D-Dimer and Serum ferritin as an Independent Risk Factor for Severity in COVID-19 Patients

Development and validation of a scoring system to predict mortality in patients hospitalized with COVID-19: A retrospective cohort study in two large hospitals in Ecuador

OBJECTIVE

To develop and validate a scoring system to predict mortality among hospitalized patients with COVID-19.

METHODS

Retrospective cohort study. We analyzed 5,062 analyzed hospitalized patients with COVID-19 treated at two hospitals; one each in Quito and Guayaquil, from February to July 2020. We assessed predictors of mortality using survival analyses and Cox models. We randomly divided the database into two sets: (i) the derivation cohort (n = 2497) to identify predictors of mortality, and (ii) the validation cohort (n = 2565) to test the discriminative ability of a scoring system. After multivariate analyses, we used the final model's β-coefficients to build the score. Statistical analyses involved the development of a Cox proportional hazards regression model, assessment of goodness of fit, discrimination, and calibration.

RESULTS

There was a higher mortality risk for these factors: male sex [(hazard ratio (HR) = 1.32, 95% confidence interval (95% CI): 1.03-1.69], per each increase in a quartile of ages (HR = 1.44, 95% CI: 1.24-1.67) considering the younger group (17-44 years old) as the reference, presence of hypoxemia (HR = 1.40, 95% CI: 1.01-1.95), hypoglycemia and hospital hyperglycemia (HR = 1.99, 95% CI: 1.01-3.91, and HR = 1.27, 95% CI: 0.99-1.62, respectively) when compared with normoglycemia, an AST-ALT ratio >1 (HR = 1.55, 95% CI: 1.25-1.92), C-reactive protein level (CRP) of >10 mg/dL (HR = 1.49, 95% CI: 1.07-2.08), arterial pH <7.35 (HR = 1.39, 95% CI: 1.08-1.80) when compared with normal pH (7.35-7.45), and a white blood cell count >10 × 103 per μL (HR = 1.76, 95% CI: 1.35-2.29). We found a strong discriminative ability in the proposed score in the validation cohort [AUC of 0.876 (95% CI: 0.822-0.930)], moreover, a cutoff score ≥39 points demonstrates superior performance with a sensitivity of 93.10%, a specificity of 70.28%, and a correct classification rate of 72.66%. The LR+ (3.1328) and LR- (0.0981) values further support its efficacy in identifying high-risk patients.

CONCLUSION

Male sex, increasing age, hypoxemia, hypoglycemia or hospital hyperglycemia, AST-ALT ratio >1, elevated CRP, altered arterial pH, and leucocytosis were factors significantly associated with higher mortality in hospitalized patients with COVID-19. A statistically significant Cox regression model with strong discriminatory power and good calibration was developed to predict mortality in hospitalized patients with COVID-19, highlighting its potential clinical utility.

Investigation of differences in coagulation characteristics between hospitalized patients with SARS-CoV-2 Alpha, Delta, and Omicron variant infection using rotational thromboelastometry (ROTEM): A single-center, retrospective, observational study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 Omicron variant has a low rate of serious illness, is highly contagious, and has spread rapidly since January 2022. The number of severe cases and deaths remains problematic. Here, we aimed to elucidate the coagulation pathology of Omicron-infected patients using rotational thromboelastometry.

METHODS

Patients with coronavirus disease 2019, hospitalized and treated from January 2021 to April 2022, were included. The Alpha-Delta and Omicron groups were defined during admission. Blood tests, clinical course, and rotational thromboelastometry measurements were compared using a propensity score-matched cohort.

RESULTS

Both groups had 21 patients each. Lactate dehydrogenase (Alpha-Delta group [interquartile range] vs. Omicron group [interquartile range]; 449 [368-518] U/L vs. 241 [196-398] U/L, p = 0.01) and ferritin (1428 [1145-3061] ng/dl vs. 481 [188-881] ng/dl, p = 0.0002) levels were significantly lower in the Omicron group. In rotational thromboelastometry, the thrombus hardness indexes FIBTEM A5 (29 [23-34] mm vs. 23 [18-28] mm, p = 0.034) and maximum clot firmness (34 [27-40] mm vs. 26 [21-33] mm, p = 0.021) were significantly lower in the Omicron group, whereas the fibrinolysis index FIBTEM LI60 (98 [92-100] % vs. 100 [100-100] %, p = 0.0082) was higher.

CONCLUSION

Severe coagulation abnormalities may be less likely in Omicron-infected patients than in those infected with the previous Alpha and Delta variants.

Molnupiravir as an Early Treatment for COVID-19: A Real Life Study

OBJECTIVES

Below we report our experience in the use of molnupiravir, the first antiviral drug against SARS-CoV-2 available to us, in the treatment of patients with COVID-19.

MATERIALS AND METHODS

We enrolled patients diagnosed with COVID-19 and comorbidities who were candidates for antiviral drug therapy. All patients received molnupiravir (800 mg twice daily). Blood chemistry checks were carried out at T0 and after 7/10 days after starting therapy (T1).

RESULTS

There were enrolled within the cohort 100 patients. There was 100.0% compliance with the antiviral treatment. No patient required hospitalization due to worsening of respiratory function or the appearance of serious side effects. The median downtime of viral load was ten days (IQR 8.0-13.0), regardless of the type of vaccination received. The patients who had a shorter distance from vaccination more frequently presented vomiting/diarrhea. During baseline and T1 we found significant differences in the median serum concentrations of the main parameters, in particular of platelets, RDW CV, neutrophils and lymphocytes, the eGFR, liver enzymes, as well as of the main inflammatory markers, CRP and Ferritin.

CONCLUSION

Participants treated with molnupiravir, albeit in risk categories, demonstrated early clinical improvement, no need for hospitalization, and a low rate of adverse events.

Association between single nucleotide polymorphism of human angiotensin-converting enzyme 2 gene locus and clinical severity of COVID-19

Background

Coronavirus disease 2019 (COVID-19) is a devastating pandemic-causing disease with a variable severity among populations. Genetic studies have pinpointed angiotensin-converting enzyme 2 (ACE2), a key enzyme for viral entry, for its possible linkage to the disease progression. The present study aimed to investigate the potential association between single nucleotide polymorphisms (SNPs) of human ACE2 gene with the severity and outcomes of COVID-19 for better patient management.

Methods

In this observational cross-sectional study, COVID-19 confirmed patients were classified into moderate and severe cases according to the "Ain Shams University Hospitals Pocket Guide for COVID-19 Diagnosis." Genetic analysis of ACE2 SNP rs2048683 was carried out using a TaqMan assay with the real-time polymerase chain reaction (PCR) technique.

Results

Among 90 confirmed COVID-19 patients, 78.9% (71/90) were classified as severe, and 21.1% (19/90) were classified as moderate. Laboratory biomarkers were significantly (P = 0.000) higher in the severe group than in the moderate group. Similarly, associated comorbidities such as hypertension were significant (P = 0.000) in the severe group, whereas asthma and deep venous thrombosis were significant in the moderate group (P = 0.007 and 0.006, respectively). Elevated serum ferritin level (odds ratio (OR) 162.589, 95% confidence interval (CI) 8.108-3260.293) and ACE2 rs2048683 genotype GG/G (OR 5.852, 95% CI 1.586-21.591) were both considered independent risk factors for severe disease.

Conclusion

The findings of the present study provide preliminary evidence of an association between ACE2 rs2048683 SNPs and COVID-19 severity in the Egyptian population, which may inform the need for targeted management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43042-022-00331-8.

Comparison between clinical characteristics and laboratory findings among patients with complicated and noncomplicated SARS-CoV-2 infection: A single-center experience from Shebin Al-Kom, Egypt

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection is considered a serious highly infectious disease caused by severe acute respiratory syndrome coronavirus 2, resulting in more than 6.27 million deaths worldwide.

AIM OF THE STUDY

The study aimed to compare clinical characteristics and laboratory findings of COVID-19 patients with complications and without complications and discriminate the important risk factors for the complications and deaths.

SUBJECTS AND METHODS

This cross-sectional study included 75 confirmed COVID-19 positive patients; out of which 49 were severely-ill cases. Analysis of all patients' clinical and laboratory information on admission including serum ferritin, thrombotic activity (d-dimer), lactate dehydrogenase (LDH), C-reactive protein (CRP), creatinine, aspartate aminotransferase, and alanine aminotransferase were done.

RESULTS

Lymphopenia, tachycardia, tachypnea, elevated CRP, d-dimer, serum ferritin, LDH, and decreased SpO2 were significantly associated with complicated cases (p < .05 for all). By using multivariate logistic regression analysis models, elevated serum ferritin and tachycardia were significantly correlated with the increased odds of complicated COVID-19 cases (odds ratio [confidence interval 95%] = 10.42 [2.32-46.89] and 8.01 [1.17-55.99]; respectively) (p = .002 and .007, respectively).

CONCLUSION

Lymphocytopenia, d-dimer, LDH, and CRP levels, which were significantly linked to the severity of COVID-19, were the prognostic biomarkers to predict the disease severity.

Effectiveness and safety profile of mesenchymal stem cell secretome as a treatment for severe cases of COVID-19: a randomized controlled trial

Background: : Patients with severe COVID-19 had a higher increase in pro-inflammatory and anti-inflammatory cytokines than patients with moderate COVID-19. Excessive release of cytokine and chemokines can lead to multi-organ failure, increasing disease severity, length of stay, and mortality rate. Mesenchymal stem cells (MSCs) are known to have immunomodulatory, anti-inflammatory, anti-apoptotic, and angiogenesis effects that are useful for relieving inflammation, recovery, and protection of lung tissues in COVID-19 patients. Secretome, a secretory product of MSCs, has several advantages over MSCs. Therefore, we conducted a study to investigate secretomes' effectiveness and safety profile as a treatment for severe COVID-19. Methods: This study was a double-blind, multicentered, randomized, placebo-controlled trial. This study involved 40 subjects recruited from three top COVID-19 referral hospitals in the Greater Jakarta area, Indonesia. Eligible subjects (n=40) were randomized in a 1:1 ratio to intervention group (n=20) and a control group (n=20). The primary outcome of this study was the improvement of inflammatory markers levels, measured by changes in inflammatory markers, and ratio of inflammatory to anti-inflammatory markers. The secondary outcomes of this study included clinical outcome, laboratory outcome, radiological outcome, RT-PCR result conversion, and safety profile of MSC secretome. Results: IL-6 marker in the control group was increased on the 14 th day after the intervention compared to before intervention [4.110 (2.403-12.820) at baseline to 13.320 (2.958-33.285) on 14 th day after intervention, p=0.017]. In the intervention group, there was no increase in the IL-6/IL-10 ratio. In contrast, in the control group, there was a significant increase in the IL-6/IL-10 ratio (p=0.036) on the 14 th day after the intervention compared to before the intervention. We also found that on the seventh day after the intervention, most of the subjects who received placebo had high levels of IL-6 and ferritin (p=0.043). There was no significant difference in the laboratory outcome, radiological outcome, RT-PCR result conversion, and safety profile between both groups. Conclusions: Our study showed an increase of inflammation markers in the control group on the 14 th day after the intervention, compared to the intervention group. The ratio of inflammatory to anti-inflammatory markers on the seventh and 14 th days after intervention also did not increase in the intervention group. On the seventh day after intervention, most of the subjects in the control group also had high IL-6 levels and high ferritin levels. There is no adverse event reported. MSC secretome is a safe and promising treatment modality for severe COVID-19.

Identifying SARS-CoV-2 Lineage Mutation Hallmarks and Correlating Them With Clinical Outcomes in Egypt: A Pilot Study

The SARS-CoV-2 pandemic has led to over 4.9 million deaths as of October 2021. One of the main challenges of creating vaccines, treatment, or diagnostic tools for the virus is its mutations and emerging variants. A couple of variants were declared as more virulent and infectious than others. Some approaches were used as nomenclature for SARS-CoV-2 variants and lineages. One of the most used is the Pangolin nomenclature. In our study, we enrolled 35 confirmed SARS-CoV-2 patients and sequenced the viral RNA in their samples. We also aimed to highlight the hallmark mutations in the most frequent lineage. We identified a seven-mutation signature for the SARS-CoV-2 C36 lineage, detected in 56 countries and an emerging lineage in Egypt. In addition, we identified one mutation which was highly negatively correlated with the lineage. On the other hand, we found no significant correlation between our clinical outcomes and the C36 lineage. In conclusion, the C36 lineage is an emerging SARS-CoV-2 variant that needs more investigation regarding its clinical outcomes compared to other strains. Our study paves the way for easier diagnosis of variants of concern using mutation signatures.

Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in non-ventilated COVID-19 patients

Aim:

Pneumothorax (PNX), pneumomediastinum (PMD) and subcutaneous emphysema (SCE) are COVID-19 complications related to positive-pressure ventilation. We analyzed the pathophysiology of these complications without ventilation.

Patients & methods:

Out of 1845 admitted COVID-19 patients, we retrospectively collected data for 15 patients, from a tertiary medical center, from 1 October 2020 to 31 March 2021.

Results:

Five patients suffered from spontaneous PNX, 8/15 developed PMD and 8/15 developed SCE. The mean BMI was 29.7, as most patients were obese or overweight. Most patients had lymphocytopenia and increased C-reactive protein, ferritin and lactate dehydrogenase levels. Eleven patients succumbed to the disease.

Conclusion:

Risk factors of spontaneous PNX, PMD and SCE in COVID-19 patients need further investigations by conducting more comprehensive case–control studies.

We have investigated spontaneous alveolar rupture as a complication in 15 COVID-19 patients. Manifested as pneumothorax, pneumomediastinum and subcutaneous emphysema, these complications are less common in patients without mechanical ventilation. Management of these patients was either conservative or by insertion of a chest tube. Eventually, 11 out of 15 patients have passed away due to respiratory failure.

Implications of SARS-CoV-2 infection on the clinical, hematological, and inflammatory parameters in COVID-19 patients: A retrospective cross-sectional study

Background

The current coronavirus pandemic (COVID-19) was caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2). COVID-19 is characterized by atypical pneumonia, mild colds, and more severe illnesses, such as severe acute respiratory distress, thrombosis, organ failure, and various secondary bacterial and fungal infections. Notably, the severity of COVID-19 in different age groups is not well known, and the validity of clinical laboratory data remains unclear.

Methods

In this retrospective cross-sectional study, we examined differential regulation of clinical, hematologic, and inflammatory biomarkers in COVID-19 patients. We divided 104 COVID-19 patients into five different groups according to age (0−17, 18−45, 46−65, 66−79, and >80 years). Baseline data (sex, comorbidities, intensive care admission, and medications), hematologic markers, liver, and renal function tests, coagulation, and inflammatory markers were examined in these groups. Receiver operator characteristic (ROC) analysis was used to determine the optimal threshold for predicting COVID-19 biological markers.

Results

We found that the highest percentage (45%) of COVID-19 patients was in the age group of 46−65 years. The hematologic parameters (WBC, HB, and PLT) were normal between the patient groups. The area under the curve in ROC analysis showed significant differences in the levels of creatine, GGT, BUN, CRP, D-dimer, ferritin, AST, and procalcitonin between the patients of age groups 46−65 and 66−79 years. Renal biomarkers were significantly high in most patients, regardless of age. In contrast, the liver biomarkers, did not differ significantly between patient groups.

Conclusion

The main finding of our study is that laboratory parameters such as GGT, creatinine, BUN, CRP, procalcitonin, ferritin and D-dimer were differentially regulated in COVID -19 patients of different age groups. Importantly, these laboratory parameters may help as clinical predictors to assess the severity of the disease in the population. We conclude here that age is an important factor influencing COVID-19 severity.