these markers could be utilized as useful prognostic indicators during the initial assessment of disease severity and thus appropriate management can be planned for such patients before the condition of the patient deteriorates.

The prognostic value of biomarker levels and chest imaging in patients with COVID-19 presenting to the emergency department

Introduction

We aimed to compare the prognostic value of a quantitative CT severity score with several laboratory parameters, particularly C-reactive protein, Procalcitonin, Neutrophil to lymphocyte ratio, D-dimer, ferritin, lactate dehydrogenase, lactate, troponin and B-type Natriuretic Peptide in predicting in-hospital mortality.

Methods

This was a retrospective chart review study of COVID-19 patients who presented to the Emergency Department of a tertiary care center between February and December 2020. All patients ≥18 years old who tested positive for the COVID-19 real-time reverse transcriptase polymerase chain reaction and underwent CT imaging at presentation were included. The primary outcome was the prognostic ability of CT severity score versus biomarkers in predicting in-hospital mortality.

Results

The AUCs were: D-dimer (AUC: 0.67 95% CI = 0.57–0.77), CT severity score (0.66, 95% CI = 0.55–0.77), LDH (0.66, 95% CI = 0.55–0.77), Pro-BNP (0.65, 95% CI = 0.55–0.76), NLR (0.64, 95% CI = 0.53–0.75) and troponin (0.64, 95% CI = 0.52–0.75). In the stepwise logistic regression, age (OR = 1.07 95% CI = 1.05–1.09), obesity (OR = 2.02 95% CI = 1.25–3.26), neutrophil/lymphocyte ratio (OR = 1.02 95% CI = 1.01–1.04), CRP (OR = 1.01 95% CI = 1.004–1.01), lactate dehydrogenase (OR = 1.003 95% CI = 1.001–1.004) and CT severity score (OR = 1.17 95% CI = 1.12–1.23) were significantly associated with in-hospital mortality.

Conclusion

In summary, CT severity score outperformed several biomarkers as a prognostic tool for covid related mortality. In COVID-19 patients requiring lung imaging, such as patients requiring ICU admission, patients with abnormal vital signs and those requiring mechanical ventilation, the results suggest obtaining and calculating the CT severity score to use it as a prognostic tool. If a CT was not performed, the results suggest using LDH, CRP or NLR if already done as prognostic tools in COVID-19 as these biomarkers were also found to be prognostic in COVID-19 patients.

Correlation of the Imbalance in the Circulating Lymphocyte Subsets With C-Reactive Protein and Cardio-Metabolic Conditions in Patients With COVID-19

The immune system is severely compromised in patients with COVID-19. The representative group of 43 patients were selected from the cohort of 342 patients with COVID-19 and pneumonia. This group of 43 patients was examined for the levels of C-reactive protein, biomarker of systemic inflammation, and for the subsets of adaptive immune cells. The immunological parameters were correlated with the metabolic parameters and cardiovascular pathology history. We identified that a decrease in the absolute number of T-lymphocytes, T-cytotoxic, T-activated and B-lymphocytes correlated with the higher levels of CRP. The absolute number of T-helpers and the absolute number of double positive T-lymphocytes positively correlated with the levels of iron in serum (Z= 0,310 and Z=0,394). The absolute numbers of T-activated lymphocytes positively correlated with serum levels of LDH (Z = 0,422), ferritin (Z = 0,407) and iron (Z = 0,418). When studying subpopulations of lymphocytes, depending on the combined pathology, we found that the absolute numbers of B-lymphocytes and double positive T-lymphocytes in the peripheral blood were significantly reduced in patients with arterial hypertension (p=0,0074 and p=0,0227, correspondingly). The increased levels of NK cell were found in patients with a history of coronary heart disease (p=0,0108). In addition, we found that deficiencies in the adaptive immune system correlated with the deficiencies in iron metabolism. The cardiovascular pathology upsets the balance in the adaptive and innate immune system in the circulation of patient with severe COVID-19.

High Dose Steroids as First-Line Treatment Increased the Risk of In-Hospital Infections in Patients With Anti-NMDAR Encephalitis

Objective

To address the effects of high dose steroids on in-hospital infection and neurologic outcome in anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis patients.

Methods

We retrospectively reviewed the clinical data of anti-NMDAR encephalitis patients in West China Hospital, the Third Hospital of Mianyang and Mianyang Central Hospital between October 2011 and August 2020. The development of infections, inflammatory factors, neurologic outcome at discharge and risk factors for in-hospital infection were assessed in patients with and without high dose steroid therapy before and after immunotherapy. Least absolute shrinkage and selection operator (LASSO) regression and logistic regression models were established to assess risk factors for in-hospital infection.

Results

A total of 278 patients with anti-NMDAR encephalitis were included in the study. Thirty-four patients received high dose methylprednisolone (IVMP) therapy only, 84 patients received intravenous immunoglobulin (IVIG) therapy, and 160 patients received IVIG and IVMP therapy. Compared with the IVIG group, IVIG + IVMP group had a higher infection rate (64.38% vs 39.29%, P < 0.001), a higher incidence of noninfectious complications (76.25% vs 61.90%, P = 0.018) and a higher modified Rankin Scale (mRS) score at discharge from the hospital (3 vs 2, P < 0.001). Inflammatory indicators, including white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII), were higher (9.93 vs 5.65, 6.94 vs 3.47 and 1.47 vs 0.70, respectively, P < 0.001) in the IVIG + IVMP group than in the IVIG group. Moreover, lymphocyte-to-monocyte ratio (LMR) was lower (2.20 vs 2.54, P = 0.047) in the IVIG + IVMP group. The LASSO model showed that mRS score on admission, seizure, body temperature, uric acid (URIC), cerebrospinal fluid immunoglobulin G (CSF IgG), NLR and LMR were risk factors for in-hospital infection. The prediction model exhibited an area under the curve (AUC) of 0.885.

Conclusions

High dose steroids therapy was significantly associated with higher in-hospital infectious complication rates and a poor short-term prognosis in relatively severe anti-NMDAR encephalitis patients. The established prediction model might be helpful to reduce the risk of in-hospital infection.

The Role of Different Inflammatory Indices in the Diagnosis of COVID-19

AIM

To assess the role of different inflammatory indices in the diagnosis of COVID-19 infection.

METHODS

The neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), derived NLR (dNLR), neutrophil to lymphocyte, platelet ratio (NLPR), systemic inflammation index (SII), aggregate index of systemic inflammation (AISI), systemic inflammation response index (SIRI) and C-reactive protein-to-lymphocyte ratio (CRP/L) were assessed in 88 COVID-19 patients compared to 41 healthy control subjects.

RESULTS

The NLR, PLR, NLPR, SIRI, and CRP/L were significantly increased, while LMR was significantly decreased in COVID-19 patients compared to the control group (P = 0.008, 0.011, <0.001, 0.032, 0.002 and P < 0.001; respectively). The AUC for the assessed indices was LMR (0.738, P = 0.008), NLPR (0.721, P < 0.001), CRP/L (0.692, P = 0.002), NLR (0.649, P < 0.001), PLR (0.643, P = 0.011), SIRI (0.623, P = 0.032), dNLR (0.590, P = 0.111), SII (0.571, P = 0.207), and AISI (0.567, P-0.244). Multivariate analysis showed that NLPR >0.011 (OR: 38.751, P = 0.014), and CRP/L >7.6 (OR: 7.604, P = 0.022) are possible independent diagnostic factors for COVID-19 infection.

CONCLUSION

NLPR and CRP/L could be potential independent diagnostic factors for COVID-19 infection.

The role of inflammatory indices in the outcome of COVID-19 cancer patients

To assess the prognostic role of different inflammatory indices on the outcome of cancer patients with COVID-19. Sixty-two adults and 22 pediatric cancer patients with COVID-19 infection were assessed for the prognostic value of certain inflammatory indices including the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), derived NLR (dNLR), systemic inflammation index (SII), mean platelet volume to platelet ratio (MPR), C-reactive protein to lymphocyte ratio (CRP/L), aggregate index of systemic inflammation (AISI), systemic inflammation response index (SIRI), and neutrophil to lymphocyte, platelet ratio (NLPR). Data were correlated to patients' outcome regarding ICU admission, and incidence of mortality. Increased CRP/L ratio in adult COVID-19 cancer patients was significantly associated with inferior survival [152 (19-2253) in non-survivors, compared to 27.4 (0.8-681) in survivors (P = 0.033)]. It achieved a sensitivity (60%) and a specificity (90.2%) at a cut-off 152, while it achieved a sensitivity of 60% and specificity 95.1% at a cut-off 252 (AUC 0.795, P = 0.033). When combining both CRP/L and NLPR for the prediction of poor outcome in adult cancer patients with COVID19, the sensitivity increased to 80% and the specificity was 70.7% (AUC 0.805, P = 0.027). Increased incidence of ICU admission in pediatric cancer patients associated significantly with the severity of covid19 infection, decreased mean corpuscular hemoglobin (MCH) < 28.3, increased red cell distribution width (RDW) > 16, lymphopenia < 1.04, pseudo Pelger-Huet appearance, and PLR < 196.4 (P = 0.004, P = 0.040, P = 0.029, P = 0. 0.039, P = 0.050, and P = 0.040; respectively). The mean corpuscular volume (MCV), MCH, and RDW could be useful prognostic markers for poor outcome in COVID-19 pediatric cancer patients (P < 0.05 for all). Increased both CRP/L and NLPR associated significantly with poor survival in adult COVID-19 cancer patients, while PLR associated significantly with ICU admission in pediatric COVID-19 cancer patients.

The role of C-reactive protein in predicting the severity of COVID-19 disease: A systematic review

Since December 2019, coronavirus diseases-2019 (COVID-19) dispersed into 200 countries and affected more than 70 million people. The clear picture of the SARS-CoV-2 infection is still under investigation. In this review, we evaluated whether C-reactive protein biomarker is able to predict the clinical outcomes or correlated with the severity of COVID-19 disease. The databases MEDLINE, Hinari, Google Scholar, and Google search were used to find potential studies published from COVID-19 epidemic until May 2021. A format prepared in Microsoft Excel spreadsheet was used to extract the appropriate details from each original report. For further review, the extracted data were exported to STATA/MP version 16.0 software. Keywords including "COVID-19," "SARS-CoV-2," and "C-reactive protein," among others were used to search relevant articles. Only studies which reported the average C-reactive protein value and COVID-19 disease stage outcomes were included. Twenty articles were included in the review. All studies found considerably higher level of C-reactive protein in patients with severe COVID-19 as compared to mildly infected patients. This review evidenced that it is still there for a given biomarker to early identify the state of progression in asymptomatic and/or mildly infected individuals into severe disease; the level of C-reactive protein may be used in predicting the likelihood of disease progression. Findings from this review showed level of C-reactive protein is a good biomarker to predict the severity of COVID-19 disease. Although COVID-19 researches are at the early stages, investigation of C-reactive protein levels throughout the disease course may have paramount importance for clinicians in early detection of severe manifestations and subsequently improve the prognosis. However, further large-scale studies are required to confirm these findings.

COVID-19 induces proatherogenic alterations in moderate to severe non-comorbid patients: A single-center observational study

Patients with COVID-19 can be asymptomatic or present mild to severe symptoms, leading to respiratory and cardiovascular complications and death. Type 2 diabetes mellitus (T2DM) and obesity are considered risk factors for COVID-19 poor prognosis. In parallel, COVID-19 severe patients exhibit dyslipidemia and alterations in neutrophil to lymphocyte ratio (NLR) associated with disease severity and mortality. To investigate whether such alterations are caused by the infection or results from preexisting comorbidities, this work analyzed dyslipidemia and the hemogram profile of COVID-19 patients according to the severity and compared with patients without T2DM or obesity comorbidities. Dyslipidemia, with a marked decrease in HDL levels, and increased NLR accompanied the disease severity, even in non-T2DM and non-obese patients, indicating that COVID-19 causes the observed alterations. Because decreased hemoglobin is involved in COVID-19 severity, and hemoglobin concentration is associated with metabolic diseases, the erythrogram of patients was also evaluated. We verified a drop in hemoglobin and erythrocyte number in severe patients, independently of T2DM and obesity, which may explain in part the need for artificial ventilation in severe cases. Thus, the control of such parameters (especially HDL levels, NLR, and hemoglobin concentration) could be a good strategy to prevent COVID-19 complications and death.

Interplay between Neutrophils, NETs and T-Cells in SARS-CoV-2 Infection-A Missing Piece of the Puzzle in the COVID-19 Pathogenesis?

Since the end of 2019, a new, dangerous virus has caused the deaths of more than 3 million people. Efforts to fight the disease remain multifaceted and include prophylactic strategies (vaccines), the development of antiviral drugs targeting replication, and the mitigation of the damage associated with exacerbated immune responses (e.g., interleukin-6-receptor inhibitors). However, numerous uncertainties remain, making it difficult to lower the mortality rate, especially among critically ill patients. While looking for a new means of understanding the pathomechanisms of the disease, we asked a question-is our immunity key to resolving these uncertainties? In this review, we attempt to answer this question, and summarize, interpret, and discuss the available knowledge concerning the interplay between neutrophils, neutrophil extracellular traps (NETs), and T-cells in COVID-19. These are considered to be the first line of defense against pathogens and, thus, we chose to emphasize their role in SARS-CoV-2 infection. Although immunologic alterations are the subject of constant research, they are poorly understood and often underestimated. This review provides background information for the expansion of research on the novel, immunity-oriented approach to diagnostic and treatment possibilities.

Cross-National Variations in COVID-19 Mortality: The Role of Diet, Obesity and Depression

Background: The COVID-19 pandemic has been characterized by wide variations in mortality across nations. Some of this variability may be explained by medical comorbidities such as obesity and depression, both of which are strongly correlated with dietary practices such as levels of sugar and seafood consumption. Methods: COVID-19 mortality indices for 156 countries were obtained from the Johns Hopkins University’s data aggregator. Correlations between these variables and (a) per capita consumption of sugar and seafood, and (b) country-wise prevalence of depression and obesity were examined. Results: Sugar consumption (r = 0.51, p < 0.001) and prevalence of obesity (r = 0.66, p < 0.001) and depression (r = 0.56, p < 0.001) were positively correlated with crude mortality rates, while seafood consumption was negatively correlated with the infection fatality rate (r = −0.28, p = 0.015). These effects were significant even after correcting for potential confounders. The associations with depression and obesity remained significant upon multivariate regression. Conclusions: Both obesity and depression, which are associated with inflammatory dysregulation, may be related to cross-national variations in COVID-19 mortality, while seafood consumption may be protective. These findings have implications in terms of protecting vulnerable individuals during the current pandemic.

C-reactive protein as a possible marker for severity and mortality of COVID-19 infection

AIM

The present study aimed to introduce a possible biomarker to differentiate between severe and fatal conditions of COVID-19.

BACKGROUND

The COVID-19 pandemic, appearing as a complicated health problem, has changed the lifestyle of people in recent years. Clinical findings indicate mild, severe, and fatal conditions of this disease. Prediction of disease severity is a significant point in managing COVID-19 infection.

METHODS

In this study, 195 differentially expressed genes (DEGs) that discriminate between fatal and severe conditions in patients were extracted from the literature and screened to determine the significant ones. The significant DEGs plus the 90 first neighbors added from the STRING database were included in the interactome using Cytoscape software v 3.7.2. The central nodes of the analyzed network were identified and assessed.

RESULTS

Ten significant DEGs were candidates for assessment, of which 9 were recognized by the STRING database. IL6, ALB, TNF, CRP, INS, MPO, C3, CXCL8, TTR, and TLR4 were determined as central nodes; IL6, CRP, and TTR were highlighted as the critical genes related to the severity of COVID-19 infection.

CONCLUSION

CRP was identified as the best possible biomarker with levels related to the severity and fatality of COVID-19 infection.