The use of neutrophil-to-lymphocyte ratio (NLR) as a marker for COVID-19 infection in Saudi Arabia: A case-control retrospective multicenter study

Back to Basics: The Diagnostic Value of a Complete Blood Count in the Clinical Management of COVID-19

Since the beginning of the COVID-19 pandemic, scientists have struggled significantly to understand the complexity of COVID-19 pathophysiology. COVID-19 has demonstrated a notoriously unpredictable clinical course. This unpredictability constituted a significant obstacle to clinicians in predicting the disease course among COVID-19 patients, more specifically, in predicting who would develop severe cases and possibly die from the infection. This brief report aims to assess the diagnostic value of using a complete blood count (CBC) and applying high-dimensional analysis, i.e., principal component analysis (PCA), on it to differentiate between patients with mild and severe COVID-19 infection. The data of 855 patients were retrieved from multiple centres in Saudi Arabia. Descriptive statistics, such as counts, percentages, and medians (interquartile ranges) were used to describe patients' characteristics and CBC parameters. Analytical statistics, such as the Mann-Whitney U test, were used to compare between survivors and non-survivors. PCA was applied using the CBC parameters, and the results were compared between survivors and non-survivors. Patients in this study had a median age of 41, with an almost equal ratio of men to women. Most participants were Saudis, and non-survivors were 13.22% of the total cohort. The median values of all CBC indices were within reference ranges; however, some statistically significant differences were observed between survivors and non-survivors. Non-survivors had lower hemoglobin levels and lower hematocrit, lymphocyte, and eosinophil counts but higher WBC and neutrophil counts compared to survivors. PCA on the CBC results of survivors yielded a significantly different profile than non-survivors, indicating the possibility of its use in the context of COVID-19. The diagnostic value of CBC in the clinical management of COVID-19 should be utilized in clinical guidelines for managing COVID-19 cases.

Neutrophil-to-lymphocyte ratio at diagnosis as a biomarker for survival of amyotrophic lateral sclerosis

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR) has previously been reported to be associated with survival in ALS. To provide further information about the role of NLR as a biomarker in ALS, we performed a systematic review, analyzed data from our local cohort of ALS subjects and performed a meta-analysis.

METHODS

(1) The systematic review used established methods. (2) Using data from our cohort of subjects, we analyzed the association of NLR with survival. (3) Meta-analysis was performed using previous studies and our local data.

RESULTS

(1) In the systematic review, higher NLR was associated with shorter survival in all studies. (2) In our subjects, survival was significantly shorter in patients in the highest NLR groups. (3) Meta-analysis showed subjects with highest NLR tertile or with NLR >3 had significantly shorter survival than other subjects.

DISCUSSION

This study supports NLR as a biomarker in ALS; high NLR is associated with poor survival.

Blood RNA Biomarkers Identify Bacterial and Biofilm Coinfections in COVID-19 Intensive Care Patients

Purpose: Secondary opportunistic coinfections are a significant contributor to morbidity and mortality in intensive care unit (ICU) patients, but can be difficult to identify. Presently, new blood RNA biomarkers were tested in ICU patients to diagnose viral, bacterial, and biofilm coinfections. Methods: COVID-19 ICU patients had whole blood drawn in RNA preservative and stored at -80°C. Controls and subclinical infections were also studied. Droplet digital polymerase chain reaction (ddPCR) quantified 6 RNA biomarkers of host neutrophil activation to bacterial (DEFA1), biofilm (alkaline phosphatase [ALPL], IL8RB/CXCR2), and viral infections (IFI27, RSAD2). Viral titer in blood was measured by ddPCR for SARS-CoV2 (SCV2). Results: RNA biomarkers were elevated in ICU patients relative to controls. DEFA1 and ALPL RNA were significantly higher in severe versus incidental/moderate cases. SOFA score was correlated with white blood cell count (0.42), platelet count (-0.41), creatinine (0.38), and lactate dehydrogenase (0.31). ALPL RNA (0.59) showed the best correlation with SOFA score. IFI27 (0.52) and RSAD2 (0.38) were positively correlated with SCV2 viral titer. Overall, 57.8% of COVID-19 patients had a positive RNA biomarker for bacterial or biofilm infection. Conclusions: RNA biomarkers of host neutrophil activation indicate the presence of bacterial and biofilm coinfections in most COVID-19 patients. Recognizing coinfections may help to guide the treatment of ICU patients.

Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

OBJECTIVE

To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients.

METHODS

An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression.

RESULTS

Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were -62.4% for C-reactive protein, +45.7% for total lymphocytes, and -32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 - 4.5; p < 0.001).

CONCLUSION

In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

Assessing the Diagnostic Values of the Neutrophil-to-Lymphocyte Ratio (NLR) and Systematic Immunoinflammatory Index (SII) as Biomarkers in Predicting COVID-19 Severity: A Multicentre Comparative Study

COVID-19 has been notoriously unpredictable in its clinical course. Such unpredictability poses a challenge to clinicians in predicting patients who will develop severe cases and possibly die from the infection. This study aims to assess and compare the diagnostic value of the NLR and SII as biomarkers in predicting COVID-19 severity, represented by mortality, with a multicentre comparative study including 855 patients in Saudi Arabia. Descriptive and analytical statistics were used to compare haematological indices between survivors and non-survivors. The median age of patients included was 41 years old, with an almost equal ratio of men to women. Most participants were Saudis, and the mortality rate in the study cohort was 13.22%. Non-survivors, as compared to survivors, were significantly older, had lower RBC counts, haemoglobin and haematocrit levels, as well as significantly higher WBC and neutrophil counts. Both the NLR and SII were capable of differentiating between survivors and non-survivors, with the latter having significantly higher values. However, the NLR was superior to the SII in such differentiation, as it had a larger area under the curve. This study further confirms the diagnostic values of the NLR and SII as biomarkers in predicting COVID-19 severity and mortality, with the NLR being more sensitive and specific. Clinical guidelines on managing COVID-19 cases should benefit from these findings by harnessing the value of the NLR in COVID-19 management.

Comparative Analysis of Red Blood Cells, White Blood Cells, Platelet Count, and Indices in Type 2 Diabetes Mellitus Patients and Normal Controls: Association and Clinical Implications

Background

Diabetes mellitus (DM) is a major health burden affecting 537 million adults worldwide, characterized by chronic metabolic disorder and various complications. This case control study aimed to assess the impact of type 2 diabetes mellitus (T2DM), including hyperglycemia levels, on hematological parameters and complete blood count (CBC) derived parameters.

Methods

A total of 250 known diabetic patients from the Jazan Diabetic Center, Saudi Arabia, between January 2021 and December 2022, along with 175 healthy adult controls were recruited from Jazan Hospital's blood donation center. Demographic characteristics, medical histories, and relevant factors such as gender, age, BMI, treatment, disease duration, and comorbidities were collected with informed consent.

Results

The results of the red blood cell (RBC) count, RBC indices, and mean platelet volume showed significant differences between patients and controls, while the white cell (WBC) and platelet count were comparable between the two groups. CBC-derived parameters, especially neutrophil/lymphocyte ratio (NLR), and platelet/neutrophil ratio (PNR) exhibited significant differences.

Conclusion

CBC and derived parameters serve as inexpensive tools for T2DM patients monitoring, indicating early blood cell alterations and potential development of anemia. Further studies are needed to explore their role in predicting T2DM pathogenesis and progression, aiming to reduce severe complications, mortality and morbidity.

Developing a COVID-19 Mortality Prediction (CoMPred) Indicator for ICU Diabetic Patients Treated with Tocilizumab in Saudi Arabia: A Proof-of-Concept Study

Since the beginning of the COVID-19 pandemic, efforts have been made to underline its discourse and identify factors contributing to its severe forms. Clinically, many physicians depended on subjective criteria to determine its severe forms, which varied significantly between practices. However, they did not rely on objective laboratory findings. This study aimed to present a novel and objective laboratory-based indicator to predict mortality among COVID-19 patients. The study included 249 COVID-19 patients who were admitted to the ICU, of which 80 did not survive. The COVID-19 Mortality Prediction (CoMPred) indicator was developed by including the age and the following lab investigations: neutrophil-to-lymphocyte ratio (NLR), D-Dimer, PT, aPTT, ESR, CRP, and urea levels. A CoMPred score of 7.5 or higher carries a sensitivity of 81.10% in predicting mortality, i.e., a patient with a CoMPred score of 7.5 or higher has an 81.10% chance of dying. The CoMPred indicator score directly correlates with mortality, i.e., the higher the score, the higher the possibility of the patient dying. In conclusion, the CoMPred indicator is an objective tool that is affordable and widely available, will assist physicians, and limit the burden on clinical decisions on an unpredicted course of COVID-19 in patients.

A Retrospective Analysis of the Association of Neutrophil-Lymphocyte Ratio (NLR) with Anemia in the Saudi Population

Background: The link between inflammation and anemia is well established but fluctuations in the emerging inflammatory index, neutrophil-lymphocyte ratio (NLR), in anemic subjects remain ambiguous. The purpose of this study is to address the prevailing knowledge gaps regarding the association of NLR with anemia in the Saudi population. Methods: Laboratory results of NLR, C-reactive protein (CRP), and hemoglobin for 14,261 subjects were obtained from Al Borg Diagnostics and retrospectively analyzed. Means, risk measures, and the diagnostic performance of NLR for anemia were examined in age- and gender-wise comparisons. Results: NLR was significantly elevated in anemic individuals and those with high NLR had a significantly lower Hb concentration. Moreover, elevated NLR was more prevalent in anemic subjects (PR: 1.87, 95% CI: 1.46-2.40, p < 0.0001) and carried a greater risk for the condition (OR: 1.91, 95% CI: 1.47-2.48, p < 0.0001) as did CRP. These observations demonstrated distinct age- and gender-specific patterns. However, both parameters were of no value in the diagnosis of anemia as seen from receiver operating characteristic curves. Conclusions: Altogether, these findings indicate that elevated NLR is associated with anemia, which suggests its usefulness for monitoring rather than diagnosing anemia associated with inflammation in Saudi subjects. Further examination of this association in longitudinal studies is needed.

Epidemiological Characteristics and Outcomes Predictors for Intensive Care Unit COVID-19 Patients in Al-Madinah, Saudi Arabia. Retrospective Cohort Study

Introduction

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) increased the demand for intensive care unit (ICU) services. Mortality and morbidity rates among ICU COVID-19 patients are affected by several factors, such as severity, comorbidities, and coinfections. In this study, we describe the demographic characteristics of COVID-19 patients admitted to an ICU in Saudi Arabia, and we determined the predictors for mortality and prolonged ICU length of stay. Additionally, we determined the prevalence of bacterial coinfection and its effect on the outcomes for ICU COVID-19 patients.

Methods

We retrospectively studied the medical records of 142 COVID-19 patients admitted to the ICU at a tertiary hospital in Madinah, Saudi Arabia. Data on demographics, medical history, mortality, length of stay, and presence of coinfection were collected for each patient.

Results

Neutrophil-to-Lymphocyte ratio (NLR) and intubation were reliable predictors of mortality and ICU length of stay among these ICU COVID-19 patients. Moreover, bacterial coinfections were detected in 23.2% of the patients and significantly (p < 0.001) prolonged their ICU length of stay, explaining the 10% increase in the length of stay for these patients. Furthermore, mortality reached 70% among the coinfected patients, and 60.8% of the isolated coinfecting pathogens were multidrug-resistant (MDR) strains of Klebsiella pneumoniae, Acinetobacter baumannii, and Staphylococcus aureus.

Conclusion

Increased NLR and intubation are predictors of mortality and prolonged length of stay in COVID-19 patients admitted to the ICU. Coinfection with MDR bacterial strains potentially results in complications and is a high-risk factor for prolonged ICU length of stay.

The Diagnostic Value of Kinetics of NLR to Identify Secondary Pulmonary Bacterial Infection Among COVID-19 Patients at Single Tertiary Hospital in Indonesia

Purpose

Coronavirus disease 2019 (COVID-19) is a new respiratory tract infection caused by severe acute respiratory syndrome coronavirus-2. The presence of secondary pulmonary bacterial infection (SPBI) made COVID-19 difficult to treat. Neutrophil-lymphocyte count ratio (NLR) is a systemic inflammatory marker used in the diagnosis and prognosis of viral or bacterial infection. At the first 3-5 days after hyperinflammation, it occurs in relation to clinical outcome. Therefore, this study aimed to evaluate the diagnostic value of NLR based on leukocyte kinetics upon admission and after 72 hours among COVID-19 patients with or without SPBI.

Patients and Methods

This retrospective cross-sectional study analyzed medical records data of admitted patients with COVID-19 according to the International Classification of Disease 10th Revision (ICD-10) between January and December 2021. The list of patients was extracted and followed by a hand search to identify the inclusion or exclusion criteria and stratified into proven and non-proven SPBI based on clinical data. The study distinguished between SPBI by means of a cut-off value (COV) on the first (D1) and third day (D3), assessed using receiver operating characteristics (ROC), as well as determined the magnitude of sensitivity, specificity, and prevalence ratio.

Results

A screening process was conducted on 2902 COVID-19 patients, of which 236 were included, accounting for 8.1%. Among these patients, 87 (36.9%) were found to have proven SPBI. A considerable difference in NLR value between proven and non-proven SPBI was observed on both D1 (11.1 vs 4.2) and D3 (15.3 vs 5.2), with optimal COV of NLR on D1, D3 was found to be 5.29, 9.47, respectively (p < 0.001).

Conclusion

NLR on the D1 and D3 distinguished the occurrence of SPBI among COVID-19 patients. The application of NLR assisted in the early determination of bacterial infection and helped in controlling the empirical use of antibiotics.

Prognostic Value of Routine Biomarkers in the Early Stage of COVID-19

Various biomarkers like certain complete blood cell count parameters and the derived ratios including neutrophil-lymphocyte ratio are commonly used to evaluate disease severity. Our study aimed to establish if baseline levels of complete blood cell count-derived biomarkers and CRP, measured before any treatment which can interfere with their values, could serve as a predictor of development of pneumonia and the need for hospitalization requiring oxygen therapy. We retrospectively analyzed the laboratory data of 200 consecutive patients without comorbidities, who denied usage of medications prior to blood analysis and visited a COVID-19 ambulance between October and December 2021. Multivariate regression analysis extracted older age, elevated CRP and lower eosinophil count as significant independent predictors of pneumonia (p = 0.003, p = 0.000, p = 0.046, respectively). Independent predictors of hospitalization were higher CRP (p = 0.000) and lower platelet count (p = 0.005). There was no significant difference in the neutrophil-lymphocyte and platelet-lymphocyte ratios between examined groups. Individual biomarkers such as platelet and eosinophil count might be better in predicting the severity of COVID-19 than the neutrophil-lymphocyte and platelet-lymphocyte ratios.

Differential Characteristics of Patients for Hospitalized Severe COVID-19 Infected by the Omicron Variants and Wild Type of SARS-CoV-2 in China

Background

As multiple mutations of SARS-Cov-2 exist, there are now many viral variants with regional differences in distribution. The clinical characteristics of patients hospitalized with the virus also vary significantly, with those of the Omicron variants being strikingly different from those of the earliest wild-type variant. However, comprehensive data on this subject is lacking. It is therefore crucial to explore these differences to develop better clinical strategies for the management of COVID-19.

Methods

A total of 554 confirmed COVID-19 cases in China were clinically classified as mild, moderate, severe, and critical according to their diagnoses and treatment plans. We compared the demographics and clinical characteristics of patients infected with the Omicron vs wild-type strains, between severe and non-severe cases. Bacterial co-infections with SARS-CoV-2 and correlation between inflammatory factors and T cells were analyzed.

Results

Compared to the wild-type cases, the severe Omicron cases were older (median age 48.36 vs 73.24), and had more upper-respiratory symptoms and comorbidities. Decreased leukocyte counts were less pronounced, although more instances of significantly decreased CD4+ and CD8+ T-cell counts, elevated infection-related biomarkers (eg procalcitonin and C-reactive protein), and abnormal coagulation factors (including increased D-dimer and fibrinogen levels) were detected in the severe Omicron cases. The mean length of hospital stay was significantly shorter in the severe Omicron cases. CD4+ and CD8+ T cell numbers were negatively correlated with neutrophil-to-lymphocyte ratios, as well as serum interleukin-6, procalcitonin, and C-reactive protein levels.

Conclusion

There were significant clinical differences between patients hospitalized with severe cases of Omicron- variant COVID-19 vs wild-type. The Omicron cases tended to be older and had more upper respiratory tract symptoms, comorbidities and bacterial co-infections. Elevated levels of inflammatory cytokines with T-cell depletion correlated with poor disease progression and prognosis. We hope these data provide a theoretical basis for future integrated prevention and control plans for COVID-19.

Role of T cells in cervical cancer

Cervical cancer is an important health problem and it is considered the fourth most lethal women's cancer worldwide. The intertumoral T cell pool is exposed in a number of immunosuppressive pathways. Therefore, it is of interest to document the effect of cervical cancer on immune system, the role of T cells in the development and pathogenesis of cervical cancer. HPV is considered the most important risk factors for developing cervical cancer, HPV 16 and 18, the two most common oncogenic types which are high risk HPV cause 70% of cervical cancer cases. In the cervical mucosa, the proportion of CD4+ and CD8+ T cells is related to the severity of the lesions. Cervical cancer can be treated by immunotherapeutic vaccine which involves T cells. T cells play an important part in cervical cancer pathogenesis because HPV exploits several methods to avoid host T-cell immune surveillance. T-cell-based immunotherapy is important because it is selective and has therapeutic potential.

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.

Comparative Study of Clinical Severity and Biochemical Markers in Pre COVID-19 and COVID-19 Rhino-Orbito Cerebral Mucormycosis

In view of high surge of sinonasal mucormycosis cases after the second wave of covid 19, present study was planned to know and compare the clinical severity of the disease and also to better understand the difference in the biochemical markers during precovid and post covid period. This retrospective observational study included all cases of sinonasal mucormycosis which were treated in our institute from August 2012 to August 2021. Details of these cases were collected from hospital database system. Biochemical parameters included FBS, HbA1C, urine ketone bodies, blood pH and creatinine. Clinical severity score was measured using self-structured severity scoring system. We found that out of 74 cases treated in our hospital 28 cases were in pre covid period while 46 cases belonged to covid 19 period. Higher male predominance was seen during post covid period (76% vs. 60%). Urine ketone bodies were positive in 7% patients in precovid period compared to 26% in post-covid period. FBS and HbA1C were high approximately 80 and 90% patients respectively in both groups. Clinical severity was significantly high in post covid patients. The present study showed that in spite of similar biochemical profile. The severity of mucormycosis was high in covid positive patients. This study shows that Covid-19 is an independent high risk factor in mucormycosis patients.

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 Reasons behind COVID-19 Vaccination Hesitancy among the Parents of Children Aged between 5 to 11 Years Old in Saudi Arabia

Simultaneously with the development of the COVID-19 vaccination plan for minors, it is critical to understand the reasons related to parental COVID-19 vaccination hesitancy. This study aims to determine the reasons associated with vaccination hesitancy among parents, and the prevalence and the characteristics of the parents who are hesitant to allow their children aged between 5 to 11 years old to be administered the COVID-19 vaccines. A web-based questionnaire was used to perform this study between May 2022 to September 2022 in Saudi Arabia (SA). Several factors, personal and social, affected the participants' willingness to vaccinate their children with the COVID-19 vaccines. The age of the parents was found to have a significant impact on their decision to vaccinate their children. Those between the age of 40-49 years of age were the most willing to vaccinate (almost 41%) compared to those 50 years or older who were most resistant to vaccination. Female participants were more resistant to vaccinating their children compared to their male counterparts. Saudis were more resistant to vaccinating their children compared to the non-Saudi participants. Those private sector-employed parents were the most willing to vaccinate (16.6%), followed by those working in the governmental sector (13.8%). About 40.7% of non-healthcare workers were resistant to vaccinating their minor compared to healthcare workers (8.7%). In conclusion, the study presents several factors that affect the parental willingness to vaccinate their children in SA. These factors should be properly addressed when developing public health strategies to promote the COVID-19 vaccination of children in SA.

Assessing the Impact of Use and Trust in Different Sources of Information on COVID-19 Vaccination Uptake in Saudi Arabia (SA) Using the COVID-19 Vaccine Hesitancy and Resistance in SA (CoV-HERSA) Tool

COVID-19 vaccination has been the cornerstone measure to tackle the severe morbidity and mortality of the ongoing global pandemic. However, vaccine hesitancy and resistance were observed in different populations, including Saudi Arabia (SA), yet such hesitancy was not accurately measured, nor were its influencing factors determined. The COVID-19 Vaccine Hesitance and Resistance in SA (CoV-HERSA) tool was developed, validated, and distributed to 387 participants to accurately measure their COVID-19 vaccine hesitancy and its influencing factors. Different chronic conditions affected participants' CoV-HERSA differently, with those having autoimmune disorders having the highest CoV-HERSA scores. Previous exposure to COVID-19 significantly increased the CoV-HERSA scores. The use and trust of the different sources of information had a significant influence on the CoV-HERSA scores. Those who used newspapers and healthcare practitioners as their source of information had the highest CoV-HERSA scores, while those who relied on family/friends had the lowest scores. The CoV-HERSA is a validated tool that accurately reflects participants' willingness and hesitancy to COVID-19 vaccination and can be used to explore the influence of different factors on the participants' attitudes towards the COVID-19 vaccine.

The Cost-Effectiveness of Requesting a Complete Blood Count (CBC) in the Management of COVID-19 in Saudi Arabia

Background: Since the beginning of the COVID-19 pandemic, studies have attempted to determine the value of the different laboratory investigations. This study aims to assess the cost-effectiveness of requesting a complete blood count (CBC) for COVID-19 patients, as opposed to ordering a COVID-19 antibody titer in Saudi Arabia. Methods: The prices of a CBC, COVID-19 PCR, and antibody titer were obtained from 40 healthcare establishments in Saudi Arabia, between January and February 2022. Results: Requesting a CBC is significantly cheaper than requesting a COVID-19 antibody titer, which was available in almost all of the establishments, as compared to COVID-19 PCR and antibody titer testing. The investigation prices did not differ significantly between hospitals and private laboratories, nor across cities in Saudi Arabia. Conclusions: CBC, which provides valuable information on the patient’s condition and prognosis, is a cost-effective and widely available tool for managing COVID-19. The price and availability of CBC warrant it to be included in the COVID-19 management protocols.

Neutrophil-to-Lymphocyte Ratio and Cut-off Values as Predictor of Severity and Mortality in COVID-19 Patients in Millennium COVID-19 Care Center, Addis Ababa, Ethiopia

Background

Early identification of patients at high risk of poor clinical outcomes is the key to success in saving the lives of patients with coronavirus disease 2019 (COVID-19). Neutrophil to Lymphocyte Ratio (NLR) is an easily available and cheap surrogate inflammatory marker, its baseline NLR role in African COVID-19 patients remains to be investigated. The objective of the study aimed to evaluate the role of NLR as a predictor of severity and mortality of COVID-19 patients admitted at the Millennium COVID 19 care center in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted on patients with COVID-19 admitted to the Millennium COVID-19 care center from August 1 to October 30, 2021. Receiver Operating Characteristic curve analysis was used to calculate the area under the curve to assess the predictive capacity of NLR on mortality and severity. Multivariable logistic regression analysis was done to identify the association between independent variables and disease outcomes with an Adjusted Odds Ratio (AOR), P-value, and 95% CI for AOR were used for testing significance.

Results

The NLR of 9.47 was identified as the optimal cut-off value for predicting mortality with a sensitivity of 88.7% and a specificity of 95.4% (Area Under the Curve (AUC):0.95, 95% CI 0.92-98; P<0.001) and the NLR of 5.86 was an effective threshold value in predicting the severity of disease with a sensitivity of 92.2% and a specificity of 75% (AUC:0.85, 95% CI 0.800-0.905; P<0.001). In multivariable logistic regression analysis, after adjusting for confounding factors, NLR of more than 9.47 and 5.86 was significantly associated with all-cause of in-hospital mortality (AOR=4.73, 95% CI, 1.19-33.68; P<0.02), and severity of disease (AOR=12.98, 95% CI 3.85-43.80; P=0.001), respectively.

Conclusion

NLR greater than 9.47 and 5.86 effectively predict mortality and severity of the disease, respectively. It provides an objective input for early decision-making in inpatient management especially in resources limited area.

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.

Comparative analysis of neutrophil to lymphocyte ratio and derived neutrophil to lymphocyte ratio with respect to outcomes of in-hospital coronavirus disease 2019 patients: A retrospective study

Introduction and objectives

In patients with coronavirus disease 2019 (COVID-19), several abnormal hematological biomarkers have been reported. The current study aimed to find out the association of neutrophil to lymphocyte ratio (NLR) and derived NLR (dNLR) with COVID-19. The objective was to compare the accuracy of both of these markers in predicting the severity of the disease.

Materials and methods

The study was conducted in a single-center having patients with COVID-19 with a considerable hospital stay. NLR is easily calculated by dividing the absolute neutrophil count (ANC) with the absolute lymphocyte count (ALC) {ANC/ALC}, while dNLR is calculated by ANC divided by total leukocyte count minus ANC {ANC/(WBC-ANC)}. Medians and interquartile ranges (IQR) were represented by box plots. Multivariable logistic regression was performed obtaining an odds ratio (OR), 95% CI, and further adjusted to discover the independent predictors and risk factors associated with elevated NLR and dNLR.

Results

A total of 1,000 patients with COVID-19 were included. The baseline NLR and dNLR were 5.00 (2.91–10.46) and 4.00 (2.33–6.14), respectively. A cut-off value of 4.23 for NLR and 2.63 for dNLR were set by receiver operating characteristic (ROC) analysis. Significant associations of NLR were obtained by binary logistic regression for dependent outcome variables as ICU stay (p < 0.001), death (p < 0.001), and invasive ventilation (p < 0.001) while that of dNLR with ICU stay (p = 0.002), death (p < 0.001), and invasive ventilation (p = 0.002) on multivariate analysis when adjusted for age, gender, and a wave of pandemics. Moreover, the indices were found correlating with other inflammatory markers such as C-reactive protein (CRP), D-dimer, and procalcitonin (PCT).

Conclusion

Both markers are equally reliable and sensitive for predicting in-hospital outcomes of patients with COVID-19. Early detection and predictive analysis of these markers can allow physicians to risk assessment and prompt management of these patients.

Comparison of haematologic abnormalities between hospitalized Coronavirus disease 2019 (COVID-19) positive and negative patients with correlation to disease severity and outcome

Peripheral blood smear (PBS) changes in coronavirus disease 2019 (COVID‐19) are diverse and have been reported in the literature in the form of case series with relatively smaller sample sizes and with a handful of studies showing the association between PBS and clinical severity. This study aims to highlight the numerical and morphological changes in peripheral blood of COVID‐19 patients and to compare the same in intensive care unit (ICU) and non‐ICU settings as well as with disease severity and outcome. The study included 80 COVID‐19 positive (41 ICU and 39 non‐ICU) patients and 32 COVID‐19 negative ICU patients. Complete blood counts (CBCs) and PBS findings were studied and scored by two pathologists blindfolded. Absolute lymphocyte count (ALC) and absolute eosinophil count (AEC) were significantly lower in COVID‐19 positive cases as compared to the COVID‐19 negative group (p = 0.001 and p = 0.001). COVID‐19 positive group showed significant left myeloid shift (p = 0.021), Dohle bodies (p = 0.025) with significant prominence of acquired pseudo–Pelger–Huët anomaly, ring‐shaped neutrophils, monolobate neutrophils, and plasmacytoid lymphocytes as compared to control group (p = 0.000, p = 0.009, p = 0.046, and p = 0.011, respectively). The overall mean white blood cell (WBC) counts were higher in COVID‐19 positive ICU patients as compared to non‐ICU COVID patients with significant shift to left, presence of ring‐shaped neutrophils, monocyte vacuolation, and large granular lymphocytes (p = 0.017, p = 0.007, p = 0.008, and p = 0.004, respectively). Deceased group showed significantly higher WBC count (p = 0.018) with marked neutrophilia (p = 0.024) and toxic granulation (p = 0.01) with prominence of monocyte vacuolization, ring‐shaped neutrophils, large granular lymphocytes, and reactive lymphocytes. Parameters like myeloid left shift, ring‐shaped neutrophils, monocyte vacuolation, and large granular lymphocytes emerged as highly sensitive markers of disease severity. Therefore, serial CBC with comprehensive PBS analysis should be done in every newly diagnosed hospitalized COVID‐19 patient which potentially predicts the course of the disease.

Procoagulant Microvesicles in COVID-19 Patients: Possible Modulators of Inflammation and Prothrombotic Tendency

Background

The hypercoagulability and thrombotic tendency in coronavirus disease 2019 (COVID-19) is multifactorial, driven mainly by inflammation, and endothelial dysfunction. Elevated levels of procoagulant microvesicles (MVs) and tissue factor–bearing microvesicles (TF-bearing MVs) have been observed in many diseases with thrombotic tendency. The current study aimed to measure the levels of procoagulant MVs and TF-bearing MVs in patients with COVID-19 and healthy controls and to correlate their levels with platelet counts, D-Dimer levels, and other proposed calculated inflammatory markers.

Materials and Methods

Forty ICU-admitted patients with COVID-19 and 37 healthy controls were recruited in the study. Levels of procoagulant MVs and TF-bearing MVs in the plasma of the study population were measured using enzyme linked immunosorbent assay.

Results

COVID-19 patients had significantly elevated levels of procoagulant MVs and TF-bearing MVs as compared with healthy controls (P<0.001). Procoagulant MVs significantly correlated with TF-bearing MVs, D-dimer levels, and platelet count, but not with calculated inflammatory markers (neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and platelet/neutrophil ratio).

Conclusion

Elevated levels of procoagulant MVs and TF-bearing MVs in patients with COVID-19 are suggested to be (i) early potential markers to predict the severity of COVID-19 (ii) a novel circulatory biomarker to evaluate the procoagulant activity and severity of COVID-19.

RNA Sequencing in COVID-19 patients identifies neutrophil activation biomarkers as a promising diagnostic platform for infections

Infection with the SARS-CoV2 virus can vary from asymptomatic, or flu-like with moderate disease, up to critically severe. Severe disease, termed COVID-19, involves acute respiratory deterioration that is frequently fatal. To understand the highly variable presentation, and identify biomarkers for disease severity, blood RNA from COVID-19 patient in an intensive care unit was analyzed by whole transcriptome RNA sequencing. Both SARS-CoV2 infection and the severity of COVID-19 syndrome were associated with up to 25-fold increased expression of neutrophil-related transcripts, such as neutrophil defensin 1 (DEFA1), and 3-5-fold reductions in T cell related transcripts such as the T cell receptor (TCR). The DEFA1 RNA level detected SARS-CoV2 viremia with 95.5% sensitivity, when viremia was measured by ddPCR of whole blood RNA. Purified CD15+ neutrophils from COVID-19 patients were increased in abundance and showed striking increases in nuclear DNA staining by DAPI. Concurrently, they showed >10-fold higher elastase activity than normal controls, and correcting for their increased abundance, still showed 5-fold higher elastase activity per cell. Despite higher CD15+ neutrophil elastase activity, elastase activity was extremely low in plasma from the same patients. Collectively, the data supports the model that increased neutrophil and decreased T cell activity is associated with increased COVID-19 severity, and suggests that blood DEFA1 RNA levels and neutrophil elastase activity, both involved in neutrophil extracellular traps (NETs), may be informative biomarkers of host immune activity after viral infection.

MPR and NLR as Prognostic Markers in ICU-Admitted Patients with COVID-19 in Jazan, Saudi Arabia

Objective

The aims of the current study were to evaluate the importance of MPR and NLR as prognostic markers in ICU-admitted COVID-19 patients and to investigate the impact of COVID-19 on hematological and coagulation parameters in patients from Jazan region of Saudi Arabia.

Methods

This retrospective study was conducted between October 2020 and January 2021 at King Fahad Central Hospital, Jazan region. Medical files, which included the results of complete blood count (CBC), calculated mean platelet volume to platelet count ratio (MPR) and neutrophils-to-lymphocytes ratio (NLR) parameters, coagulation profile and D-dimer test, of 96 (64 male and 32 female) COVID-19-infected patients admitted to the intensive care unit were reviewed. Associations between the test results and COVID-19 infection outcomes (discharged [DC] or passed away [PA]) were measured.

Results

The results of the current study demonstrate overall significant differences in CBC parameters between PA group as compared to DC group (P < 0.05). The PA group had a significantly elevated MPR (10.15±12.16 vs 4.04±1.5; P < 0.01) and NLR (18.29±19.82 vs 7.35±9.68; P < 0.01) as compared to the DC group, suggesting an association between these parameters and mortality. Odds ratios analysis also showed that adjustment for demographic variables and comorbidities did not weaken the observed association.

Conclusion

Elevated MPR and NLR are associated with poor prognosis in COVID-19 patients and could be useful as therapy management indicators.

Value of the Neutrophil-Lymphocyte Ratio in Predicting COVID-19 Severity: A Meta-analysis

Background

Coronavirus disease 2019 (COVID-19) is highly contagious and continues to spread rapidly. However, there are no simple and timely laboratory techniques to determine the severity of COVID-19. In this meta-analysis, we assessed the potential of the neutrophil-lymphocyte ratio (NLR) as an indicator of severe versus nonsevere COVID-19 cases.

Methods

A search for studies on the NLR in severe and nonsevere COVID-19 cases published from January 1, 2020, to July 1, 2021, was conducted on the PubMed, EMBASE, and Cochrane Library databases. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and area under the curve (AUC) analyses were done on Stata 14.0 and Meta-disc 1.4 to assess the performance of the NLR.

Results

Thirty studies, including 5570 patients, were analyzed. Of these, 1603 and 3967 patients had severe and nonsevere COVID-19, respectively. The overall sensitivity and specificity were 0.82 (95% confidence interval (CI), 0.77-0.87) and 0.77 (95% CI, 0.70-0.83), respectively; positive and negative correlation ratios were 3.6 (95% CI, 2.7-4.7) and 0.23 (95% CI, 0.17-0.30), respectively; DOR was 16 (95% CI, 10-24), and the AUC was 0.87 (95% CI, 0.84-0.90).

Conclusion

The NLR could accurately determine the severity of COVID-19 and can be used to identify patients with severe disease to guide clinical decision-making.

Active Covid-19 infection and transmission after the first dose of the BNT162b2 mRNA vaccination in Saudi Arabia: A case report

A 47-year-old non-smoker male who has received the first dose of the BNT162b2 mRNA Covid-19 vaccine in Saudi Arabia. At day 3 post-vaccination, he tested negative for Covid-19 and travelled to Egypt. On day 12 he developed runny nose, body ache and fever, and he reportedly tested (PCR) negative for Covid-19 Upon his return to Saudi on day 15, his symptoms have worsened and he presented to the Emergency Department, at which he tested positive for Covid-19. The patient was overweight (BMI = 29), was not suffering from any comorbidities and was not taking any medication. Upon examination, he was vitally stable and his laboratory investigation only revealed a slightly increased Creatinine. His chest X-ray was unremarkable.

His condition did not require hospital admission, so he was discharged and advised to home-isolate himself. Four days after his discharge, his entire household came to the hospital and tested positive for Covid-19.

This is the first case report, in Saudi Arabia, of a person receiving the first dose of the BNT162b2 vaccine and got infected with Covid-19 afterwards. The report highlights the significance of receiving the second dose of the vaccine to be effective. It also demonstrates that those with a single dose mRNA vaccine, could get infected and transmit the infection.

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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