1
|
Jamil Z, Khalid S, Khan HMMH, Waheed I, Ehsan A, Alissa M, Muhammad K, Munawar N, Waheed Y. Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) as a Novel Score in Early Detection of Complicated Dengue Fever. J Multidiscip Healthc 2024; 17:2321-2330. [PMID: 38770172 PMCID: PMC11104365 DOI: 10.2147/jmdh.s459929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/03/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction The occurrence of dengue fever presents a considerable burden for public health care in developing countries. This study aims to validate APRI as predictor score for severity of dengue fever so that catastrophic events could be prevented, and early triage can save lives. Methods The retrospective cross-sectional study was done on dengue positive patients from August to November 2023. APRI score was calculated for every patient at the time of admission. The primary end-point was non-complicated disease (Simple dengue fever) vs complicated disease (dengue hemorrhagic fever and dengue shock syndrome). ROC curve was used to identify the role of APRI in prediction of dengue complication. Youden index was used to find the cut-off value of APRI along with sensitivity, specificity, positive and negative likelihood ratios. To further evaluate the role of APRI score, patients were divided into two groups, patients with APRI score greater and lesser than cut-off value. The qualitative variables among two groups were compared by chi-square testing. The predictors of complicated dengue were first determined by univariate regression analysis and then confirmed by multivariate regression analysis. Results The mean APRI score of 135 patients was 20.06 ± 6.31. AUC for APRI score was 0.93 (p < 0.0001) indicating that APRI score calculated at the time of admission is an excellent marker in determining the complicated dengue. The cut-off value for APRI score was 9.04 (sensitivity 84.91%, specificity 89.02%, p < 0.0001). The patients with APRI <9.04 mostly developed simple dengue fever (54.1%) vs DHF (4.4%) and DSS (1.5%), while patients with APRI >9.04 had more DHF (20.7%) and DSS (12.6%) vs simple dengue fever (6.7%). None of the patient died with APRI <9.04 while the mortality rate was 3.7% in patients with APRI >9.04. Conclusion The APRI score, calculated at the time of admission, is an excellent marker in determining the severe dengue.
Collapse
Affiliation(s)
- Zubia Jamil
- Department of Medicine, Foundation University School of Health Sciences, Foundation University, Islamabad, 44000, Pakistan
| | - Samreen Khalid
- Department of Medicine, Foundation University School of Health Sciences, Foundation University, Islamabad, 44000, Pakistan
| | | | - Ikram Waheed
- Department of Medicine, Foundation University School of Health Sciences, Foundation University, Islamabad, 44000, Pakistan
- Department of Medicine, Fauji Foundation Hospital, Rawalpindi, 43600, Pakistan
| | - Amna Ehsan
- Department of Medicine, Foundation University School of Health Sciences, Foundation University, Islamabad, 44000, Pakistan
- Department of Medicine, Fauji Foundation Hospital, Rawalpindi, 43600, Pakistan
| | - Mohammed Alissa
- Department of Medical Laboratory, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Khalid Muhammad
- Department of Biology, College of Science, UAE University, Al Ain, 15551, United Arab Emirates
| | - Nayla Munawar
- Department of Chemistry, College of Science, UAE University, Al Ain, 15551, United Arab Emirates
| | - Yasir Waheed
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, 1401, Lebanon
- MEU Research Unit, Middle East University, Amman, 11831, Jordan
| |
Collapse
|
2
|
Jayachandran AK, Nelson V, Anisha K. APRI as a predictor of severe dengue fever. J Family Med Prim Care 2024; 13:613-618. [PMID: 38605798 PMCID: PMC11006074 DOI: 10.4103/jfmpc.jfmpc_1127_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 04/13/2024] Open
Abstract
Introduction The AST/platelet ratio index (APRI) is a well-researched indicator of liver fibrosis. Some studies have shown that APRI can be used as a predictor of severe dengue, but the data is limited. As dengue epidemics are common in our country with limited healthcare resources, we believe APRI can help emergency physicians/primary physicians in predicting the severity of dengue and plan for the appropriate use of limited healthcare resources. Objective 1) To determine the utility of APRI as a predictor of severe dengue. 2) To determine the association of APRI with length of hospital stay and platelet requirement. Materials and Methods A retrospective cross-sectional study was done on patients presented to the Emergency Medicine department at Travancore Medicity Medical College with a positive Dengue NS1 antigen or IgM antibody. Results We found from the univariate analysis results that ALT > 74.5 IU/L has a sensitivity of 59.6 and a specificity of 76.3 (AUC: 0.696; 95% CI: 0.606-0.786), AST > 160.5 IU/L has a sensitivity of 42.3 and a specificity of 93.7 (AUC: 0.747; 95% CI: 0.665-0.829), and APRI > 3.2 has a sensitivity of 69.2 and a specificity of 84.2 (AUC: 0.806; 95% CI: 0.72-0.884) to predict severe dengue. Patients with an APRI of >3.2 required a mean hospital stay of 5.47 days (P = 0.005); 27 (81.8%) requiring platelet transfusion had an APRI of > 3.2 (P = 0.00). Conclusion APRI is a straightforward index that can be easily derived from AST and platelet values. APRI values of >3.2 can predict severe dengue with a sensitivity of 69.2 and a specificity of 84.2. APRI values of >3.2 are also associated with the length of hospital stay and requirement of platelet transfusion.
Collapse
Affiliation(s)
| | - Vincy Nelson
- Department of Community Medicine, Travancore Medical College, Kollam, Kerala, India
| | - K. Anisha
- Department of Emergency Medicine, Travancore Medical College, Kollam, Kerala, India
| |
Collapse
|
3
|
Wang Q, Zhao H, Tong Y, Qin J, Zhou M, Xu L. Aspartate Aminotransferase/Platelet Ratio Index Upon Admission Predicts 24-Week Mortality in Patients With HIV-Associated Talaromyces marneffei. Open Forum Infect Dis 2023; 10:ofad593. [PMID: 38107017 PMCID: PMC10721445 DOI: 10.1093/ofid/ofad593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/20/2023] [Indexed: 12/19/2023] Open
Abstract
Background A high aspartate aminotransferase/platelet ratio index (APRI) predicts mortality in patients with severe infection. This study aims to assess the potential of APRI as a predictor for mortality in patients with HIV-associated Talaromyces marneffei (HTM). Methods Associations between APRI and CD4 count, white blood cell count, C-reactive protein (CRP) level, procalcitonin (PCT) level, and cytokines were assessed in 119 patients. Univariate and multivariate Cox regression models were used to predict APRI on 24-week mortality. Results APRI was positively associated with CRP (r = 0.190, P = .039), PCT (r = 0.220, P = .018), interleukin 6 (r = 0.723, P < .001), interleukin 10 (r = 0.416, P = .006), and tumor necrosis factor α (r = 0.575, P < .001) and negatively associated with CD4 count (r = -0.234, P = .011). In total, 20.2% (24/119) of patients died within the 24-week follow-up. The 24-week survival rate was 88.0% for patients with APRI <5.6% and 61.1% for those with APRI ≥5.6 (log-rank P < .001). After adjustment for sex, age, body mass index, and CD4 count, as well as serum levels of hemoglobin, APRI ≥5.6 (adjusted hazard ratio [95% CI]; 3.0 [1.2-7.1], P = .015), PCT ≥1.7 ng/mL (3.7 [1.5-9.6], P = .006), and non-amphotericin B deoxycholate treatment (2.8 [1.2-6.6], P = .018) were independent risk factors for 24-week mortality. Conclusions For patients with HTM, APRI is associated with severity and is an independent risk factor for 24-week mortality.
Collapse
Affiliation(s)
- Qi Wang
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Infectious Diseases, Huzhou Central Hospital of Zhejiang University, Huzhou, China
| | - Handan Zhao
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Yong Tong
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Infectious Diseases, Huzhou Central Hospital of Zhejiang University, Huzhou, China
| | - Jiaying Qin
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Minghan Zhou
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
4
|
Zhang K, Tan YH, Cao KL, Gong C, Zhang YT, Lv DM, Ding YH, Wang JY, Zuo Y, Wang ZX, Xu YH. Aspartate transferase-to-platelet ratio (APRI): A novel predictor of fatal outcome in patients with SFTS. J Infect 2023; 87:465-468. [PMID: 36918071 DOI: 10.1016/j.jinf.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Ke Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Yu-Hang Tan
- Department of Ultrasound Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kang-Li Cao
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Chen Gong
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yun-Tao Zhang
- Anhui Medical University, Hefei, Anhui Province, China
| | - Dong-Mei Lv
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Yi-Han Ding
- Department of Thyroid and Breast Surgery, the Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Jin-Yu Wang
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China; Anhui Public Health Clinical Center, Hefei, Anhui Province, China
| | - Yan Zuo
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China.
| | - Zhong-Xin Wang
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China.
| | - Yuan-Hong Xu
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China.
| |
Collapse
|
5
|
Low GKK, Jiee SF, Masilamani R, Shanmuganathan S, Rai P, Manda M, Omosumwen OF, Kagize J, Gavino AI, Azahar A, Jabbar MA. Routine blood parameters of dengue infected children and adults. A meta-analysis. Pathog Glob Health 2023; 117:565-589. [PMID: 36593636 PMCID: PMC10392251 DOI: 10.1080/20477724.2022.2161864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The World Health Organization (WHO) has revised dengue case classification in 2009 to better reflect the severity of the disease. However, there was no comprehensive meta-analysis of pooled routine blood parameters according to the age or the categories of the 2009 WHO classification. This study aimed to meta-analyze the routine blood parameters of dengue infected children and adults. Electronic search was performed with eligible articles included for review. Meta-analysis was conducted for six blood parameters stratified into children, adults and all ages, which were further grouped into the three 2009 WHO case classifications (dengue without warning signs, DwoWS; dengue with warning signs, DwWS; severe dengue, SD), non-severe dengue (non-SD) and 'All' cases. A total of 55 articles were included in the meta-analysis. Fifteen studies were conducted in the children's age category, 31 studies in the adult category and nine studies in all ages. The four selected pooled blood parameters for children were white blood cell (WBC) (×103/L) with 5.11 (SD), 5.64 (DwWS), 5.52 (DwoWS) and 4.68 (Non-SD) hematocrit (HCT) (%) with 36.78 (SD), 40.70 (DwWS), 35.00 (DwoWS) and 29.78 (Non-SD) platelet (PLT) (×103/µL) with 78.66 (SD), 108.01 (DwWS), 153.47 (DwoWS) and 108.29 (non-SD); and aspartate aminotransferase (AST) (/µL) with 248.88 (SD), 170.83 (DwWS), 83.24 (DwoWS) and 102.99 (non-SD). For adult, WBC were 4.96 (SD), 6.44 (DwWS), 7.74 (DwoWS) and 3.61 (non-SD); HCT were 39.50 (SD), 39.00 (DwWS), 37.45 (DwoWS) and 41.68 (non-SD); PLT were 49.62 (SD), 96.60 (DwWS), 114.37 (DwoWS) and 71.13 (non-SD); and AST were 399.50 (SD), 141.01 (DwWS), 96.19 (DwoWS) and 118.13 (non-SD). These blood parameters could not differentiate between each dengue severity according to the WHO 2009 classification, SD, DwoWS, DwWS and non-SD, because the timing of blood drawing was not known and there was an overlapping confidence interval among the clinical classification. Hence, these pooled blood parameter values could not be used to guide clinicians in management and did not correlate with severity as in previous scientific literatures and guidelines.
Collapse
Affiliation(s)
- Gary KK Low
- Research Operations, Nepean Hospital, Kingswood, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sam Froze Jiee
- Sarawak State Health Department, Ministry of Health Malaysia, Sri Aman District Health Office, Sri Aman, Sarawak, Malaysia
| | - Retneswari Masilamani
- Department of Population Medicine, Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Kajang, Selangor, Malaysia
| | - Selvanaayagam Shanmuganathan
- Quality Unit, Hospital Kulim, Kulim, Kedah, Malaysia
- Menzies Centre Health Policy and Economics, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Health Vertical, Torrens University Australia, Sydney, New South Wales, Australia
| | - Pramila Rai
- Health Vertical, Torrens University Australia, Sydney, New South Wales, Australia
| | - Mitali Manda
- Hammondcare Neringah Hospital, Wahroonga,New South Wales, Australia
| | - Osamudiamen Favour Omosumwen
- Department of Addiction and Community Health Professional, Faculty of Health and Social Science, Sundance College Edmonton, Edmonton, Alberta, Canada
| | - Jackob Kagize
- Health Vertical, Torrens University Australia, Sydney, New South Wales, Australia
| | - Alex I. Gavino
- Centre for Health Futures, Torrens University Australia, Sydney, New South Wales, Australia
- Public Health Department, Torrens University Australia, Sydney, New South Wales, Australia
| | - Aizad Azahar
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Mohammed Abdulrazzaq Jabbar
- Department of Population Medicine, Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Kajang, Selangor, Malaysia
| |
Collapse
|
6
|
Tsheten T, Clements ACA, Gray DJ, Adhikary RK, Furuya-Kanamori L, Wangdi K. Clinical predictors of severe dengue: a systematic review and meta-analysis. Infect Dis Poverty 2021; 10:123. [PMID: 34627388 PMCID: PMC8501593 DOI: 10.1186/s40249-021-00908-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/11/2022] Open
Abstract
Background Severe dengue is a life-threatening complication; rapid identification of these cases, followed by adequate management is crucial to improve the clinical prognosis. Therefore, this study aimed to identify risk factors and predictors of severe dengue.
Methods A literature search for studies reporting risk factors of severe dengue among individuals with dengue virus infection was conducted in PubMed, Scopus and Web of Science database from inception to December 31, 2020. Pooled odds ratios (ORs) for patients’ demographic characteristics, co-morbidities, and warning signs were estimated using an inverse variance heterogeneity model.
Results We included 143 articles in the meta-analysis from a total of 13 090 articles retrieved from the literature search. The risk factors of severe dengue were: being a child [OR = 1.96; 95% confidence interval (CI): 1.22–3.13], secondary infection (OR = 3.23; 95% CI: 2.28–4.57), and patients with pre-existing diabetes (OR = 2.88; 95% CI: 1.72–4.81) and renal disease (OR = 4.54; 95% CI: 1.55–13.31). Warning signs strongly associated with severe disease were increased haematocrit with a concurrent decrease in platelet count (OR = 5.13; 95% CI: 1.61–16.34), abdominal pain (OR = 2.00; 95% CI: 1.49–2.68), lethargy (OR = 2.73; 95% CI: 1.05–7.10), vomiting (OR = 1.80; 95% CI: 1.43–2.26), hepatomegaly (OR = 5.92; 95% CI: 3.29–10.66), ascites (OR = 6.30; 95% CI: 3.75–10.60), pleural effusion (OR = 5.72; 95% CI: 3.24–10.10) and melena (OR = 4.05; 95% CI: 1.64–10.00). Conclusions Our meta-analysis identified children, secondary infection, diabetes and renal disease(s) as important predictors of severe dengue. Our finding also supports the predictive ability of the WHO warning signs to identify severe dengue. These findings are useful for clinicians to identify severe dengue for management and timely interventions. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00908-2.
Collapse
Affiliation(s)
- Tsheten Tsheten
- Department of Global Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia. .,Royal Centre for Disease Control, Ministry of Health, Thimphu, Bhutan.
| | - Archie C A Clements
- Telethon Kids Institute, Nedlands, Australia.,Curtin University, Perth, Australia
| | - Darren J Gray
- Department of Global Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Ripon K Adhikary
- Department of Global Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| | - Luis Furuya-Kanamori
- UQ Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - Kinley Wangdi
- Department of Global Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
| |
Collapse
|
7
|
Hoyos W, Aguilar J, Toro M. Dengue models based on machine learning techniques: A systematic literature review. Artif Intell Med 2021; 119:102157. [PMID: 34531010 DOI: 10.1016/j.artmed.2021.102157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/08/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dengue modeling is a research topic that has increased in recent years. Early prediction and decision-making are key factors to control dengue. This Systematic Literature Review (SLR) analyzes three modeling approaches of dengue: diagnostic, epidemic, intervention. These approaches require models of prediction, prescription and optimization. This SLR establishes the state-of-the-art in dengue modeling, using machine learning, in the last years. METHODS Several databases were selected to search the articles. The selection was made based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Sixty-four articles were obtained and analyzed to describe their strengths and limitations. Finally, challenges and opportunities for research on machine-learning for dengue modeling were identified. RESULTS Logistic regression was the most used modeling approach for the diagnosis of dengue (59.1%). The analysis of the epidemic approach showed that linear regression (17.4%) is the most used technique within the spatial analysis. Finally, the most used intervention modeling is General Linear Model with 70%. CONCLUSIONS We conclude that cause-effect models may improve diagnosis and understanding of dengue. Models that manage uncertainty can also be helpful, because of low data-quality in healthcare. Finally, decentralization of data, using federated learning, may decrease computational costs and allow model building without compromising data security.
Collapse
Affiliation(s)
- William Hoyos
- Grupo de Investigaciones Microbiológicas y Biomédicas de Córdoba, Universidad de Córdoba, Montería, Colombia; Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia.
| | - Jose Aguilar
- Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia; Centro de Estudios en Microelectrónica y Sistemas Distribuidos, Universidad de Los Andes, Mérida, Venezuela; Universidad de Alcalá, Depto. de Automática, Alcalá de Henares, Spain
| | - Mauricio Toro
- Grupo de Investigación en I+D+i en TIC, Universidad EAFIT, Medellín, Colombia
| |
Collapse
|
8
|
Different Profiles of Cytokines, Chemokines and Coagulation Mediators Associated with Severity in Brazilian Patients Infected with Dengue Virus. Viruses 2021; 13:v13091789. [PMID: 34578370 PMCID: PMC8473164 DOI: 10.3390/v13091789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 12/27/2022] Open
Abstract
The incidence of dengue in Latin America has increased dramatically during the last decade. Understanding the pathogenic mechanisms in dengue is crucial for the identification of biomarkers for the triage of patients. We aimed to characterize the profile of cytokines (IFN-γ, TNF-α, IL-1β, IL-6, IL-18 and IL-10), chemokines (CXCL8/IL-8, CCL2/MCP-1 and CXCL10/IP-10) and coagulation mediators (Fibrinogen, D-dimer, Tissue factor-TF, Tissue factor pathway inhibitor-TFPI and Thrombomodulin) during the dengue-4 epidemic in Brazil. Laboratory-confirmed dengue cases had higher levels of TNF-α (p < 0.001), IL-6 (p = 0.005), IL-10 (p < 0.001), IL-18 (p = 0.001), CXCL8/IL-8 (p < 0.001), CCL2/MCP-1 (p < 0.001), CXCL10/IP-10 (p = 0.001), fibrinogen (p = 0.037), D-dimer (p = 0.01) and TFPI (p = 0.042) and lower levels of TF (p = 0.042) compared to healthy controls. A principal component analysis (PCA) distinguished between two profiles of mediators of inflammation and coagulation: protective (TNF-α, IL-1β and CXCL8/IL-8) and pathological (IL-6, TF and TFPI). Lastly, multivariate logistic regression analysis identified high aspartate aminotransferase-to-platelet ratio index (APRI) as independent risk factors associated with severity (adjusted OR: 1.33; 95% CI 1.03–1.71; p = 0.027), the area under the receiver operating characteristics curve (AUC) was 0.775 (95% CI 0.681–0.869) and an optimal cutoff value was 1.4 (sensitivity: 76%; specificity: 79%), so it could be a useful marker for the triage of patients attending primary care centers.
Collapse
|
9
|
Htun TP, Xiong Z, Pang J. Clinical signs and symptoms associated with WHO severe dengue classification: a systematic review and meta-analysis. Emerg Microbes Infect 2021; 10:1116-1128. [PMID: 34036893 PMCID: PMC8205005 DOI: 10.1080/22221751.2021.1935327] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The World Health Organization (WHO) introduced the new dengue classification in 2009. We aimed to assess the association of clinical signs and symptoms with WHO severe dengue classification in clinical practice. A systematic literature search was performed using the databases of PubMed, Embase, and Scopus between 2009 and 2018 according to PRISMA guideline. Meta-analysis was performed with the RevMan software. A random or fixed-effect model was applied to pool odds ratios and 95% confidence intervals of important signs and symptoms across studies. Thirty nine articles from 1790 records were included in this review. In our meta-analysis, signs and symptoms associated with higher risk of severe dengue were comorbidity, vomiting, persistent vomiting, abdominal pain or tenderness, pleural effusion, ascites, epistaxis, gum bleeding, GI bleeding, skin bleeding, lethargy or restlessness, hepatomegaly (>2 cm), increased HCT with decreased platelets, shock, dyspnea, impaired consciousness, thrombocytopenia, elevated AST and ALT, gall bladder wall thickening and secondary infection. This review shows new factors comorbidity, epistaxis, GI and skin bleeding, dyspnea, gall bladder wall thickening and secondary infection may be useful to refine the 2009 classification to triage severe dengue patients.
Collapse
Affiliation(s)
- Tha Pyai Htun
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Zhonghui Xiong
- Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Junxiong Pang
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| |
Collapse
|
10
|
Gemcioglu E, Davutoglu M, Catalbas R, Karabuga B, Kaptan E, Aypak A, Kalem AK, Özdemir M, Yeşilova NY, Kalkan EA, Civak M, Kücüksahin O, Erden A, Ates I. Predictive values of biochemical markers as early indicators for severe COVID-19 cases in admission. Future Virol 2021. [PMCID: PMC8114836 DOI: 10.2217/fvl-2020-0319] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aim: COVID-19 is a pandemic that causes high morbidity and mortality, especially in severe patients. In this study, we aimed to search and explain the relationship between biochemical markers, which are more common, easily available and applicable to diagnose and to stage the disease. Materials & methods: In this study, 609 patients were evaluated retrospectively. 11 biochemical parameters were included in analysis to explain the relationship with severity of disease. Results: Nearly, all the parameters that have been evaluated in this study were statistically valuable as a predictive parameter for severe disease. Areas under the curve of blood urea nitrogen (BUN)/albumin ratio (BAR), CALL score and lymphocyte/C-reactive protein ratio were 0.795, 0.778 and 0.770. The BAR and neutrophil/albumin ratios provide important prognostic information for decision-making in severe patients with COVID-19. Conclusion: High BAR and neutrophil/albumin ratios may be a better predictor of severity COVID-19 than other routinely used parameters in admission.
Collapse
Affiliation(s)
- Emin Gemcioglu
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| | - Mehmet Davutoglu
- Yıldırım Beyazıt University School of Medicine, Department of Internal Medicine, Ankara 06800, Turkey
| | - Ramis Catalbas
- Yıldırım Beyazıt University School of Medicine, Department of Internal Medicine, Ankara 06800, Turkey
| | - Berkan Karabuga
- Yıldırım Beyazıt University School of Medicine, Department of Internal Medicine, Ankara 06800, Turkey
| | - Enes Kaptan
- Yıldırım Beyazıt University School of Medicine, Department of Internal Medicine, Ankara 06800, Turkey
| | - Adalet Aypak
- Ankara City Hospital, Department of Infectious Diseases & Clinical Microbiology, Ankara 06800, Turkey
| | - Ayse K Kalem
- Yıldırım Beyazıt University School of Medicine, Department of Infectious Diseases & Clinical Microbiology, Ankara 06800, Turkey
| | - Mustafa Özdemir
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| | - Necati Y Yeşilova
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| | - Emra A Kalkan
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| | - Musa Civak
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| | - Orhan Kücüksahin
- Yıldırım Beyazıt University School of Medicine, Department of Rheumatology, Ankara 06800, Turkey
| | - Abdulsamet Erden
- Ankara City Hospital, Department of Rheumatology, Ankara 06800, Turkey
| | - Ihsan Ates
- Ankara City Hospital, Department of Internal Medicine, Ankara 06800, Turkey
| |
Collapse
|
11
|
Identification of dengue patients with high risk of severe disease, using early clinical and laboratory features, in a resource-limited setting. Arch Virol 2020; 165:2029-2035. [DOI: 10.1007/s00705-020-04720-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
|
12
|
The aspartate aminotransferase/platelet count ratio index as a marker of dengue virus infection: Course of illness. J Infect Public Health 2020; 13:980-984. [PMID: 32265161 DOI: 10.1016/j.jiph.2020.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/27/2020] [Accepted: 03/09/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The usefulness of laboratory tests in the decision-making process with regard to early identification of dengue virus infection has not been widely reported, particularly the aspartate aminotransferase (AST)/platelet count ratio index during a patient's days of illness. The aim of this study was to examine the pattern of the ratio index over the course of illness and identify whether it is a marker of dengue virus infection in dengue patients, as well as to assess the role of other laboratory tests. METHODS A chart review of 205 dengue patients was analyzed using available records of 845 laboratory results within different time intervals or exam dates during the course of illness. We used repeated measures mixed binary logistic regression analyses to model the dengue virus infection, defined as giving at least one positive antibody test (yes/no). RESULTS The high risk of dengue virus infection in dengue patients was found in the male gender (adjusted OR=4.316, 95% CI: 1.285-14.498, P=0.018), in patients with a high AST/platelet count ratio index (adjusted OR=1.438, 95% CI: 1.057-1.957, P=0.021), in patients with a low MCV level (adjusted OR=0.815, 95% CI: 0.679-0.978, P=0.028), and in patients with a low ALT level (adjusted OR=0.996, 95% CI: 0.993-0.999, P=0.010). CONCLUSION Laboratory markers, in particular the AST/platelet count ratio index, can be useful for clinicians to strengthen the decision-making process in primary care settings. Furthermore, our model revealed that low MCV and low ALT are predictors of the dengue virus infection, while being a male increases the risk of dengue virus infection. More studies are needed to evaluate the impact of the AST/platelet count ratio index on the severity of dengue fever infection during the onset of symptoms and course of treatment.
Collapse
|
13
|
Chia PY, Thein TL, Ong SWX, Lye DC, Leo YS. Severe dengue and liver involvement: an overview and review of the literature. Expert Rev Anti Infect Ther 2020; 18:181-189. [PMID: 31971031 DOI: 10.1080/14787210.2020.1720652] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Two billion population are at risk of dengue fever and by 2080, over six billion population will be at risk. Hepatitis is common in dengue and the liver is invariably involved in severe cases. We conducted a literature review using the PubMed database on articles covering a broad range of issues related to dengue and hepatitis.Areas covered: This article overviews available literature on changes in the definition of severe dengue, pathogenesis of liver involvement in dengue, clinical manifestations, and predictors of mortality in severe dengue with liver involvement, impact of viral hepatitis co-infections and hepatotoxic drugs, and hemophagocytic lymphohistiocytosis.Expert commentary: Hepatitis is commonly seen in dengue however the degree of elevation of transaminases did not correlate well with severity of illness in observational studies, except in the elderly. The underlying pathogenesis of liver injury is still being elucidated and further studies are required to fully understand the cellular pathways. Acute or chronic viral hepatitis does not appear to affect dengue outcomes. Commonly used medications such as paracetamol and statins may influence dengue outcomes.
Collapse
Affiliation(s)
- Po Ying Chia
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Tun-Linn Thein
- National Centre for Infectious Diseases, Singapore, Singapore
| | - Sean Wei Xiang Ong
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Chien Lye
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yee Sin Leo
- National Centre for Infectious Diseases, Singapore, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| |
Collapse
|
14
|
Yeh CY, Lu BZ, Liang WJ, Shu YC, Chuang KT, Chen PL, Ko WC, Ko NY. Trajectories of hepatic and coagulation dysfunctions related to a rapidly fatal outcome among hospitalized patients with dengue fever in Tainan, 2015. PLoS Negl Trop Dis 2019; 13:e0007817. [PMID: 31805088 PMCID: PMC6894745 DOI: 10.1371/journal.pntd.0007817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 09/29/2019] [Indexed: 11/18/2022] Open
Abstract
Background Hepatic dysfunction and coagulopathy are common in acute dengue illness. We analyzed the trajectories of the above parameters in the survivors and fatal patients in the outbreak in Tainan, 2015. Methods A retrospective study was conducted using data from a tertiary hospital between January and December 2015. Multilevel modeling (MLM) was used to identify the changes in aminotransferase (AST), alanine aminotransferase (ALT), activated partial thromboplastin time (aPTT), and platelet counts from Day 0 to Day 7 of the onset of dengue infection. The machine-learning algorithm was used by purity measure assumption to calculate the accuracy of serum transaminases and coagulation variables to discriminate between the fatal and survival groups. Results There were 4,069 dengue patients, of which 0.9% died in one week after illness onset (i.e., early mortality). Case fatality rate was the highest for those aged ≥70 years. Both AST and ALT values of the fatal group were significantly higher than those of the survivor group from Day 3 (AST median, 624 U/L vs. 60 U/L, p < 0.001; ALT median, 116 U/L vs. 29 U/L, p = 0.01) of illness onset and peaked on Day 6 (AST median, 9805 U/L vs. 90 U/L, p < 0.001; ALT median, 1504 U/L vs. 49 U/L, p < 0.001). AST ≥ 203 U/L, ALT ≥ 55 U/L, AST2/ALT criteria ≥337.35, or AST/platelet count ratio index (APRI) ≥ 19.18 on Day 3 of dengue infection had a high true positive rate, 90%, 78%, 100%, or 100%, respectively, of early mortality. The platelet counts of the fatal group declined significantly than those of the survivor group since Day 3 of illness onset (median, 19 x103/μl vs. 91 x103/μl, p < 0.01), and aPTT values of the fatal group significantly prolonged longer since Day 5 (median, 68.7 seconds vs. 40.1 seconds, p < 0.001). Conclusions AST, ALT, and platelet counts should be monitored closely from Day 0 to Day 3 of dengue infection, and aPTT be followed up on Day 5 of infection to identify the individuals at risk for early mortality. Dengue fever (DF) is currently one of the most severe public health problems. Clinical presentations of dengue are diverse and non-specific, often with unpredictable clinical progression and outcome. Hepatic dysfunction and abnormal coagulation factors are common in acute dengue illness, reflected by abnormal alanine aminotransferase (AST), aspartate aminotransferase (ALT), activated partial thromboplastin time (aPTT), and platelet counts. However, there is no information available about the monitoring frequency required, which could help identify those dengue patients who are likely to die, especially during epidemic outbreaks with limited healthcare resources. We examined all the laboratory-confirmed dengue patients who admitted to the major tertiary hospital in Tainan during the 2015 dengue outbreak, and the different trajectories of hepatic function and coagulation factors between survivors and rapidly fatal dengue patients were analyzed. Although there were no differences in AST, ALT, aPTT, and platelet counts between the survivor and fatal groups on the day DF symptoms first appeared, the differences increased from the early stages of infection and became more prominent during the early stages of the illness. The necessity of monitoring the AST, ALT, aPTT, and platelet count frequently during the febrile phase is emphasized by this study.
Collapse
Affiliation(s)
- Chun-Yin Yeh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bing-Ze Lu
- Department of Mathematics, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Jie Liang
- Department of Artificial Intelligence, CTBC Business School, Tainan, Taiwan
| | - Yu-Chen Shu
- Department of Mathematics, National Cheng Kung University, Tainan, Taiwan
| | - Kun-Ta Chuang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail: (PLC); (NYK)
| | - Wen-Chien Ko
- Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail: (PLC); (NYK)
| |
Collapse
|
15
|
Guedes KS, Sanchez BAM, Gomes LT, Fontes CJF. Aspartate aminotransferase-to-platelet ratio index (APRI): A potential marker for diagnosis in patients at risk of severe malaria caused by Plasmodium vivax. PLoS One 2019; 14:e0224877. [PMID: 31765438 PMCID: PMC6876935 DOI: 10.1371/journal.pone.0224877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023] Open
Abstract
Acute infection with Plasmodium vivax, classically associated with benign disease, has been presenting as serious and even fatal disease in recent years. Severe disease is mainly due to biochemical and hematological alterations during the acute phase of infection. In the present cross-sectional study, the aspartate aminotransferase-to-platelet ratio index (APRI) was evaluated as a method for identifying patients at risk of severe vivax malaria. This retrospective study included 130 patients with confirmed P. vivax infection between June 2006 and January 2018. Clinical-epidemiological data were obtained from medical records. Hematological and biochemical parameters were determined using automated equipment. The criteria of severity for infection by Plasmodium falciparum, established by the World Health Organization (WHO), were adapted to classify patients with danger signs of severe vivax malaria. Of the 130 patient’s records evaluated, 19 (14.6%) had one or more signs and symptoms of severe malaria. The mean APRI values among patients with and without severe malaria were 2.11 and 1.09, respectively (p = 0.044). Among those with severe disease, the proportion with an APRI value above 1.50 was 30% compared to the 10% among those without severe disease (p = 0.007). The area under the receiver operating characteristic curve (95% CI), calculated to assess the accuracy of the APRI in discriminating between patients with and without severe disease, was 0.645 (0.494; 0.795). An APRI cutoff of 0.74 resulted in sensitivity of 74.0%, specificity of 56.0%, and accuracy of 65.0%. This study shows that the APRI is elevated in patients with evidence of infection by P. vivax. Based on the good sensitivity found in this study, we conclude that this simple index can serve as a diagnostic biomarker to identify patients at risk of severe disease during the acute phase of P. vivax infection.
Collapse
Affiliation(s)
- Karla Sena Guedes
- Institute of Health Sciences, Federal University of Mato Grosso, Sinop, Brazil
| | | | | | - Cor Jesus Fernandes Fontes
- Institute of Health Sciences, Federal University of Mato Grosso, Sinop, Brazil.,Júlio Müller University Hospital, Federal University of Mato Grosso, Cuiabá, Brazil
| |
Collapse
|
16
|
Sigera PC, Amarasekara R, Rodrigo C, Rajapakse S, Weeratunga P, De Silva NL, Huang CH, Sahoo MK, Pinsky BA, Pillai DR, Tissera HA, Jayasinghe S, Handunnetti S, Fernando SD. Risk prediction for severe disease and better diagnostic accuracy in early dengue infection; the Colombo dengue study. BMC Infect Dis 2019; 19:680. [PMID: 31370795 PMCID: PMC6676631 DOI: 10.1186/s12879-019-4304-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/22/2019] [Indexed: 01/14/2023] Open
Abstract
Background A major challenge in dengue management in resource limited settings is the confirmation of diagnosis. Clinical features of dengue often overlap with other infections and molecular diagnostic tools are not readily accessible to clinicians at hospitals. In addition, the prediction of plasma leakage in dengue is also difficult. Hematocrit level and ultrasound scans (combined with clinical parameters) are helpful to detect plasma leakage once it has happened, not before. Methods Colombo Dengue Study (CDS) is a prospective cohort study of clinically suspected adult dengue patients recruited from the National hospital of Sri Lanka (within the first 3 days of fever) that aimed to a) identify clinical and basic laboratory test parameters to differentiate dengue from non-dengue fever, b) evaluate the comparative efficacy of loop-mediated isothermal amplification (LAMP) for dengue diagnosis (vs. NS1 antigen test and RT-qPCR) and c) identify early associations that are predictive of plasma leakage or severe dengue. The basic laboratory tests considered here included hematological parameters, serum biochemistry and inflammatory markers. Results Only 70% of clinically suspected patients were confirmed as having dengue by either the NS1 antigen test or RT-qPCR. On a Bayesian latent class model which assumes no “gold standard”, LAMP performed equally or better than RT-qPCR and NS1 antigen test respectively. When confirmed dengue patients were compared with others, the earlier group had significantly lower lymphocyte counts and higher aspartate aminotransferase levels (AST) within the first 3 days of fever. Confirmed dengue patients with plasma leakage had a lower mean age and a higher median baseline AST level compared to those without plasma leakage (p < 0.05). Conclusion Clinical suspicion overestimates the true number of dengue patients. RT-LAMP is a potentially useful low-cost diagnostic tool for dengue diagnosis. Confirmed dengue patients had significantly higher AST levels and lower lymphocyte counts in early disease compared to others. In confirmed dengue patients, younger age and a higher AST level in early infection were associated with subsequent plasma leakage. Electronic supplementary material The online version of this article (10.1186/s12879-019-4304-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Ranmalee Amarasekara
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Canada
| | - Chaturaka Rodrigo
- Department of Pathology, School of Medical Sciences, UNSW Sydney, Kensington, Australia
| | - Senaka Rajapakse
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Praveen Weeratunga
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Nipun Lakshita De Silva
- Department of Clinical Medicine, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Chun Hong Huang
- Department of Pathology, Stanford University School of Medicine, Standford, USA
| | - Malaya K Sahoo
- Department of Pathology, Stanford University School of Medicine, Standford, USA
| | - Benjamin A Pinsky
- Department of Pathology, Stanford University School of Medicine, Standford, USA.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Standford, USA
| | - Dylan R Pillai
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Canada
| | | | - Saroj Jayasinghe
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Shiroma Handunnetti
- The Institute of Biochemistry, Molecular Biology and Biotechnology, Colombo, Sri Lanka
| | - Sumadhya D Fernando
- Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| |
Collapse
|
17
|
Wiwanitkit V. The aspartate aminotransferase/platelet count ratio index (APRI) in dengue. J Med Virol 2018; 91:723. [DOI: 10.1002/jmv.25372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/14/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Viroj Wiwanitkit
- Department of Community Medicine; Dr DY Patil University; Pune India
- Department of Laboratory Medicine; Chulalongkorn University; Bangkok Thailand
| |
Collapse
|