Serum ferritin at admission in hospitalized COVID-19 patients as a predictor of mortality

Identifying COVID-19 Confirmed Patients at Elevated Risk for Mortality and Need of Mechanical Ventilation Using a Novel Criteria for Hyperinflammatory Syndrome: A Retrospective Cohort, Single-center, Validation Study

Background and Objectives

A mounting evidence links dysregulated immune response to cases of fatal pneumonia seen in COVID-19 infection. We aimed to validate the COVID-19-associated Hyperinflammatory Syndrome (cHIS) score, a novel clinical tool devised to identify those at risk for adverse outcomes, in a local population and investigate the relationship of cHIS score taken at admission and the risk of mortality and the need of mechanical ventilation.

Methods

This retrospective cohort study analyzed the sociodemographic, clinical, and laboratory data of 1,881 COVID-19 patients admitted at a tertiary hospital in Davao City, Philippines from January to December 2021. We calculated the cHIS score, composed of six clinical and laboratory criteria from admission, and used multivariate logistic regression to determine the risk of mortality and need of mechanical ventilation.

Results

The cHIS score taken at admission, regardless of cut-off value, was a significant predictor of mortality (OR 0.979 [99% CI 0.894-1.064]) and need of mechanical ventilation (OR 0.586 [99% CI 0.4975-0.6745]). Using the Youden Index, a cut-off cHIS score of 3 or more was a better predictor of mortality (sensitivity, 88.59%; specificity, 71.72%), and a cut-off score of 2 or more was a better predictor of need of mechanical ventilation (sensitivity, 84.02%; specificity, 70.82%) than other cut-off cHIS scores.

Conclusion

Among COVID-19 patients, the cHIS score at admission correlated with the risk of mortality and the need of mechanical ventilation. Cutoff scores of 3 and 2 had the optimal sensitivities and specificities to predict the risk of mortality and the need of mechanical ventilation, respectively.

A review on the effective natural compounds of medicinal plants on the COVID-19

In this review out of 300 selected articles 70 articles were evaluated, and the most significant compounds impacting COVID-19 and their mechanism of action were introduced. The compounds belong to four categories as follow: Phenolic, Flavonoid, Terpenoid, and Alkaloid compounds. In the phenol groups, the most effective compounds are scutellarin (suppressor of COVID-19 virus), thymol and carvacrol (the most inhibitory effect on COVID-19 virus), in the flavonoid groups, hesperdin (a strong inhibitor on COVID-19), in the terpenoids, methyl tanshinonate and sojil COVID-19 inhibitory effect) and 1,8-cineol (COVID-19 inhibitory effect) and in the last group, niglidine and quinoline alkaloid compounds (COVID-19 inhibitory effect) have been identified and introduced. These compounds have shown promising results due to their structure and effective mechanisms on COVID-19, so it can be an idea for researchers in this field to try to produce drugs by using natural compounds against the COVID-19 and Corona viruses.

Severe COVID-19 in HIV/Leishmania infantum coinfected patient: a successfully managed case report

BACKGROUND

Coronavirus disease 2019 originated in China and swiftly spread worldwide, posing a significant threat to public health. Caused by SARS-CoV-2, it manifests as a flu-like illness that can escalate to Acute Respiratory Distress Syndrome, potentially resulting in fatalities. In countries where HIV/Leishmania infantum is endemic, the occurrence of concurrent SARS-CoV-2/HIV/Leishmania infantum infections is a reality, prompting inquiries into appropriate clinical management.

CASE PRESENTATION

We present the case of a 48-year-old woman who was hospitalized for 36 days across three different hospitals in the state of Pernambuco, Brazil. She was diagnosed with SARS-CoV-2/HIV/L. infantum coinfection. The patient exhibited severe COVID-19 symptoms, including fever, productive cough, and dyspnea. Throughout her hospitalization, she experienced oxygen saturation levels of ≤ 93%, along with fluctuations in blood pressure, respiratory rate, and heart rate. Her blood tests revealed lymphopenia, leukopenia, and neutropenia, while laboratory results indicated abnormal levels of d-dimer, AST, ALT, lactate dehydrogenase, ferritin, and C-reactive protein. A computed tomography scan revealed 75% involvement of the lung parenchyma with patchy ground-glass opacities.

CONCLUSION

Against all odds, the patient was discharged. The leukopenia associated with HIV/L. infantum may have played a decisive role. Further studies are necessary to better understand diagnostic strategies and clinical management measures for HIV/L. infantum coinfected patients who are susceptible to SARS-CoV-2 infection.

Evaluation of the relationship of treatment and vaccination with prognosis in patients with a diagnosis of COVID-19

PURPOSE

Coronavirus disease 2019 (COVID-19) has affected millions of people worldwide and caused mortality. Many factors have been reported to affect the prognosis of COVID-19. In this study, we aimed to investigate the effects of drug therapy and vaccination on prognosis in patients hospitalized with a COVID-19 diagnosis.

METHODS

In this single-center, cross-sectional study, data were retrospectively collected from patients receiving inpatient treatment at a university hospital with a diagnosis of COVID-19 between January 1, 2020, and April 30, 2022. The patients' demographic and clinical characteristics were recorded. The Chi-square, Cox and logistic regression was performed, P < 0.05 was considered statistically significant.

RESULTS

Total 1723 patients (50.1% were men, mean age: 60.6 ± 16.90) who had not been vaccinated rate was 27.0% (> 3 doses: 45.7%). Mortality rate was 17.0%. Increasing age, male, a high Charlson Comorbidity Index (CCI), and no vaccination significantly increased mortality (P < 0.05). The mortality rate was significantly lower in the chloroquine treatment group than in the other treatment groups. Increasing age, male, and a high CCI were determined to be factors that significantly increased the length of hospital stay (LOHS). LOHS found to be significantly lower in the favipiravir or chloroquine groups compared to the remaining treatment groups (P < 0.001). Both mortality and the LOHS significantly differed according to AST, d-dimer, ferritin, and GFR.

CONCLUSION

This study primarily investigated the effect of treatment and vaccination on the prognosis of COVID-19. This was determined to be prepared for another potential pandemic that may arise due to COVID-19.

Melatonin: a ferroptosis inhibitor with potential therapeutic efficacy for the post-COVID-19 trajectory of accelerated brain aging and neurodegeneration

The unprecedented pandemic of COVID-19 swept millions of lives in a short period, yet its menace continues among its survivors in the form of post-COVID syndrome. An exponentially growing number of COVID-19 survivors suffer from cognitive impairment, with compelling evidence of a trajectory of accelerated aging and neurodegeneration. The novel and enigmatic nature of this yet-to-unfold pathology demands extensive research seeking answers for both the molecular underpinnings and potential therapeutic targets. Ferroptosis, an iron-dependent cell death, is a strongly proposed underlying mechanism in post-COVID-19 aging and neurodegeneration discourse. COVID-19 incites neuroinflammation, iron dysregulation, reactive oxygen species (ROS) accumulation, antioxidant system repression, renin-angiotensin system (RAS) disruption, and clock gene alteration. These events pave the way for ferroptosis, which shows its signature in COVID-19, premature aging, and neurodegenerative disorders. In the search for a treatment, melatonin shines as a promising ferroptosis inhibitor with its repeatedly reported safety and tolerability. According to various studies, melatonin has proven efficacy in attenuating the severity of certain COVID-19 manifestations, validating its reputation as an anti-viral compound. Melatonin has well-documented anti-aging properties and combating neurodegenerative-related pathologies. Melatonin can block the leading events of ferroptosis since it is an efficient anti-inflammatory, iron chelator, antioxidant, angiotensin II antagonist, and clock gene regulator. Therefore, we propose ferroptosis as the culprit behind the post-COVID-19 trajectory of aging and neurodegeneration and melatonin, a well-fitting ferroptosis inhibitor, as a potential treatment.

Protective effects of IL18-105G > A and IL18-137C > Ggenetic variants on severity of COVID-19

OBJECTIVE AND DESIGN

A cross-sectional study evaluated the IL18-105G > A (rs360717) and IL18-137C > G (rs187238) variants on Coronavírus Disease 2019 (COVID-19) severity.

SUBJECTS AND METHODS

528 patients with COVID-19 classifed with mild (n = 157), moderate (n = 63) and critical (n = 308) disease were genotpyed for the IL18-105G > A and IL18-137C > G variants.

RESULTS

We observed associations between severe + critical COVID-19 groups (reference group was mild COVID-19) and the IL18-105G > A (p = 0.008) and IL18-137C > G (p = 0.01) variants, which remained significant after adjusting for sex, ethnicity and age. Consequently, we have examined the associations between moderate + critical COVID-19 and the genotypes of both variants using different genetic models. The IL18-105G > A was associated with severe disease (moderate + critical), with effects of the GA genotype in the codominant [Odds ratio (OR), (95 % confidence interval) 0.55, 0.34-0.89, p = 0.015], overdominant (0.56, 0.35-0.89, p = 0.014) and dominant (0.60, 0.38-0.96, p = 0.031) models. IL18-105 GA coupled with age, chest computed tomograhy scan anormalities, body mass index, heart diseases, type 2 diabetes mellitus, hypertension, and inflammation may be used to predict the patients who develop severe disease with an accuracy of 84.3 % (sensitivity: 83.3 % and specificity: 86.5 %). Therefore, the presence of the IL18-105 A allele in homozygosis or heterozygosis conferred about 44.0 % of protection in the development of moderate and severe COVID-19. The IL18-137C > G variant was also associated with protective effects in the codominant (0.55, 0.34-0.89, p = 0.015), overdominant (0.57, 0.36-0.91, p = 0.018), and dominant models (0.59, 0.37-0.93, p = 0.025). Therefore, the IL18-137 G allele showed a protective effect against COVID-19 severity.

CONCLUSION

The IL18-105G > A and IL18-137C > Gvariants may contribute with protective effects for COVID-19 severity and the effects of IL18-137C > G may be modulating IL-18 production and Th1-mediated immune responses.

Biochemical Analysis of Ferritin and D-dimer in COVID-19 Survivors and Non-survivors

Background COVID-19 is a major cause of illness and mortality. The management of COVID-19-related illnesses might change if variables connected to their severity and the requirement for ICU admission could be found. The severity of COVID-19 might be efficiently predicted with several laboratory measures, such as ferritin levels and D-dimer analysis. Objectives This study aimed to evaluate the association between serum D-dimer and ferritin levels and their effects on mortality in patients with COVID-19. Methods This retrospective observational study included all patients with positive real-time polymerase chain reaction (RT-PCR) results for COVID-19 who were hospitalized in the Ministry of Health South Al-Qunfudah General Hospital between March and September 30, 2020. Their laboratory parameters, serum D-dimer, and ferritin levels were evaluated. IBM SPSS Statistics for Windows, Version 26.0 (released 2019; IBM Corp., Armonk, New York, United States) was used to analyze the data. Results A total of 318 COVID-19 patients were analyzed; 56.9% (n=181) were male and 43.1% (n=137) were female. Of these, 78.6% (n=250) survived, including 58% of men and 42% of women. The mean D-dimer was 2.1 mcg/mL (SD=3.16) and the mean ferritin was 698.59 ng/mL (SD=603.11). Non-recovered patients were substantially older (66.16 years old) and had higher D-dimer (5.46) mcg/mL and ferritin levels (992.96) ng/mL. Intubation length and gender did not affect survival. Of the non-survivors, 95.6% (n=239) were admitted to the ICU, and 50% (n=34) required mechanical ventilation. Conclusions COVID-19 infection mortality dramatically increased with older age and increased mean ferritin and plasma D-dimer values, which were significantly higher in COVID-19 non-survivors than in survivors. Therefore, assessing and monitoring these laboratory markers in the early stages of the disease may have a significant impact on preventing disease progression and death.

The utility of serum amyloid A and other acute-phase reactants determination in ambulatory care COVID-19 patients

Background

The unpredictable course of Coronavirus Disease 19 (COVID-19) is making good severity assessment tools crucial. This study aimed to assess the usefulness of serum amyloid A (SAA) and other acute-phase reactants (APRs) in ambulatory care COVID-19 patients and identified relationships between these markers and disease outcomes.

Methods

From August to November 2020, patients seen in the outpatient department of the Clinic for Infectious and Tropical Diseases (Belgrade, Serbia) with confirmed COVID-19 were included. Patients were classified into mild, moderate, and severe disease groups based on World Health Organization criteria. SAA, C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT), ferritin, fibrinogen, D-dimer, albumin, and transferrin were measured. The median values of all APRs were compared between COVID-19 severity groups, hospitalized and non-hospitalized patients, and survivors and non-survivors. The Receiver operator characteristic (ROC) curve analysis was used for the classification characteristics assessment of individual APRs for the severity of illness, hospitalization, and survival.

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

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

Association of Serum Ferritin With Severity of Disease in Real-Time Reverse Transcription-Polymerase Chain Reaction Negative COVID-19 Patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) is still causing disastrous effects in various parts of the world through recurring waves. Real-time reverse transcription polymerase chain reaction (RT-PCR)-negative COVID-19 is particularly challenging as these patients are less likely to receive treatment and more likely to progress to severe disease. Thus, it is imperative to find markers that can predict the severity of disease at an early stage. The objective of the present study was to analyze the association of ferritin levels with severe disease in RT-PCR-negative COVID-19 patients.

METHODS

A prospective cross-sectional analytical study was conducted in adults with COVID-19 pneumonia with a negative RT-PCR test from October 2020 to September 2021. Hematologic, biochemical, and inflammatory parameters were investigated within 24 h of hospitalization. Demographic, clinical, and laboratory findings were compared between patients with and without severe disease.

RESULTS

A total of 220 patients were included. The mean age of the study participants was 47.3 ± 14.2 years, and 55.5% (n=122) were male. C-reactive protein, D-dimer, and ferritin levels were significantly higher in patients with severe disease (p<0.01). Receiver operating characteristic curve analyses were performed, and ferritin was found as significant predictor of severe disease (area under the curve=0.642, p<0.001).

CONCLUSION

Early analysis of ferritin can predict the severity of disease in COVID-19 patients, irrespective of the RT-PCR status.

Prognostic Value of Serum Ferritin for Patients with Severe Fever with Thrombocytopenia Syndrome: A Single-Center Retrospective Cohort Study

INTRODUCTION

This article aims to evaluate the prognostic value of ferritin in patients with severe fever with thrombocytopenia syndrome (SFTS).

METHODS

Patients with SFTS diagnosed at the Infection Department of Wuhan Union Medical College Hospital from July 2018 to November 2021 were included. The best cutoff value was determined by receiver-operating characteristic (ROC) curve. The survival curve was analyzed by Kaplan-Meier method and compared among different serum ferritin subgroups by log-rank test. Cox regression model was used to evaluate the effect of prognosis on overall survival (OS).

RESULTS

A total of 229 patients with febrile thrombocytopenia syndrome were enrolled. There were 42 fatal cases, with a fatality rate of 18.3%. The best critical value of serum ferritin was 16.775 mg/l. With increasing serum ferritin level, the cumulative mortality increased significantly (log-rank, P < 0.001). Cox univariate regression analysis and adjusted confounding factors such as age, viral load, liver and kidney function and blood coagulation function showed that, compared with the low ferritin group, the high ferritin group demonstrated poorer OS.

CONCLUSIONS

The serum ferritin level before treatment can be considered a valuable index for predicting the prognosis of patients with SFTS.

CORRELATION BETWEEN HEPCIDIN AND PROCALCITONIN AND THEIR DIAGNOSTIC ROLE IN PATIENTS WITH COVID-19

OBJECTIVE

The aim: The purpose of this study is to find out the association between procalcitonin and hepcidin in patients with COVID-19, in addition to their role as diagnostic markers.

PATIENTS AND METHODS

Materials and methods: A total of 75 patients infected with coronavirus were included in the current study, their age is ranging between 20 to 78 years. Those patients was hospitalized in Al-Sadr Teaching Hospital in Najaf, in Iraq. This study also included 50 healthy subjects which are volunteers and considered as a (control group). Biomarker (procalcitonin and hepcidin) measurements were achieved by electrochemiluminescent immunoassay (ECLIA) in the Elecsys immunoassay system.

RESULTS

Results: The present study showed a significant increase the serum cencentration of hepcidin and procalcitonin in patients with COVID-19 as compared tohealthy subjects. There was a highly significant increasing(p < 0.01) in hepcidin and PCT level in patients with severe infection comparing to other catgaries.The current study also revealed that the sensitivity values of the markers were: 0.88%, 0.85 for procalcitonin and hepcidin respectively, which indicate high diagnostic power.

CONCLUSION

Conclusions: Serum levels of hepcidin and procalcitonin are increased as inflammatory markers in COVID-19 patients with relatively high sensitivity. It seems that these imflammatory markers obviously elevate in the severe cases COVID-19dusease.

Ferritin-haemoglobin ratio as a predictor of severity and fatal outcome in patients with Covid-19

Background/Aim: Although ferritin and haemoglobin were well-studied for adverse outcome prediction in COVID-19 patients, a ferritin-haemoglobin ratio (FHR) was studied poorly. The study aimed to evaluate the prognostic ability of FHR at hospital admission in hypertensive and non-hypertensive patients with COVID-19. Methods: The study included 135 patients hospitalised for COVID-19-associated pneumonia. The 78.5 % of patients were hypertensive. Results: FHR at admission was higher in patients with critical condition (39.8 [17.1-83.0]) than in patients with moderate (22.0 [12.1-32.1], p = 0.01) and severe condition (34.6 [15.1-64.5], p = 0.01). FHR was higher in patients who required supplemental oxygen (40.4 [29.4-47.8]) than in patients without the need for supplemental oxygen (22.0 [18.0-25.5]) (p = 0.001). FHR at admission was higher in non-survivors (40.1 [24.6-95.9]) than in survivors (24.5 [21.6-28.4]) (p = 0.047). FHR showed weak discriminative ability for the prediction of severe/critical conditions in hypertensive patients (AUC = 0.636, p = 0.015) and all (hypertensive and non-hypertensive patients) patients (AUC = 0.658, p = 0.001), whereas FHR had an acceptable discriminative ability in non-hypertensive patients (AUC = 0.764, p = 0.015). There was an acceptable discriminative ability of FHR for in-hospital mortality prediction in hypertensive patients (AUC = 0.717, p = 0.029). Patients with FHR > 33.98 (Youden index, 0.39) had higher odds of severe/critical clinical condition (OR: 4.57; 95 % CI: 1.87-11.18; p = 0.001). FHR of > 37.64 (Youden index, 0.55) was associated with higher in-hospital mortality among hypertensive patients (OR: 12.06; 95 % CI: 2.44-59.71; p = 0.002). There was no difference in AUC for the discriminative ability of FHR regarding severe/ critical condition (p = 0.296) and mortality (p = 0.663) in hypertensive and non-hypertensive patients. Conclusion: FHR at admission of > 33.98 is a predictor of severe/critical COVID-19 in both hypertensive and non-hypertensive patients. FHR of > 37.64 is a predictor of in-hospital mortality in hypertensive patients. There was no significant difference in the discriminative ability of FHR between hypertensive and non-hypertensive patients.

Variability of Steroid Prescription for COVID-19 Associated Pneumonia in Real-Life, Non-Trial Settings

The RECOVERY study documented lower 28-day mortality with the use of dexamethasone in hospitalized patients on invasive mechanical ventilation or oxygen with COVID-19 Pneumonia. We aimed to examine the practice patterns of steroids use, and their impact on mortality and length of stay in ICU. We retrospectively examined records of all patients with confirmed Covid 19 pneumonia admitted to the ICU of Dubai hospital from January 1st, 2020 – June 30th, 2020. We assigned patients to four groups (No steroids, low dose, medium dose, and high dose steroids). The primary clinical variable of interest was doses of steroids. Secondary outcomes were 28-day mortality and length of stay in ICU”. We found variability in doses of steroid treatment. The most frequently used dose was the high dose. Patients who survived were on significantly higher doses of steroids and had significantly longer stays in ICU. The prescription of steroids in Covid-19 ARDS is variable. The dose of steroids impacts mortality rate and length of stay in ICU, although patients treated with high dose steroids seem to stay more days in ICU.

The Impact of Antibiotic Use on Mortality in Patients Hospitalized in a COVID-19 Centre from Romania: A Retrospective Study

Background and Objectives: Considering the significant number of patients worldwide that received empirical antibiotic therapy for COVID-19 infection due to their critical condition and the lack of therapeutical guidelines, we wanted to find out the consequences of antibiotic use in our study population. Materials and Methods: We conducted a retrospective cohort study including symptomatic patients older than 18 years, hospitalized for SARS-CoV-2 between March and December 2020 in the Internal Medicine and Pneumology Departments of Colentina Clinical Hospital. The elected outcome was death, while independent variables were antibiotic therapy and literature-cited parameters associated with mortality in this disease. Results: Out of 198 included patients, 96 (48.48%) patients received antibiotic therapy during hospitalization. Female gender (OR = 2.61, p = 0.04), history of neoplasm (OR = 7.147, p = 0.01), heart failure (OR = 8.62, p = 0.002), and diabetes mellitus (OR = 3.05, p = 0.02) were significantly associated with death in multivariate analysis. Antibiotic treatment showed a higher probability of death both in bivariate (OR = 5.333, p < 0.001) and multivariate analysis adjusted for the aforementioned prognostic factors (OR = 3.55, p = 0.01). Conclusions: After adjusting for confounders, in-hospital antibiotic administration did not improve survival in COVID-19 patients.

Accuracy of conventional disease severity scores in predicting COVID-19 ICU mortality: retrospective single-center study in Turkey

BACKGROUND

Disease severity scores are important tools for predicting mortality in intensive care units (ICUs), but conventional disease severity scores may not be suitable for predicting mortality in coronavirus disease-19 (COVID-19) patients.

OBJECTIVE

Compare conventional disease severity scores for discriminative power in ICU mortality.

DESIGN

Retrospective cohort SETTING: Intensive care unit in tertiary teaching and research hospital.

PATIENTS AND METHODS

COVID-19 patients who were admitted to our ICU between 11 March 2020 and 31 December 2021 were included in the study. Patients who died within the first 24 hours were not included. SAPS II, APACHE II and APACHE 4 scores were calculated within the first 24 hours of ICU admission. A receiver operating characteristics (ROC) analysis was performed for discriminative power of disease severity scores.

MAIN OUTCOME MEASURE

ICU mortality SAMPLE SIZE AND CHARACTERISTICS: 510 subjects with median (interquartile percentiles) age of 65 (56-74) years.

RESULTS

About half (n=250, 51%) died during ICU stay. Three disease severity scores had similar discriminative power, the area under the curve (AUC), SAPS II (AUC 0.79), APACHE II (AUC 0.76), APACHE 4 (AUC 0.78) (P<.001). Observed mortality was higher than predicted mortality according to conventional disease severity scores.

CONCLUSION

Conventional disease severity scores are good indicators of COVID-19 severity. However, they may underestimate mortality in COVID-19. New scoring systems should be developed for mortality prediction in COVID-19.

LIMITATION

A single-center study CONFLICT OF INTEREST: None.

Exploring Urinary Extracellular Vesicles and Immune Mediators as Biomarkers of Kidney Injury in COVID-19 Hospitalized Patients

Kidney injury is an important outcome associated with COVID-19 severity. In this regard, alterations in urinary extracellular vesicles (uEVs) could be detected in the early phases of renal injury and may be reflective of the inflammatory process. This is an observational study performed with a case series of COVID-19 hospitalized patients presenting mild-to-critical disease. Total and podocyte-derived uEVs were identified by nanoscale flow cytometry, and urinary immune mediators were assessed by a multiplex assay. We studied 36 patients, where 24 (66.7%) were considered as mild/moderate and 12 (33.3%) as severe/critical. Increased levels of total uEVs were observed (p = 0.0001). Importantly, total uEVs were significantly higher in severe/critical patients who underwent hemodialysis (p = 0.03) and were able to predict this clinical outcome (AUC 0.93, p = 0.02). Severe/critical patients also presented elevated urinary levels (p < 0.05) of IL-1β, IL-4, IL-6, IL-7, IL-16, IL-17A, LIF, CCL-2, CCL-3, CCL-11, CXCL-10, FGFb, M-CSF, and CTAcK. Lastly, we observed that total uEVs were associated with urinary immune mediators. In conclusion, our results show that early alterations in urinary EVs could identify patients at higher risk of developing renal dysfunction in COVID-19. This could also be relevant in different scenarios of systemic and/or infectious disease.

COVID-19 in Older Individuals Requiring Hospitalization

Older individuals have an increased risk for severe coronavirus disease 2019 (COVID-19) and a higher risk for complications and death. The aim of this study was to investigate the clinical characteristics of older patients admitted with COVID-19 and describe their outcomes. This was a retrospective cohort study of patients older than 65 years admitted to the COVID-19 Department of the University Hospital of Heraklion. Data recorded and evaluated included age, gender, Infectious Diseases Society of America (IDSA) severity score, Charlson comorbidity index (CCI), high-flow nasal oxygen (HFNO) use, admission to the Intensive Care Unit (ICU), laboratory exams, treatment administered, and outcome. In total, 224 patients were evaluated in the present study. The median age was 75 years and 105 (46.9%) were female. In 50 patients (22.7%), HFNO was used and 23 (10.3%) were admitted to the ICU. Mortality was 13.4% (30 patients). Patients that died had higher age, were more likely to be male, had an IDSA severity score of 3, had prior HFNO use, had been admitted to the ICU, and were also more likely to have a higher white blood cell (WBC) count, CRP, ferritin, procalcitonin, d-dimers, and troponin. A multivariate logistic regression analysis identified age and the need for HFNO use to be independently positively associated with mortality. To conclude, COVID-19 carries significant mortality in hospitalized older patients, which increases with age, while the need for HFNO also increased the likelihood of worse outcomes. Clinicians caring for patients with COVID-19 should bear in mind these two factors. Future studies could elaborate on the effect of new variants on the dynamics of mortality in older patients.

The Associations of Iron Related Biomarkers with Risk, Clinical Severity and Mortality in SARS-CoV-2 Patients: A Meta-Analysis

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is spreading rapidly around the world and has led to millions of infections and deaths. Growing evidence indicates that iron metabolism is associated with COVID-19 progression, and iron-related biomarkers have great potential for detecting these diseases. However, the results of previous studies are conflicting, and there is not consistent numerical magnitude relationship between those biomarkers and COVID-19. Thereby, we aimed to integrate the results of current studies and to further explore their relationships through a meta-analysis. We searched peer-reviewed literature in PubMed, Scopus and Web of Science up to 31 May 2022. A random effects model was used for pooling standard mean difference (SMD) and the calculation of the corresponding 95% confidence interval (CI). I2 was used to evaluate heterogeneity among studies. A total of 72 eligible articles were included in the meta-analysis. It was found that the ferritin levels of patients increased with the severity of the disease, whereas their serum iron levels and hemoglobin levels showed opposite trends. In addition, non-survivors had higher ferritin levels (SMD (95%CI): 1.121 (0.854, 1.388); Z = 8.22 p for Z < 0.001; I2 = 95.7%, p for I2 < 0.001), lower serum iron levels (SMD (95%CI): −0.483 (−0.597, −0.368), Z = 8.27, p for Z < 0.001; I2 = 0.9%, p for I2 =0.423) and significantly lower TIBC levels (SMD (95%CI): −0.612 (−0.900, −0.324), Z = 4.16, p for Z < 0.001; I2 = 71%, p for I2 = 0.016) than survivors. This meta-analysis demonstrates that ferritin, serum iron, hemoglobin and total iron banding capacity (TIBC) levels are strongly associated with the risk, severity and mortality of COVID-19, providing strong evidence for their potential in predicting disease occurrence and progression.

Clinical characteristics and mortality predictors of patients with cancer hospitalized by COVID-19 in a pediatric third-level referral center

Background

More than 135 million COVID-19 cases (coronavirus disease 2019) have been reported worldwide until today, with over 2.9 million deaths. Several studies have demonstrated that disease severity is lower in the pediatric population than in adults; however, differences are described in patients with chronic diseases, including oncological patients. Current world literature suggests patients with comorbidities, including cancer, have an increased risk of unfortunate outcomes. Therefore, our objective was to describe the clinical characteristics and epidemiological factors associated with mortality in a cohort of pediatric cancer patients hospitalized for COVID-19.

Methods

This is a retrospective, descriptive study of the cases of patients with cancer hospitalized for COVID-19. A total of 40 pediatrics were included in the analysis. Data from pediatric patients with COVID-19 included clinical and epidemiological records, laboratory, imaging studies, COVID-19 diagnostic methods, and medical treatment.

Results

Of the 40 pediatric patients admitted with cancer with a confirmed diagnosis of COVID-19, 42.5% were solid tumors, 40% leukemias, and 17.5% lymphomas. The clinical parameters associated with mortality were stage IV tumor (p = 0.029) and intubation (p < 0.001). The biochemical factors associated with lower survival were thrombocytopenia under 25,000 cells/mm3 (p < 0.001), D-dimer over 1 μg/ml (p = 0.003), clinical malnutrition (p = 0.023), and disseminated intravascular coagulation (p = 0.03).

Conclusion

Our findings showed that the fever was the most frequent symptom, and the clinical parameters associated with mortality were stage IV tumor, intubation, saturation percentage, RDW, platelets, creatinine, ALT, D-dimer, ferritin, and FiO2 percentage. The thrombocytopenia, D-dimer, nutritional status, and disseminated intravascular coagulation were significantly associated with lower survival.

An Assessment of the Profile and Predictors of Outcomes in COVID-19 Patients Hospitalized in a Tertiary Care Institute in Central India

Background

Coronavirus disease 2019 (COVID-19) is the largest pandemic that has affected people around the globe. Various researches have been conducted worldwide, but there is a scarcity of data from Central India on the relationship between several risk factors for infection and mortality. Our study assessed the predictors and patient profiles of those with COVID-19, which will aid in prioritizing patient treatment and preventive measures.

Methods

A retrospective study was done between March and December 2020. The study included 5,552 COVID-19 patients admitted to the All India Institute of Medical Sciences (AIIMS), Raipur. A validated questionnaire form provided by the WHO was used. Data for multiple clinical and nonclinical parameters were collected, and analysis was done using SPSS version 26 (IBM Corp., Armonk, NY, USA) and STATA version 12 (StataCorp LLC, College Station, TX, USA). Mortality and risk assessment of patients was done using multivariate logistic regression.

Result

In our study cohort of 5,552 COVID-19 patients, the median age was found to be 47 years (interquartile range (IQR): 31-60 years; range: 14-100 years), and 3,557 (64%) were male. Predominantly, patients presented with fever (41.30%), cough (40.20%), and dyspnea (29.29%). The major comorbidities were hypertension (29.70%), diabetes (25.40%), and chronic cardiac disease (5.79%). The common complications were liver dysfunction (26.83%), viral pneumonitis (23.66%), acute renal injury (15.25%), and acute respiratory distress syndrome (ARDS) (13.41%). In multivariate analysis, age (more than 40 years) (odds ratio (OR): 2.63; 95% confidence interval (CI): 1.531-4.512; p<0.001), diabetes (OR: 1.61; 95% CI: 1.088-2.399; p=0.017), obesity (OR: 6.88; 95% CI: 2.188-12.153; p=0.004), leukocytosis (OR: 1.74; 95% CI: 1.422-2.422; p<0.001), lymphocytopenia (OR: 2.54, 95% CI: 1.718-3.826; p<0.001), thrombocytopenia (OR: 1.15; 95% CI: 1.777-8.700; p=0.001), and ferritin concentration > 1,000 ng/mL (OR: 4.67; 95% CI: 1.991-10.975; p<0.001) were the independent predictors of mortality among COVID-19 patients.

Conclusion

The leading comorbidities in our study were hypertension, followed by diabetes. Patients who were 40 years or older, obese patients, and diabetic patients have a higher mortality risk. The poor prognostic predictors in COVID-19 patients were high ferritin levels (>1,000 ng/mL), leukocytosis, lymphocytopenia, and thrombocytopenia.

Role of Serum Ferritin and PRISM-III in Predicting Mortality in Children with Acute Encephalitis Syndrome in Northern India

The aim of this study was to evaluate the role of serum ferritin (SF) and PRISM-III (Pediatric Risk of Mortality) score in predicting mortality in critically ill children aged 6 months to 15 years diagnosed with acute encephalitis syndrome (AES) admitted to the pediatric intensive care unit (PICU). This prospective observational study was conducted in the PICU of a tertiary teaching hospital in Northern India between July 2018 and June 2019. The primary outcome was to determine the association of admission SF levels with mortality. Secondary outcomes included estimating the prevalence of hyperferritinemia and comparing SF with PRISM-III scores in predicting mortality. Etiology could be established in 85.5% (n = 219) of the 256 children enrolled. Scrub typhus accounted for nearly two-thirds of the cases (60.5%), while dengue and Japanese encephalitis were the next common diagnoses. The median [interquartile range] SF at admission was significantly higher among the nonsurvivors than survivors: 514 [260–1,857] and 318 [189–699] µg/L, respectively (p = 0.029). SF and PRISM-III independently predicted mortality in AES. However, both had poor discriminatory power with area under receiver operating curve (95% confidence interval) of 0.61 (0.51–0.72) and 0.67 (0.56–0.77), respectively. Elevated SF and higher PRISM-III scores independently predicted mortality in children admitted to PICU with AES.

A Pilot Study on COVID-19 Positive Subjects: An Excerpt of Post-Infection-Pro-Diabetic Disposition & Related Consequences in Correlation to Hepato-Pancreatic Bio-Markers, Pro-Inflammatory Cytokines and Other Risk Factors

COVID-19, a global pandemic that led to increased morbidity and mortality worldwide since its outcome at the end of the year 2019. A newly discovered variant of severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) was the arbitrator for spreading the syndrome by droplet transmission causing multi-organ failure in many occasions. A post-infection-pro-diabetic disposition was found evident in this study with the persistence of hepato-pancreatic aberrations in respect of reference range of tissue specific bio-markers in hospital admitted COVID-19 cases. The results of this study show that hyperglycemia is a risk factor in precipitating disease oriented complications to the patients with COVID-19 disease. A post-infection follow- up on glycemic-index and related complexities is a vital need to the COVID-19 infected convalescent subjects. Implementation of guidelines on social measure and awareness of anti-viral interventions may be the only way to prevent COVID-19 transmission.

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

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

Dysregulation in erythrocyte dynamics caused by SARS-CoV-2 infection: possible role in shuffling the homeostatic puzzle during COVID-19

Introduction

The evolving COVID-19 pandemic became a hallmark in human history, not only by changing lifestyles, but also by enriching scientific knowledge on viral infection and its consequences.

Objective

Although the management of cardiorespiratory changes is pivotal to a favorable prognosis during severe clinical findings, dysregulation of other systems caused by SARS-CoV-2 infection may imbalance erythrocyte dynamics, such as a bidirectional positive feedback loop pathophysiology.

Method and Results

Recent evidence shows that SARS-CoV-2 is capable of affecting the genetics and dynamics of erythrocytes and this coexists with a non-homeostatic function of cardiovascular, respiratory and renal systems during COVID-19. In hypothesis, SARS-CoV-2-induced systematical alterations of erythrocytes dynamics would constitute a setpoint for COVID-19-related multiple organ failure syndrome and death.

Conclusion

The present review covers the most frequent erythrocyte-related non-homeostatic findings during COVID-19 capable of providing mechanistic clues of SARS-CoV-2-induced infection and inspiring therapeutic-oriented scientific evidence.

The detrimental impact of elevated Ferritin to Iron ratio on in-hospital prognosis of patients with COVID-19

BACKGROUND

Acute viral infections, including coronavirus disease 2019 (COVID-19), are characterized by the dysregulation of iron metabolism, resulting in high serum ferritin and low iron levels.

RESEARCH DESIGN AND METHODS

This study aimed to evaluate the prospective impact of iron metabolism dysregulation, as expressed by serum Ferritin-to-Iron Ratio (FIR), on the in-hospital prognosis of patients with COVID-19. Serum levels of ferritin and iron, as well as other iron metabolism markers and recognized prognostic indicators of COVID-19 severity, were measured in 362 patients consecutively hospitalized for COVID-19. The prospective relationship between FIR and the risk of the composite outcome of intensive care unit (ICU) admission/in-hospital death was analyzed.

RESULTS

In the population examined (mean age 74 ± 15 years, males 55%), the rates of radiographic signs of pneumonia, respiratory distress, and the need for noninvasive ventilation were higher in patients with high FIR (≥29.2, the 75th percentile) than in those with low FIR (<29.2, the 75th percentile) (p < 0.05 for all comparisons). High FIR was associated with a 1.7-fold (HR 1.709, 95% CI 1.017-2.871, p = 0.043) higher risk of ICU admission/in-hospital death.

CONCLUSIONS

Increasing FIR values significantly and independently predicts worse in-hospital prognosis in hospitalized patients with COVID-19.

The study of serum hsCRP, ferritin, IL-6 and plasma D-dimer in COVID-19: a retrospective study

OBJECTIVES

The cut off values for serum high sensitivity C-reactive protein (hsCRP), ferritin, interleukin 6 (IL-6) and plasma D-dimer could be of profound help in detecting COVID-19 patients at risk of adverse outcomes. Therefore, the aim of the present study is to determine the cut off values of the serum hsCRP, ferritin, IL-6 and plasma D-dimer in predicting mortality in COVID-19 patients.

METHODS

Four hundred RT-PCR confirmed cases of COVID-19 were sub divided into two groups based on their outcome during hospitalisation. Group I consisted of survivors and Group II consisted of non-survivors. The survivors were further divided into three sub-groups: mild, moderate and severe based on the severity of infection. The laboratory data of serum hsCRP, ferritin, IL-6 and plasma D-dimer for all these patients was retrieved from the Medical Record Section of the Hospital.

RESULTS

Mean serum hsCRP, ferritin, IL-6 and plasma D-dimer levels were significantly higher in non-survivors as compared to survivors of COVID-19. The levels of these biomarkers correlated with the severity of COVID-19 illness. ROC curve analysis revealed that plasma D-dimer is having a better predictive value as compared to other parameters in predicting mortality in COVID-19.

CONCLUSIONS

The serum hsCRP, ferritin, IL-6 and plasma D-dimer levels could be used in risk stratification of COVID-19 patients. The optimum cut off given by the current study could be considered in predicting adverse outcome in these patients. Amongst the many studied biomarkers, plasma D-dimer might be the best early biomarker to predict mortality in COVID-19 patients.

Safety and long-term improvement of mesenchymal stromal cell infusion in critically COVID-19 patients: a randomized clinical trial

BACKGROUND

COVID-19 is a multisystem disease that presents acute and persistent symptoms, the postacute sequelae (PASC). Long-term symptoms may be due to consequences from organ or tissue injury caused by SARS-CoV-2, associated clotting or inflammatory processes during acute COVID-19. Various strategies are being chosen by clinicians to prevent severe cases of COVID-19; however, a single treatment would not be efficient in treating such a complex disease. Mesenchymal stromal cells (MSCs) are known for their immunomodulatory properties and regeneration ability; therefore, they are a promising tool for treating disorders involving immune dysregulation and extensive tissue damage, as is the case with COVID-19. This study aimed to assess the safety and explore the long-term efficacy of three intravenous doses of UC-MSCs (umbilical cord MSCs) as an adjunctive therapy in the recovery and postacute sequelae reduction caused by COVID-19. To our knowledge, this is one of the few reports that presents the longest follow-up after MSC treatment in COVID-19 patients.

METHODS

This was a phase I/II, prospective, single-center, randomized, double-blind, placebo-controlled clinical trial. Seventeen patients diagnosed with COVID-19 who require intensive care surveillance and invasive mechanical ventilation-critically ill patients-were included. The patient infusion was three doses of 5 × 105 cells/kg UC-MSCs, with a dosing interval of 48 h (n = 11) or placebo (n = 6). The evaluations consisted of a clinical assessment, viral load, laboratory testing, including blood count, serologic, biochemical, cell subpopulation, cytokines and CT scan.

RESULTS

The results revealed that in the UC-MSC group, there was a reduction in the levels of ferritin, IL-6 and MCP1-CCL2 on the fourteen day. In the second month, a decrease in the levels of reactive C-protein, D-dimer and neutrophils and an increase in the numbers of TCD3, TCD4 and NK lymphocytes were observed. A decrease in extension of lung damage was observed at the fourth month. The improvement in all these parameters was maintained until the end of patient follow-up.

CONCLUSIONS

UC-MSCs infusion is safe and can play an important role as an adjunctive therapy, both in the early stages, preventing severe complications and in the chronic phase with postacute sequelae reduction in critically ill COVID-19 patients. Trial registration Brazilian Registry of Clinical Trials (ReBEC), UTN code-U1111-1254-9819. Registered 31 October 2020-Retrospectively registered, https://ensaiosclinicos.gov.br/rg/RBR-3fz9yr.

Interpretable deep learning for the prediction of ICU admission likelihood and mortality of COVID-19 patients

The global healthcare system is being overburdened by an increasing number of COVID-19 patients. Physicians are having difficulty allocating resources and focusing their attention on high-risk patients, partly due to the difficulty in identifying high-risk patients early. COVID-19 hospitalizations require specialized treatment capabilities and can cause a burden on healthcare resources. Estimating future hospitalization of COVID-19 patients is, therefore, crucial to saving lives. In this paper, an interpretable deep learning model is developed to predict intensive care unit (ICU) admission and mortality of COVID-19 patients. The study comprised of patients from the Stony Brook University Hospital, with patient information such as demographics, comorbidities, symptoms, vital signs, and laboratory tests recorded. The top three predictors of ICU admission were ferritin, diarrhoea, and alamine aminotransferase, and the top predictors for mortality were COPD, ferritin, and myalgia. The proposed model predicted ICU admission with an AUC score of 88.3% and predicted mortality with an AUC score of 96.3%. The proposed model was evaluated against existing model in the literature which achieved an AUC of 72.8% in predicting ICU admission and achieved an AUC of 84.4% in predicting mortality. It can clearly be seen that the model proposed in this paper shows superiority over existing models. The proposed model has the potential to provide tools to frontline doctors to help classify patients in time-bound and resource-limited scenarios.

Coagulation profile and correlation between D-dimer, inflammatory markers, and COVID-19 severity in an Indonesian national referral hospital

Background

Coagulopathy and inflammation are associated with coronavirus disease 2019 (COVID-19) severity. This study assessed D-dimer concentration and its correlation with inflammatory markers and COVID-19 severity.

Methods

This was a retrospective cross-sectional study involving 194 COVID-19 cases, with the severity of infection graded in accordance with the World Health Organization (WHO) guidelines. We measured D-dimer, C-reactive protein (CRP), and ferritin on admission and determined the cutoff values for D-dimer and CRP and evaluated the correlation between D-dimer and CRP and ferritin.

Results

Median D-dimer, CRP, and ferritin concentrations were 2240 µg/L, 73.2 mg/L, and 1173.8 µg/mL, respectively. The highest median D-dimer value was seen in mild and moderate acute respiratory distress syndrome (ARDS). The highest ferritin concentration was seen in severe ARDS. There was a significant correlation between D-dimer value and CRP (r = 0.327), but no significant correlation between D-dimer and ferritin (r = 0.101). The area under the receiver operating characteristic curve (AUC) for the combination of CRP ≥72.65 mg/L and D-dimer ≥1250 µg/L as a marker of COVID-19 severity was 0.722 (95% confidence interval (CI): 0.615–0.781).

Conclusion

The combination of CRP ≥72.65 mg/L and D-dimer ≥1250 µg/L can be used as marker of COVID-19 severity, with moderate accuracy.

Acute Kidney Disease and Mortality in Acute Kidney Injury Patients with COVID-19

BACKGROUND

The incidence of AKI in coronavirus disease 2019 (COVID-19) patients is variable and has been associated with worse prognosis. A significant number of patients develop persistent kidney damage defined as Acute Kidney Disease (AKD). There is a lack of evidence on the real impact of AKD on COVID-19 patients. We aim to identify risk factors for the development of AKD and its impact on mortality in COVID-19 patients.

METHODS

Retrospective analysis of COVID-19 patients with AKI admitted at the Centro Hospitalar Universitário Lisboa Norte between March and August of 2020. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. AKD was defined by presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event.

RESULTS

In 339 COVID-19 patients with AKI, 25.7% patients developed AKD (n = 87). The mean age was 71.7 ± 17.0 years, baseline SCr was 1.03 ± 0.44 mg/dL, and the majority of patients were classified as KDIGO stage 3 AKI (54.3%). The in-hospital mortality was 18.0% (n = 61). Presence of hypertension (p = 0.006), CKD (p < 0.001), lower hemoglobin (p = 0.034) and lower CRP (p = 0.004) at the hospital admission and nephrotoxin exposure (p < 0.001) were independent risk factors for the development of AKD. Older age (p = 0.003), higher serum ferritin at admission (p = 0.008) and development of AKD (p = 0.029) were independent predictors of in-hospital mortality in COVID-19-AKI patients.

CONCLUSIONS

AKD was significantly associated with in-hospital mortality in this population of COVID-19-AKI patients. Considering the significant risk of mortality in AKI patients, it is of paramount importance to identify the subset of higher risk patients.

Outcomes of hospitalized patients with COVID-19 pneumonia, hypoxia, and a normal initial chest roentgenogram

BACKGROUND

Outcomes of patients with coronavirus disease (COVID-19) pneumonia, hypoxia, and an initial normal chest roentgenogram (CXR) are not well defined. This study aimed to analyze the factors associated with poor outcomes in these patients.

METHODS

This retrospective study evaluated patients admitted with COVID-19 pneumonia, a CXR without infiltrates and hypoxemia requiring supplemental oxygen. Outcomes were compared based on D-dimer levels and included in-hospital mortality, need for mechanical ventilation, acute kidney injury, shock, and length of hospital stay.

RESULTS

We identified 115 patients, 31 (27%) had D-dimer levels above 4 times upper limit of normal on admission. Predictors of mortality included elevated D-dimers in hypoxic patients, use of mechanical ventilation, acute kidney injury, shock, and elevated admission serum sodium and lactic dehydrogenase.

CONCLUSIONS

Patients with COVID-19 and hypoxia on initial presentation despite a normal CXR had significant mortality rates, higher in those with elevated inflammatory markers. The use of inflammatory markers, such as D-dimer and serum ferritin levels, may assist in identifying patients with higher morbidity and mortality risks. Additional imaging with chest computed tomogram should be obtained if clinically indicated and avoidance of overreliance of a normal CXR in those patients.

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

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

Insights into Innate Immune Response Against SARS-CoV-2 Infection

The innate immune system is mandatory for the activation of antiviral host defense and eradication of the infection. In this regard, dendritic cells, natural killer cells, macrophages, neutrophils representing the cellular component, and cytokines, interferons, complement or Toll-Like Receptors, representing the mediators of unspecific response act together for both activation of the adaptive immune response and viral clearance. Of great importance is the proper functioning of the innate immune response from the very beginning. For instance, in the early stages of viral infection, the defective interferon response leads to uncontrolled viral replication and pathogen evasion, while hypersecretion during the later stages of infection generates hyperinflammation. This cascade activation of systemic inflammation culminates with cytokine storm syndrome and hypercoagulability state, due to a close interconnection between them. Thus an unbalanced reaction, either under- or over- stimulation of the innate immune system will lead to an uncoordinated response and unfavorable disease outcomes. Since both cellular and humoral factors are involved in the time-course of the innate immune response, in this review we aimed to address their gradual involvement in the antiviral response with emphasis on key steps in SARS-CoV-2 infection.