Prognostic Value of C-Reactive Protein to Lymphocyte Ratio (CLR) in Emergency Department Patients with SARS-CoV-2 Infection

Associations between neonicotinoids and inflammation in US adults using hematological indices: NHANES 2015-2016

Background

Toxicological studies suggest neonicotinoids increase oxidative stress and inflammation, but few epidemiological studies have explored these effects.

Methods

National Health and Nutrition Examination Survey (NHANES) 2015-2016 data were used to estimate associations between neonicotinoid exposure and inflammatory markers, including the C-reactive protein-to-lymphocyte count ratio (CLR), monocyte-to-high-density lipoprotein ratio (MHR), monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) using linear and multinomial logistic regression models. Sex was evaluated as a potential modifier.

Results

Detection of any parent neonicotinoid (β = -0.62, 95% confidence interval [CI] = -0.98, -0.26) and imidacloprid (β = -0.48, 95% CI = -0.87, -0.10) was associated with decreased CLR. Clothianidin was linked to reduced MLR (β = -0.04, 95% CI = -0.07, -0.02), but increased lymphocyte-to-monocyte ratio (β = 0.52, 95% CI = 0.27, 0.77). Higher dNLR (β = 0.85; 95% CI = 0.26, 1.43) was noted with detection of any neonicotinoid metabolite. Moderately high PLR was observed with detection of any neonicotinoid metabolite (relative risk ratio [RRR] = 1.63, 95% CI = 1.27, 2.09) or 5-hydroxy-imidacloprid (RRR = 2.19, 95% CI = 1.40, 3.41). Sex-modified analyses showed positive associations in males and inverse associations in females for MHR (P int = 0.099, clothianidin), PLR (P int = 0.026, clothianidin), and SII (P int = 0.056, any parent neonicotinoid; P int = 0.002, clothianidin), while the opposite pattern was noted with CLR (P int = 0.073, any parent neonicotinoid) and NLR (P int = 0.084, clothianidin).

Conclusion

Neonicotinoids may be associated with inflammatory changes, with potential sexual dimorphism. Further studies are required to explore these findings.

Impact and Contributing Factors of Maternal Pyrexia Peaks During Labor on Maternal and Neonatal Outcomes

This study aims to equip clinicians with the necessary insights for identifying and managing pregnant women experiencing elevated maternal pyrexia during labor. It examines maternal and neonatal outcomes along with the factors associated with varying peak temperatures. A retrospective analysis was conducted on 319 pregnant women presenting with maternal pyrexia during labor. Participants were categorized into two groups based on peak temperature: Group A (n = 180, temperature <38°C) and Group B (n = 139, temperature ≥38°C). Basic characteristics, blood markers, and maternal and neonatal outcomes were compared between the two groups. (1) Group B exhibited a higher percentage of neutrophilic granulocytes (NE%) and C-reactive protein to lymphocyte ratio (CLR) compared with Group A (p < 0.05). (2) The rates of meconium-stained amniotic fluid, histological chorioamnionitis, hospitalization of neonates, and infections in neonates were greater in Group B than in Group A (p < 0.05). (3) Logistic regression analysis identified elevated CLR levels as a risk factor for peak temperatures exceeding 38°C, indicating that CLR could serve as a reliable predictor of maternal pyrexia above 38°C during labor. Higher maternal pyrexia peaks may exacerbate adverse maternal and neonatal outcomes, emphasizing the importance of timely clinical intervention. NE% and CLR could serve as valuable indicators for identifying underlying causes and predicting peak maternal pyrexia during labor.

The relationship between C-reactive protein to lymphocyte ratio and the prevalence of chronic kidney disease in US adults: a cross-sectional study

Objective

The C-reactive protein/Lymphocyte Ratio (CLR) is a novel biomarker whose role in the development of chronic kidney disease (CKD) is not well understood. This study aimed to investigate the correlation between CLR and the prevalence of CKD.

Methods

This cross-sectional study included participants from the US National Health and Nutrition Examination Survey conducted between 1999 and 2010. Multivariate regression analyses and subgroup analyses were performed, controlling for socio-demographic variables, lifestyle behaviors, chronic diseases associated with kidney disease, and biochemical markers of bone metabolism. The associations between CLR and CKD prevalence, as well as indicators of renal damage, were explored. Non-linear relationships were analyzed using weighted restricted cubic splines. The predictive ability of CLR for CKD was assessed by the receiver operating characteristic curve and the area under the curve was calculated. Subgroup and sensitivity analyses were conducted to validate the robustness of the model.

Results

A total of 13,862 respondents were included, comprising 2,449 CKD patients and 11,413 non-CKD patients. Weighted logistic regression modeling revealed a positive correlation between CLR levels and CKD prevalence (Odds ratio [OR] = 1.54, 95% Confidence interval [CI] = 1.30 to 1.83, P < 0.001). Additionally, CLR levels were negatively correlated with the glomerular filtration rate, a marker of renal injury, and positively correlated with the urinary albumin/creatinine ratio. The receiver operating characteristic curve demonstrated that the area under the curve for CLR in predicting CKD was 0.653 (95% CI, 0.641-0.665). The optimal cutoff value was 0.856, with a sensitivity of 0.703, specificity of 0.526, positive predictive value of 0.874, and negative predictive value of 0.275. The robustness of the model was confirmed through subgroup and sensitivity analyses.

Conclusion

Analysis of a large cross-sectional dataset demonstrated a positive correlation between CLR levels and CKD prevalence, suggesting that CLR may serve as a novel marker for the development and treatment of CKD.

Immune Cell-Based versus Albumin-Based Ratios as Outcome Predictors in Critically Ill COVID-19 Patients

Purpose

The aim of the retrospective, single-center study was to assess the prognostic value of immune cell-based and albumin-based ratios regarding lethal outcome in critically ill COVID-19 patients.

Patients and Methods

We analyzed 612 adult critically ill COVID-19 patients admitted to the intensive care unit (ICU) between April 2020 and November 2022. Blood measurement on admission to the ICU encompassed complete blood count (CBC), IL-6, C-reactive protein (CRP), albumin, lactate, lactate dehydrogenase (LDH), serum bicarbonate, arterial base deficit/excess (BD/E), and D-dimer. All the measured and calculated parameters were compared between survivors and nonsurvivors, with the outcome measure being hospital mortality.

Results

Immune cell-based ratios [NLR - Neutrophil-to-Lymphocyte Ratio, MLR - Monocyte-to-Lymphocyte Ratio, PLR - Platelet-to-Lymphocyte Ratio, MPV - Mean Platelet Volume, MPV/PC - Mean Platelet Volume-to-Platelet Count Ratio, Derived (d-)NLR ratio - neutrophil count divided by the result of white blood cell (WBC) count - neutrophil count), N/LP - Neutrophil count x 100/Lymphocyte count x Platelet count, CLR - C-reactive protein (CRP)-to-Lymphocyte Ratio, CPR - CRP-to-Platelet Ratio, LLR - Lactate dehydrogenase (LDH)-to-Lymphocyte Ratio, Systemic Immune Inflammation Index (SII) - platelet x neutrophil/lymphocyte count, Systemic Inflammation Response Index (SIRI) - neutrophil x monocyte/lymphocyte count] were investigated. White blood cell and neutrophil counts were significantly higher, while lymphocyte and platelet counts were significantly lower in nonsurvivors. MPV, MPV/PC, NLR, d-NLR, MLR, N/LP, CRP, LDH, CPR, CLR, LLR, SII, and SIRI values were significantly higher in nonsurvivors. Monocyte count and PLR values did not differ significantly between groups. Albumin-based ratios included CRP-to-Albumin Ratio (CAR), Lactate-to-Albumin Ratio (LAR) and LDH-to-Albumin Ratio (LDH/ALB). All values were significantly higher in nonsurvivors.

Conclusion

The only independent predictor of lethal outcomes at ICU admission is the albumin-based LDH/ALB ratio. Most of the other parameters were moderate, although highly significant predictors of mortality in critically ill COVID-19 patients.

Assessing the Predictive Utility of the C-Reactive Protein-to-Lymphocyte Ratio for Mortality in Isolated Traumatic Brain Injury: A Single-Center Retrospective Analysis

Introduction: Early identification of high-risk traumatic brain injury (TBI) patients is crucial for optimizing treatment strategies and improving outcomes. The C-reactive protein-to-lymphocyte ratio (CLR) reflects systemic immunology and inflammation function and serves as a new biomarker for patient stratification. This study aimed to assess the predictive value of the CLR for mortality in patients with isolated moderate to severe TBI. Methods: A retrospective analysis of trauma registry data from 2009 to 2022 was conducted, including 1641 adult patients with isolated moderate to severe TBI. Patient demographics, the CLR, injury characteristics, and outcomes were compared between deceased and surviving patients. Univariate and multivariate analyses were performed to identify mortality risk factors. The optimal CLR cut-off value for predicting mortality was determined using receiver operating characteristic (ROC) curve analysis. Results: The CLR was significantly higher in deceased patients compared to survivors (60.1 vs. 33.9, p < 0.001). The optimal CLR cut-off value for predicting mortality was 54.5, with a sensitivity of 0.328 and a specificity of 0.812. The area under the ROC curve was 0.566, indicating poor discriminative ability. In the multivariate analysis, the CLR was not a significant independent predictor of mortality (OR 1.03, p = 0.051). After propensity score matching to attenuate the difference in baseline characteristics, including sex, age, comorbidities, conscious level, and injury severity, the high-CLR group (CLR ≥ 54.5) did not have significantly higher mortality compared to the low-CLR group (CLR < 54.5). Conclusion: While the CLR was associated with mortality in TBI patients, it demonstrated poor discriminative ability as a standalone predictor. The association between a high CLR and worse outcomes may be primarily due to other baseline patient and injury characteristics, rather than the CLR itself.

The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study

INTRODUCTION

In acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection.

METHODS

This was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements.

RESULTS

The discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%).

CONCLUSIONS

CLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.

Characterisation of Ferritin-Lymphocyte Ratio in COVID-19

Introduction: The ferritin-lymphocyte ratio (FLR) is a novel inflammatory biomarker for the assessment of acute COVID-19 patients. However, the prognostic value of FLR for predicting adverse clinical outcomes in COVID-19 remains unclear, which hinders its clinical translation. Methods: We characterised the prognostic value of FLR in COVID-19 patients, as compared to established inflammatory markers. Results: In 217 study patients (69 years [IQR: 55-82]; 60% males), FLR was weakly correlated with CRP (R = 0.108, p = 0.115) and white cell count (R = -0.144; p = 0.034). On ROC analysis, an FLR cut-off of 286 achieved a sensitivity of 86% and a specificity of 30% for predicting inpatient mortality (AUC 0.60, 95% CI: 0.53-0.67). The negative predictive values of FLR for ruling out mortality, non-invasive ventilation requirement and critical illness (intubation and/or ICU admission) were 86%, 85% and 93%, respectively. FLR performed similarly to CRP (AUC 0.60 vs. 0.64; p = 0.375) for predicting mortality, but worse than CRP for predicting non-fatal outcomes (all p < 0.05). On Kaplan-Meier analysis, COVID-19 patients with FLR values > 286 had worse inpatient survival than patients with FLR ≤ 286, p = 0.041. Conclusions: FLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19, and may be a good "rule-out" test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management.

Lymphocyte to C-Reactive Protein Ratio as an Early Biomarker to Distinguish Sepsis from Pneumonia in Neonates

Background

Neonatal sepsis is an acute and severe disease that seriously threatens the life and health of newborns. Neonates with pneumonia may also have unrecognized neonatal sepsis. Early diagnosis of neonatal sepsis is beneficial for early treatment. This study aimed to evaluate the clinical significance of the lymphocyte-to-C-reactive protein ratio (LCR) as an early biomarker to distinguish sepsis from pneumonia.

Methods

This retrospective study enrolled 1635 neonates with pneumonia from February 2016 to March 2022. Among them, 182 cases were diagnosed with sepsis based on the positive blood culture results. Clinical and laboratory data were extracted from the electronic medical records. LCR was calculated as the ratio of the total lymphocyte count (×109 cells/L) to the C-reactive protein level (mg/L). Binary logistic regression analysis was conducted to evaluate the clinical significance of LCR as an early biomarker in distinguishing sepsis from pneumonia. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic value of LPCR in sepsis cases. All statistical analyses were conducted using Statistical Product and Service Solutions, version 24.0.

Results

The neonates with pneumonia combined with sepsis had a lower LCR than that of the neonates with pneumonia. Further analysis showed that the prevalence of neonatal pneumonia combined with sepsis was significantly higher in the low-LCR group than in the high-LCR group (20.7% vs 5.5%, P < 001). Binary logistic regression revealed that LCR was an independent risk factor for identifying pneumonia combined with sepsis. The ROC curve analysis revealed that LCR had better power than the lymphocyte count and CRP level individually in diagnosing neonatal pneumonia combined with sepsis (0.72 vs 0.65 vs 0.66, P < 0.001), with 62% sensitivity and 72% specificity.

Conclusion

LCR can be a potential early biomarker in distinguishing neonates with sepsis from those with pneumonia.

Comparison of Lymphocyte-CRP Ratio to Conventional Inflammatory Markers for Predicting Clinical Outcomes in COVID-19

Background: In COVID-19 patients, lymphocyte-CRP ratio (LCR) is a promising biomarker for predicting adverse clinical outcomes. How well LCR performs compared to conventional inflammatory markers for prognosticating COVID-19 patients remains unclear, which hinders the clinical translation of this novel biomarker. Methods: In a cohort of COVID-19 inpatients, we characterised the clinical applicability of LCR by comparing its prognostic value against conventional inflammatory markers for predicting inpatient mortality and a composite of mortality, invasive/non-invasive ventilation and intensive care unit admissions. Results: Of the 413 COVID-19 patients, 100 (24%) patients suffered inpatient mortality. On Receiver Operating Characteristics analysis, LCR performed similarly to CRP for predicting mortality (AUC 0.74 vs. 0.71, p = 0.049) and the composite endpoint (AUC 0.76 vs. 0.76, p = 0.812). LCR outperformed lymphocyte counts (AUC 0.74 vs. 0.66, p = 0.002), platelet counts (AUC 0.74 vs. 0.61, p = 0.003) and white cell counts (AUC 0.74 vs. 0.54, p < 0.001) for predicting mortality. On Kaplan-Meier analysis, patients with a low LCR (below a 58 cut-off) had worse inpatient survival than patients with other LCR values (p < 0.001). Conclusion: LCR appears comparable to CRP, but outperformed other inflammatory markers, for prognosticating COVID-19 patients. Further studies are required to improve the diagnostic value of LCR to facilitate clinical translation.

The Role of Hemogram-derived Ratios in COVID-19 Severity Stratification in a Primary Healthcare Facility

Background

Coronavirus disease 2019 (COVID-19) can cause a wide clinical spectrum, ranging from asymptomatic to severe disease with a high mortality rate. In view of the current pandemic and the increasing influx of patients into healthcare facilities, there is a need to identify simple and reliable tools for stratifying patients.

Objective

Study aimed to analyze whether hemogram-derived ratios (HDRs) can be used to identify patients with a risk of developing a severe clinical form and admission to hospital.

Methods

This cross-sectional and observational study included 500 patients with a confirmed diagnosis of COVID-19. Data on clinical features and laboratory parameters were collected from medical records and 13 HDRs were calculated and analyzed. Descriptive and inferential statistics were included in the analysis.

Results

Of the 500 patients, 43.8% had a severe form of the disease. Lymphocytopenia, monocytopenia, higher C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were found in severe patients (p < 0.05). Significantly higher neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), neutrophil-to-platelet ratio (NPR), neutrophil-to-lymphocyte-to-platelet ratio (NLPR) and CRP-to-lymphocyte ratio (CRP/Ly) values were found in severe patients (p < 0.001). In addition, they have statistically significant prognostic potential (p < 0.001). The area under the curve (AUC) for CRP/Ly, dNLR, NLPR, NLR, and NPR were 0.693, 0.619, 0.619, 0.616, and 0.603, respectively. The sensitivity and specificity were 65.7% and 65.6% for CRP/Ly, 51.6% and 70.8 for dNLR, 61.6% and 57.3% for NLPR, 40.6% and 80.4% for NLR, and 48.8% and 69.1% for NPR.

Conclusion

The results of the study suggest that NLR, dNLR, CRP/Ly, NPR, and NLPR can be considered as potentially useful markers for stratifying patients with a severe form of the disease. HDRs derived from routine blood tests results should be included in common laboratory practice since they are readily available, easy to calculate, and inexpensive.

Use of canakinumab and remdesivir in moderate-severe COVID-19 patients: A retrospective analysis

Objectives: The dysregulated immune response occurring upon COVID-19 infection can lead to tissue damage and organ failure. Different therapeutic strategies are needed to cope with the current and future outspread of COVID-19, including antiviral and anti-inflammatory agents. We describe the outcome of hospitalized patients treated with canakinumab and remdesivir plus the standard of care therapy. Methods: This observational study describes the outcome of the combination of canakinumab (450 mg for patients ≥40 and <60 kg, 600 mg for those ≥60 and <80 kg, or 750 mg for patients ≥80 kg) and 200 mg remdesivir intravenous infusion, plus standard of care (SOC), in 17 moderate-to-severe COVID-19 patients hospitalized in the "Annunziata" Hospital, Cosenza, Italy, between August and November 2021. Hematological markers, biochemical, and hemogasanalysis values at baseline versus day 7 of combination treatment were compared by paired t test after checking for normal distribution and correcting for multiple comparison. Results: The median age of patients was 64 years (range: 39-85), and the median hospitalization time (calculated on the 16 patients that were not transferred to intensive care unit) was of 12.5 days (range: 7-35 days); 15/17 patients (88%) did not experience complications. After 7 days of combination therapy, all the inflammatory parameters were significantly reduced with the exception of procalcitonin; moreover, hematological prognostic markers such neutrophil-to-lymphocyte ratio, CRP-to-lymphocyte ratio, and derived neutrophil-to-lymphocyte ratio reduced. Overall, 16/17 patients (94%) recovered after 14 days. Conclusions: Canakinumab and remdesivir treatment, in addition to SOC, in the early stage of moderate-to-severe COVID-19 showed promising outcomes in terms of safety and effectiveness potentially leading to a reduction in inflammatory and hematological prognostic markers after 7 days of treatment.

Evaluation of emerging inflammatory markers for predicting oxygen support requirement in COVID-19 patients

Coronavirus disease 2019 (COVID-19), a highly contagious pathogenic viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly and remains a challenge to global public health. COVID-19 patients manifest various symptoms from mild to severe cases with poor clinical outcomes. Prognostic values of novel markers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein to lymphocyte ratio (CLR) calculated from routine laboratory parameters have recently been reported to predict severe cases; however, whether this investigation can guide oxygen therapy in COVID-19 patients remains unclear. In this study, we assessed the ability of these markers in screening and predicting types of oxygen therapy in COVID-19 patients. The retrospective data of 474 COVID-19 patients were categorized into mild and severe cases and grouped according to the types of oxygen therapy requirement, including noninvasive oxygen support, high-flow nasal cannula and invasive mechanical ventilator. Among the novel markers, the ROC curve analysis indicated a screening cutoff of CRP ≥ 30.0 mg/L, NLR ≥ 3.0 and CLR ≥ 25 in predicting the requirement of any type of oxygen support. The NLR and CLR with increasing cut-off values have discriminative power with high accuracy and specificity for more effective oxygen therapy with a high-flow nasal cannula (NLR ≥ 6.0 and CLR ≥ 60) and mechanical ventilator (NLR ≥ 8.0 and CLR ≥ 80). Our study thus identifies potential markers to differentiate the suitable management of oxygen therapy in COVID-19 patients at an earlier time for improving disease outcomes with limited respiratory support resources.

The Novel Predictive Biomarkers for Type 2 Diabetes Mellitus in Active Pulmonary Tuberculosis Patients

Purpose

This study was to explore the predictive value of monocyte to high-density lipoprotein cholesterol ratio (MHR), neutrophils to high-density lipoprotein cholesterol ratio (NHR), C-reactive protein-to-lymphocyte ratio (CLR), and C-reactive protein-to-albumin ratio (CAR) for type 2 diabetes mellitus (T2DM) in patients with active pulmonary tuberculosis (APTB).

Patients and Methods

A total of 991 active pulmonary tuberculosis (APTB) patients (201 with T2DM) were hospitalized in the Department of Tuberculosis, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology were included. The routine blood examination indicators and biochemical parameters were collected to calculate MHR, NHR, CLR, and CAR. The Pearson correlation analysis, Univariate Logistic regression analysis, and receiver operating characteristic (ROC) curve analysis were performed to assess the predictive value of MHR, NHR, CLR, and CAR for APTB-T2DM patients.

Results

The levels of MHR, NHR, CLR, and CAR in the APTB-T2DM patients were significantly higher than in the APTB-no T2DM patients (P < 0.05). Additionally, the MHR, NHR, CLR, and CAR have a positive correlation with fasting blood glucose in the whole study population. However, in the APTB-T2DM patients, MHR, NHR, and CAR were not correlated with fasting blood glucose, and only CLR was positively correlated with fasting blood glucose. The area under curve (AUC) predicting APTB-T2DM patients of the MHR, NHR, CLR, and CAR was 0.632, 0.72, 0.715, and 0.713, respectively. Further, univariate logistic regression analyses showed that the higher MHR, NHR, CLR, and CAR were independent risk factors for APTB-T2DM (P < 0.01). The MHR, NHR, CLR, and CAR quartiles were used to divide the APTB patients into four groups for further analysis. The prevalence of T2DM was significantly higher in APTB individuals as MHR, NHR, CLR, and CAR values increased (P < 0.05).

Conclusion

MHR, NHR, CLR, and CAR are simple and practicable inflammatory parameters that could be used for assessing T2DM in APTB. APTB patients have a greater possibility to be diagnosed with T2DM with the higher MHR, NHR CLR, and CAR values. Therefore, more attention should be given to the indicator in the examination of APTB.