D-dimer as a biomarker for assessment of COVID-19 prognosis: D-dimer levels on admission and its role in predicting disease outcome in hospitalized patients with COVID-19

Does the IL-6/KL-6 ratio distinguish different phenotypes in COVID-19 Acute Respiratory Distress Syndrome? An observational study stemmed from prospectively derived clinical, biological, and computed tomographic data

BACKGROUND

As new SARS-CoV-2 variants emerge and as treatment of COVID-19 ARDS remains exclusively supportive, there is an unmet need to better characterize its different phenotypes to tailor personalized treatments. Clinical, biological, spirometric and CT data hardly allow deciphering of Heavy (H), Intermediate (I) and Light (L) phenotypes of COVID-19 ARDS and the implementation of tailored specific strategies (prone positioning, PEEP settings, recruitment maneuvers). We hypothesized that the ratio of two pivotal COVID-19 biomarkers (interleukin 6 [IL-6] and Krebs von den Lungen 6 [KL-6], related to inflammation and pneumocyte repair, respectively) would provide a biologic insight into the disease timeline allowing 1) to differentiate H, I and L phenotypes, 2) to predict outcome and 3) to reflect some of CT findings.

METHODS AND FINDINGS

This was a retrospective analysis of prospectively acquired data (COVID HUS cohort). Inclusion concerned any patient with severe COVID-19 pneumonia admitted to two intensive care units between March 1st and May 1st, 2020, in a high-density cluster of the first epidemic wave (Strasbourg University Hospital, France). Demographic, clinical, biological (standard, IL-6 [new generation ELISA], KL-6 [CLEIA technique]), spirometric (driving pressure, respiratory system compliance) and CT data were collected longitudinally. CT analysis included semi-automatic and automatic lung measurements and allowed segmentation of lung volumes into 4 (poorly aerated, non-aerated, overinflated and normally aerated) and 3 (ground-glass, restricted normally aerated, and overinflated) zones, respectively. The primary outcome was to challenge the IL-6/KL-6 ratio capacity to decipher the three COVID-19 ARDS phenotypes (H, I and L) defined on clinical, spirometric and radiologic grounds. Secondary outcomes were the analysis of the prognostic value of the IL-6/KL-6 ratio and its correlates with CT-acquired data. Multivariate analysis was based on principal component analysis. One hundred and forty-eight ventilated COVID-19 ICU patients from the COVID HUS cohort were assessed for eligibility and 77 were included in the full analysis. Most were male, all were under invasive mechanical ventilation and vasopressor therapy and displayed high severity scores (SAPSII: 48 [42-56]; SOFA: 8 [7-10]). The L, I and H COVID ARDS phenotypes were identified in 11, 15 and 48 patients, respectively. In three patients, the phenotype could not be defined precisely. Thirty patients (39%) died in the ICU and the number of ventilator-free days was 2 [0-2] days. The IL-6/KL-6 ratio was not significantly different between the L, I and H phenotypes and evolved according to similar patterns over time. Surviving and deceased patients displayed an inverse kinetic of KL-6. IL-6 and the IL-6/KL-6 ratio were linearly associated with ground-glass volume on semi-automatic and automatic CT lung measurements.

CONCLUSIONS

In our population of severe ventilated COVID ARDS patients, the IL-6/KL-6 ratio was not clue to differentiate the H, I and L phenotypes and tailor a personalized ventilatory approach. There was an interesting correlation between IL-6/KL-6 ratio and ground-glass volume as determined by automated lung CT analysis. Such correlation deserves more in-depth pathophysiological study, at best gathered from a prospective cohort with a larger sample size and histological analysis.

TRIAL REGISTRATION

COVID HUS Trial registration number: NCT04405726.

Persistent neuropsychological deficits in recovered COVID-19 patients: Correlations with disease biomarkers

OBJECTIVE

Cognitive impairment, including deficits in attention, memory, executive function, and processing speed, is common in post-COVID-19 conditions, though language performance remains less studied. The present study examined the long-term effects of COVID-19 condition on cognition and language - communication, and its associations with disease severity, Body Mass Index (BMI), inflammatory markers, and quality of life.

METHOD

Nighty eight Greek participants under 65 years of age were recruited for this study. Forty-seven participants were allocated in the COVID-19 group and 51 served as cognitively healthy controls. The COVID-19 group was categorized by disease severity and long COVID status. Assessments occurred 12 weeks post-infection, with 12 patients reevaluated after another 12 weeks. Neurocognitive tests included ABCD-II, verbal fluency, CCT, SDMT, and Euro QoL EQ-5D. Blood samples were analyzed for inflammatory markers.

RESULTS

Covid-19 survivors experienced significant cognitive deficits compared to healthy controls, particularly in processing speed, memory, and verbal fluency. Long COVID patients showed notably lower scores in processing speed and QoL, compared to those without Long COVID. However, no significant differences were observed between groups on episodic memory and executive functions tasks. Cognitive deficits were associated with biomarkers such as d-dimers and C-Reactive protein, with elevated d-dimers linked to poorer performance on generative drawing and cognitive flexibility. Higher education served as a protective factor, and was associated with higher scores in tasks such as story retelling, confrontation naming, generative drawing and reading comprehension. Older age and higher Body Mass Index were associated with poorer cognitive performance, especially on processing speed. Sex appears to influence language comprehension outcomes, with males exhibiting enhanced performance on the reading comprehension-sentence task. Disease severity negatively affected performance on the Symbol Digit Modalities Test and generative naming, indicating that greater severity was linked to poorer outcomes in these domains. Follow-up evaluations of recovered COVID-19 patients revealed significant improvements in processing speed and recall, suggesting partial recovery in these areas, although some deficits persisted over time.

CONCLUSION

The study supports findings that the prolonged effects of COVID-19 markedly impaired neurocognitive functions in recovering patients, especially those with severe or long COVID syndrome. Moreover, while several cognitive domains may improve over time, many other domains remain impaired and vulnerable.

Post-transfusion activation of coagulation pathways during severe COVID-19 correlates with COVID-19 convalescent plasma antibody profiles

Early antibody therapy can prevent severe SARS-CoV-2 infection (COVID-19). However, the effectiveness of COVID-19 convalescent plasma (CCP) therapy in treating severe COVID-19 remains inconclusive. To test a hypothesis that some CCP units are associated with a coagulopathy hazard in severe disease that offsets its benefits, we tracked 304 CCP units administered to 414 hospitalized COVID-19 patients to assess their association with the onset of unfavorable post-transfusion D-dimer trends. CCP recipients with increasing or persistently elevated D-dimer trajectories after transfusion experienced higher mortality than those whose D-dimer levels were persistently low or decreasing after transfusion. Within the CCP donor-recipient network, recipients with increasing or persistently high D-dimer trajectories were skewed toward association with a minority of CCP units. In in vitro assays, CCP from "higher-risk" units had higher cross-reactivity with the spike protein of human seasonal betacoronavirus OC43. "Higher-risk" CCP units also mediated greater Fcγ receptor IIa signaling against cells expressing SARS-CoV-2 spike compared with "lower-risk" units. This study finds that post-transfusion activation of coagulation pathways during severe COVID-19 is associated with specific CCP antibody profiles and supports a potential mechanism of immune complex-activated coagulopathy.

Prognostic significance of cytokine dysregulation in critically ill COVID-19 patients

BACKGROUND

Understanding the immunopathogenesis of COVID-19 has yielded valuable insights into predicting adverse outcomes-particularly mortality. However, significant gaps persist in our comprehension of the complex interplay among the proposed pathophysiological mechanisms. Here, we aim to investigate the immunological factors associated with mortality in critically ill, unvaccinated COVID-19 patients admitted to the intensive care unit (ICU).

METHODS

We conducted a single-center, prospective study involving 56 unvaccinated COVID-19 patients admitted to the ICU. Plasma cytokine levels at admission were quantified using enzyme-linked immunosorbent assay (ELISA). Continuous variables were presented as median (IQR), and categorical variables as frequencies and percentages. Non-parametric tests assessed group differences. Logistic regression and receiver operating characteristic (ROC) curve analyses identified predictors of mortality, with bootstrapping (1000 re-samplings; 95 % BCa CI) applied for model validation.

RESULTS

Deceased patients exhibited significantly higher levels of interleukin (IL)-1β, IL-2, IL-6, transforming growth factor (TGF)-β, and interferon (IFN)-γ compared to survivors. Conversely, IL-10 and IL-27 were associated with favorable outcomes. Logistic regression modeling identified elevated IL-2 and IFN-γ levels as significant predictors of mortality. Notably, individual ROC curve analyses demonstrated that IL-1β and TGF-β had excellent discriminatory ability for mortality, while IFN-γ, IL-2, and IL-27 showed very good to excellent discriminatory capacity.

CONCLUSION

Our results indicate that distinct cytokine profiles differentiate survivors from non-survivors in critically ill, unvaccinated COVID-19 patients. These findings highlight the importance of cytokine dysregulation in severe COVID-19 cases and suggest potential targets for prognostic approaches. Further research is warranted to validate these results and translate them into effective clinical management strategies.

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.

Clinical overview and characteristics of neonates from mothers confirmed with COVID-19 at Sulianti Saroso Infectious Disease Hospital

Background

Pregnant women need special attention during emergencies and infectious disease outbreaks. Pregnancy is a standalone risk factor for the severity of COVID-19, heightening the vulnerability of both the mother and foetus. Neonatal admission, foetal distress, and low birth weight were correlated to the severity of COVID-19. The aim of this study was to provide a clinical overview and characteristics of neonates from mothers who were confirmed with COVID-19.

Methods

A cross-sectional study was conducted at Sulianti Saroso Infectious Disease Hospital (SSIDH) from March 2020 to December 2022. Inclusion criteria included pregnant women with confirmed SARS-CoV-2 infection who either gave birth in a hospital according to the regulations of the Ministry of Health of the Republic of Indonesia. All newborns were tested using RT-PCR SARS-COV-2 swab tests within 24 hours after birth. We used electronic medical records as a secondary source.

Result

A total of 181 pregnant women with positive SARS-CoV-2, 103 (56.9%) gave birth, with 101 (98.1%) undergoing caesarean section. Of the 103 who gave birth, a small proportion of mothers with COVID-19 were aged <20 years or >35 years (29.13%) and had preterm deliveries (15.53%). All newborns born to SARS-CoV-2-positive mothers were alive. The severity of illness was associated with the first-minute and fifth-minute APGAR scores of newborns (P < 0.05).

Conclusion

The severity of maternal COVID-19 impacts newborns' 1-minute and 5-minute APGAR scores. Implementing a strict COVID-19 protocol effectively prevents neonatal infections.

The evolving landscape of COVID-19: factors associated with in-hospital COVID-19 related mortality during the 2023-2024 phase of JN.1 subvariant dominance

BACKGROUND

COVID-19 remains a complex health challenge. We analysed the characteristics and outcomes of COVID-19-related hospitalisations during JN.1 variant dominance.

METHODS

Conducted in a hospital serving a socioeconomically deprived population, this study included all adults hospitalised with COVID-19 from 1st November 2023 to 31st August 2024. The primary outcome was in-hospital mortality, analysed in relation to demographic, clinical, and laboratory parameters.

RESULTS

Among 122 individuals (median age 76 years, 58.2% males, median comorbidity index 5), 114/122 (93.4%) had received ≥ 1 SARS-CoV-2 vaccination, with a median of 23 months elapsed since the last dose. Fever (67/122, 54.9%) and dyspnoea (49/122, 40.2%) were common presenting symptoms, with 78/122 (64%) showing CT evidence of SARS-CoV-2 pneumonia; 25/122 (20%) had purely neurological presentations. Treatment included remdesivir (115/122, 94.3%) and/or nirmatrelvir/ritonavir (9/122, 7.4%), sotrovimab (15/122, 12.3%), corticosteroids (61/122, 50.0%), and oxygen supplementation (76/122, 62.3%). Whereas 107/122 (87.7%) were discharged after a median of seven days, in-hospital mortality was 15/122 (12.3%) after a median of 16 days. Baseline factors associated with mortality were neutrophil-lymphocyte ratio > 8, D-dimer ≥ 1800 ng/mL, procalcitonin ≥ 1.0 ng/mL, and albumin < 3.2 g/dL; during admission, nasopharyngeal SARS-CoV-2 antigen positivity persisting for > 12 days, hospitalisation for ≥ 10 days, higher oxygen requirements with the resulting corticosteroid use, and healthcare-associated bacteraemia were associated with increased odds of mortality.

CONCLUSIONS

Baseline laboratory parameters and persistent SARS-CoV-2 antigen positivity despite antiviral therapy offer readily available prognostic insights for patients hospitalised with COVID-19. It is imperative to advocate for up-to-date COVID-19 vaccination among older people and other vulnerable groups.

Haematological Manifestations of SARS-CoV-2: Insights into Erythropoiesis, Hepcidin Regulation, and Cytokine Storm

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19, a respiratory disease that can range in presentation from mild symptoms to severe conditions such as pneumonia and acute respiratory distress syndrome. SARS-CoV-2, a single-stranded RNA virus, spreads through aerosols and respiratory droplets. It enters human cells by binding to the angiotensin-converting enzyme 2 receptor, leading to various complications, including significant alterations in red blood cells and potential disruptions in haemoglobin function and oxygen transport. During infection, the interaction between hypoxia, inflammation, and haematopoiesis affects erythropoiesis at multiple levels. Hypoxia and inflammation, resulting from lung complications and a reduced red blood cell count, influence the regulation of hepcidin, a key regulator of iron levels in the blood. Elevated hepcidin levels are associated with hypoxia and the suppression of erythroferrone, a hormone that normally inhibits hepcidin production. Despite high levels of inflammation, patients in intensive care units often exhibit elevated ferritin levels, which, rather than indicating low hepcidin, suggest disrupted iron metabolism and the development of severe anaemia. Iron is kept in stores, likely due to paradoxically high hepcidin levels, which explains the elevated ferritin measurements. An increase in immature blood cells and a decrease in CD71+ erythroid cells are observed. The elevated levels of CD71+ erythroid cells highlight their dual role in modulating hyper-inflammation and immune response during disease progression. This review examines the pathway by which SARS-CoV-2 affects red blood cell production and the haematopoietic system and how it triggers cytokine storms through interleukins, immature blood cells, and CD71+ erythroid cells. Understanding these processes provides novel pathways for managing haematological manifestations and immune responses in patients with COVID-19.

Metformin use and its association with various outcomes in COVID-19 patients with diabetes mellitus: a retrospective cohort study in a tertiary care facility

BACKGROUND

Evidence shows that diabetes raises the probability of contracting COVID-19 and associated complications. We hypothesize that metformin, being pleiotropic, may improve COVID-19 in diabetics.

METHODS

A retrospective cohort study was conducted with 421 COVID-19 patients with diabetes, hospitalized between 1st April 2020 and 31st March 2022 in a tertiary-care hospital. Patients with metformin or its combination constituted the study cohort (SC; n = 221), while other antidiabetics constituted the reference cohort (RC; n = 200).

RESULTS

SC and RC were matched for mean age ± SD (SC: 53.3 ± 5.7 vs. RC: 54.3 ± 8.2 years). The mean length of hospitalization (days) was significantly shorter in SC (9.0 ± 5.7) than in RC (12.7 ± 6) (p < 0.02). Metformin use was associated with reduction in mortality risk (OR: 0.106, 95% CI = 0.039-0.287; p < 0.001). Moreover, SC also improved levels of LDH (OR: 0.243, 95% CI = 0.104-0.566; p < 0.001), CRP (OR: 0.281, 95% CI = 0.120-0.659; p < 0.004), and D-dimer (OR: 0.220, 95% CI = 0.089-0.539; p < 0.001) than RC. The calculated number needed to treat for metformin was 3.1.

CONCLUSION

Metformin users have a decrease in hospital stay and mortality rates and improvement in LDH, CRP, and D-dimer levels. Therefore, metformin might protect against mortality in COVID-19 with diabetes.

Liver Enzymes and Inflammatory Markers Among Severely Ill COVID-19 Patients: A Retrospective Case-Control Study in Telangana

Introduction The COVID-19 pandemic originated in Wuhan, China, and swiftly spread across all continents. The respiratory system is the most affected in people who acquire sickness as a result of SARS-CoV-2. However, the virus can also affect other systems. The COVID-19 pandemic has become one of the most fatal infectious diseases in the recent past. Patients present with symptoms of fever, cough, tiredness, loss of taste or smell, sore throat, headache, and diarrhea. Objective This study intends to evaluate how COVID-19 has shown its effects on the well-being of the liver by collecting and correlating the data of the liver enzymes and inflammatory markers among hospitalized COVID-19 patients with age- and sex-matched healthy controls.  Materials and methods A retrospective case-control study that included 200 patients diagnosed and hospitalized with COVID-19 was compared with an equal number of age- and sex-matched healthy control groups without COVID-19 at RVM Institute of Medical Sciences and Research Centre (RVMIMS & RC), a tertiary care teaching hospital in Siddipet, Telangana, India. Liver function tests (LFTs) and inflammatory markers were evaluated in both groups.  Results Out of 200 patients, 179 (89.5%) had elevated alanine transaminase (ALT), 191 (95.5%) had elevated aspartate aminotransferase (AST), 33 (16.5%) had elevated alkaline phosphatase (ALP), and 183 (91.5%) showed elevated D-dimer levels. All the patients had elevated interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Conclusion COVID-19 patients have exhibited elevations in liver enzyme panels and inflammatory markers. Further research and follow-up studies may aid in understanding the role of the well-being of the liver in patients affected by COVID-19. Considering the emergence of newer COVID-19 strains, we recommend LFT to patients who test positive for the virus to monitor prognosis and guide treatment protocols through this study.

Development of a Model for Predicting Mortality Among Patients Hospitalized with COVID-19 During Their Stay in a Clinical Centre

Background: Various tools have been proposed for predicting mortality among patients hospitalized with COVID-19 to improve clinical decision-making, the predictive capacities of which vary in different populations. The objective of this study was to develop a model for predicting mortality among patients hospitalized with COVID-19 during their time in a clinical centre. Methods: This was a retrospective study that included 201 patients hospitalized with COVID-19. Mortality was evaluated with the Kaplan-Meier curve and Cox proportional hazards models. Six models were generated for predicting mortality from laboratory markers and patients' epidemiological data during their stay in a clinical centre. Results: The model that presented the best predictive power used D-dimer adjusted for C-reactive protein (CRP) and oxygen saturation. The sensitivity (Sn) and specificity (Sp) at 15 days were 75% and 71.9%, respectively. At 30 days, Sn was 75% and Sp was 75.4%. Conclusions: These results allowed us to establish a model for predicting mortality among patients hospitalized with COVID-19 based on D-dimer laboratory biomarkers adjusted for CRP and oxygen saturation. This mortality predictor will allow patients to be identified who require more continuous monitoring and health care.

Could Anemia Impact the Severity of Infections? COVID-19 as an Example

Background

The association between anemia and severity of infection as well as mortality rates among patients infected with COVID-19 has scarcely been studied. This is the first study from the UAE aimed to assess the influence of anemia on COVID-19 severity, ICU admission, and mortality rate.

Methods

A retrospective chart review of hospitalized COVID-19 patients was conducted in a large COVID-19 referral hospital in UAE. The study included adult patients with confirmed COVID-19. Clinical and laboratory data, severity of the disease, ICU admissions, and mortality rates were analyzed and correlated to the presence of anemia among the patients.

Results

A total of 3092 patients were included. 362 patients (11.7%) were anemic and most of the cases were between asymptomatic and mild COVID-19 (77.4%, n=2393). Among patients with anemia, 30.1% (n=109) had moderate to severe COVID-19. Statistically, anemia was associated significantly with a higher risk for severe COVID-19 outcome compared to nonanemic patients (AOR:1.59, 95% CI:1.24-2.04, p<0.001). Intensive care unit (ICU) admission was almost 3 times higher among anemic patients compared to nonanemic (AOR:2.83,95% CI:1.89-4.25, p<0.001). In addition, the overall mortality rate of 2.8% (n=87) was 2.5-fold higher in anemic than nonanemic patients (OR:2.56, CI: 1.49-4.06, p<0.001). Moreover, older age (≥48-year-old) and male gender were independent predictors for severe illness (Age: OR=1.26, CI:1.07-1.51, p=0.006; Gender: OR:1.43,CI:1.15-1.78, p<0.001)) and ICU admission (Age: OR:2.08, CI:1.47-2.94, p<0.001; Gender: OR: 1.83, CI:1.12-3.00, p=0.008) whereas only age ≥48 years old contributed to higher mortality rate (OR:1.60, CI:1.04-2.46, p=0.034).

Conclusion

Anemia was a major risk factor for severe COVID-19, ICU admission and mortality among hospitalized COVID-19 patients. Thus, healthcare providers should be aware of monitoring the hematological parameters among hospitalized patients with COVID-19 and anemia to reduce the risk of disease complications and mortality. This association should also be considered in other infectious diseases.

Significance of Initial Chest CT Severity Score (CTSS) and Patient Characteristics in Predicting Outcomes in Hospitalized COVID-19 Patients: A Single Center Study

The aim of this study is to examine the prognostic role of initial chest computed tomography severity score index (CTSS) and its association with demographic, socio-epidemiological, and clinical parameters in COVID-19 hospitalized patients. A retrospective study included patients who were hospitalized in the COVID Hospital of the Clinical Hospital Center Kosovska Mitrovica from July 2020 to March 2022. We compared patient characteristics and outcome of their hospital stay with values of CT severity score (mild, moderate, and severe form of the disease). Patients with severe disease were statistically significantly older, they treated more days, and they presented statistically significant highest mortality rate compared to mild and moderate forms. Smokers and obese were significantly more frequent among patients with higher CT, while vaccinated patients were more common among those with a mild form. Biochemical parameters at admission also showed statistical significance between the examined groups. We can conclude that by employing the initial CT severity score as the strongest predictor of mortality, it is possible to predict the outcome in hospitalized patients. A comprehensive examination of the patient upon admission, including determining the extent of inflammatory changes in the lungs using computed tomography, the levels of oxygen saturation, and other laboratory parameters, can assist doctors in making an adequate clinical evaluation and apply appropriate therapeutic protocols in the treatment of COVID-19.

Association of COVID-19 with acute and post-acute risk of multiple different complications and mortality in patients infected with omicron variant stratified by initial disease severity: a cohort study in Hong Kong

BACKGROUND

Few studies have attempted to use clinical and laboratory parameters to stratify COVID-19 patients with severe versus non-severe initial disease and evaluate age-specific differences in developing multiple different COVID-19-associated disease outcomes.

METHODS

A retrospective cohort included patients from the electronic health database of Hong Kong Hospital Authority between 1 January 2022 and 15 August 2022 until 15 November 2022. The cohort was divided into three cohorts by age (≤ 40, 41-64, and ≥ 65 years old). Each age cohort was stratified into four groups: (1) COVID-19 critically exposed group (ICU admission, mechanical ventilation support, CRP > 80 mg/L, or D-dimer > 2 g/mL), (2) severely exposed group (CRP 30-80 mg/L, D-dimer 0.5-2 g/mL, or CT value < 20), (3) mildly-moderately exposed group (COVID-19 positive-tested but not fulfilling the criteria for the aforementioned critically and severely exposed groups), and (4) unexposed group (without COVID-19). The characteristics between groups were adjusted with propensity score-based marginal mean weighting through stratification. Cox regression was conducted to determine the association of COVID-19 disease severity with disease outcomes and mortality in the acute and post-acute phase (< 30 and ≥ 30 days from COVID-19 infection) in each age group.

RESULTS

A total of 286,114, 320,304 and 194,227 patients with mild-moderate COVID-19 infection; 18,419, 23,678 and 31,505 patients with severe COVID-19 infection; 1,168, 2,261 and 10,178 patients with critical COVID-19 infection, and 1,143,510, 1,369,365 and 1,012,177 uninfected people were identified in aged ≤ 40, 40-64, and ≥ 65 groups, respectively. Compared to the unexposed group, a general trend tending towards an increase in risks of multiple different disease outcomes as COVID-19 disease severity increases, with advancing age, was identified in both the acute and post-acute phases. Notably, the mildly-moderately exposed group were associated with either insignificant risks (aged ≤ 40) or the lowest risks (aged > 40) for the disease outcomes in the acute phase of infection (e.g., mortality risk HR (aged ≤ 40): 1.0 (95%CI: 0.5,2.0), HR (aged 41-64): 2.1 (95%CI: 1.8, 2.6), HR (aged > 65): 4.8 (95%CI: 4.6, 5.1)); while in the post-acute phase, these risks were largely insignificant in those aged < 65, remaining significant only in the elderly (age ≥ 65) (e.g., mortality risk HR (aged ≤ 40): 0.8 (95%CI: (0.5, 1.0)), HR (aged 41-64): 1.1 (95%CI: 1.0,1.2), HR (aged > 65): 1.5 (95%CI: 1.5,1.6)). Fully vaccinated patients were associated with lower risks of disease outcomes than those receiving less than two doses of vaccination.

CONCLUSIONS

The risk of multiple different disease outcomes in both acute and post-acute phases increased significantly with the increasing severity of acute COVID-19 illness, specifically among the elderly. Moreover, future studies could improve by risk-stratifying patients based on universally accepted thresholds for clinical parameters, particularly biomarkers, using biological evidence from immunological studies.

D-dimer as a Predictor of ICU Admission and Mortality in COVID-19 Patients: Insights From a Two-Year Retrospective Study From a Tertiary Care Center in South India

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced pneumonitis results in a prothrombotic and hypercoagulable state. Prognostic indicators are crucial for identifying patients at risk of complications. D-dimer, a degradation product of cross-linked fibrin, is a specific marker for thrombosis. Elevated D-dimer levels have been strongly correlated with poor prognosis and increased severity of illness in COVID-19 patients. Given D-dimer's eight-hour half-life, periodic measurement is necessary to track disease progression. This study aimed to analyze and derive threshold and peak D-dimer values to predict outcomes in COVID-19 patients, comparing those treated in isolation wards to those requiring intensive care. Methods This two-year retrospective observational study included patients above 18 years with confirmed COVID-19. Patients were categorized into those treated in isolation wards and those admitted to the intensive care unit (ICU). Based on the outcome, they were further divided into survivors and non-survivors. Demographic and outcome-related data were collected from the hospital's laboratory information system. Serial D-dimer measurements were taken at eight time points. Statistical analysis was performed using the Mann-Whitney test for laboratory values and the chi-square test for demographic data. Receiver operating characteristic (ROC) curve analysis was utilized to derive critical D-dimer values. The area under the curve (AUC) was calculated for initial and peak D-dimer values. Results Of 2.149 patients with confirmed COVID-19, 811 (38%) presented with elevated D-dimer levels. ICU admission was required for 239 patients, either due to direct admission or worsening conditions. An initial D-dimer value of ≥0.93 mg/L FEU indicated the need for ICU admission, while a peak D-dimer value of 5.65 mg/L FEU predicted mortality. The AUC for the initial D-dimer was 0.60 (95% CI: 0.55-0.64), indicating moderate discriminatory power. The AUC for the peak D-dimer was 0.58 (95% CI: 0.54-0.62), suggesting lower predictive accuracy for peak values. Sensitivity was high for both initial (0.925) and peak (0.960) D-dimer values, although specificity was lower, especially for the peak D-dimer (0.486), resulting in a higher rate of false positives. Among the ICU patients, the age range was 27-97 years, with a mean of 53.5 years. Males were more affected than females (71% vs. 29%), with a male-to-female ratio of 1.4:1. Of the ICU patients, 64.8% recovered, while 35.2% succumbed to the disease. Younger patients (mean age: 50.5 ± 12 years) recovered faster than older patients (mean age: 64 ± 16 years), with a significant difference in recovery time (p < 0.001). Gender did not significantly impact outcomes (p = 0.743). Survivors spent less time in the ICU (3-7 days) compared to non-survivors (4-14 days) (p = 0.041). Conclusion Serial D-dimer monitoring is essential for predicting outcomes and guiding treatment in COVID-19 patients. Initial and peak D-dimer values can help identify patients requiring intensive care and those at risk of mortality, allowing for timely interventions. D-dimer levels should be integrated into routine clinical assessments for managing COVID-19 patients.

Alteration of circulating ACE2-network related microRNAs in patients with COVID-19

Angiotensin converting enzyme 2 (ACE2) serves as the primary receptor for the SARS-CoV-2 virus and has implications for the functioning of the cardiovascular system. Based on our previously published bioinformatic analysis, in this study we aimed to analyze the diagnostic and predictive utility of miRNAs (miR-10b-5p, miR-124-3p, miR-200b-3p, miR-26b-5p, miR-302c-5p) identified as top regulators of ACE2 network with potential to affect cardiomyocytes and cardiovascular system in patients with COVID-19. The expression of miRNAs was determined through qRT-PCR in a cohort of 79 hospitalized COVID-19 patients as well as 32 healthy volunteers. Blood samples and clinical data of COVID-19 patients were collected at admission, 7-days and 21-days after admission. We also performed SHAP analysis of clinical data and miRNAs target predictions and advanced enrichment analyses. Low expression of miR-200b-3p at the seventh day of admission is indicative of predictive value in determining the length of hospital stay and/or the likelihood of mortality, as shown in ROC curve analysis with an AUC of 0.730 and a p-value of 0.002. MiR-26b-5p expression levels in COVID-19 patients were lower at the baseline, 7 and 21-days of admission compared to the healthy controls (P < 0.0001). Similarly, miR-10b-5p expression levels were lower at the baseline and 21-days post admission (P = 0.001). The opposite situation was observed in miR-124-3p and miR-302c-5p. Enrichment analysis showed influence of analyzed miRNAs on IL-2 signaling pathway and multiple cardiovascular diseases through COVID-19-related targets. Moreover, the COVID-19-related genes regulated by miR-200b-3p were linked to T cell protein tyrosine phosphatase and the HIF-1 transcriptional activity in hypoxia. Analysis focused on COVID-19 associated genes showed that all analyzed miRNAs are strongly affecting disease pathways related to CVDs which could be explained by their strong interaction with the ACE2 network.

Association of TLR8 Variants in Sex-Based Clinical Differences in Patients with COVID-19

The host immune response might confer differential vulnerability to SARS-CoV-2 infection. The Toll-like receptor 8 (TLR8), could participated for severe COVID-19 outcomes. To investigated the relationship of TLR8 rs3764879-C/G, rs3764880-A/G, and rs3761624-A/G with COVID-19 outcomes and with biochemical parameters. A cross-sectional study of 830 laboratory-confirmed COVID-19 patients was performed, and classified into mild, severe, critical, and deceased outcomes. The TLR8 rs3764879-C/G, rs3764880-A/G, and rs3761624-A/G polymorphisms were genotyped. A logistic regression analysis was performed to determinate the association with COVID-19. A stratified analysis was by alleles was done with clinical and metabolic markets. In all outcomes, men presented the highest ferritin levels compared to women (P < 0.001). LDH levels were significantly different between sex in mild (P = 0.003), severe (P < 0.001) and deceased (P = 0.01) COVID-19 outcomes. The GGG haplotype showed an Odds Ratio of 1.55 (Interval Confidence 95% 1.05-2.32; P = 0.03) in men. Among patients with severe outcome, we observed that the carriers of the GGG haplotype had lower Ferritin, C-reactive protein and LDH levels than the CAA carriers (P < 0.01). After further stratified by sex, these associations were also seen in the male patients, except for D-dimer. Interestingly, among men patients, we could observe associations between TLR8 haplotypes and Ferritin (P < 0.001), D-dimer (P = 0.04), C-reactive protein, and Lactate dehydrogenase in mild (P = 0.04) group. Our results suggest that even though TLR8 haplotypes show a significant association with COVID-19 outcomes, they are associated with clinical markers in COVID-19 severity.

Factors Associated with All-Cause 30-Day Mortality in Indonesian Inpatient COVID-19 Patients at Cipto Mangunkusumo National General Hospital

Introduction: Indonesia, as a developing country, has limited data on the factors associated with 30-day mortality in COVID-19 patients in Indonesia. As a matter of fact, study analyzing factors associated with 30-day mortality of COVID-19 infection in Indonesia has never been conducted. This study aims to fill this gap in the literature by conducting a large-scale analysis of factors associated with 30-day mortality in COVID-19 patients in Indonesia. Method: This study employed a single-center retrospective cohort observational design, and was conducted at Cipto Mangunkusumo National General Hospital between the years 2022 and 2023. Sampling was conducted using the consecutive sampling method. The study included patients aged 18 years and above who had been confirmed to have COVID-19 infection. Survival analysis was conducted using Kaplan-Meier and multivariate Cox regression analysis. Result: Our study included a total of 644 patients, with 120 patients (18.6%) expiring within 30 days. In the multivariate analysis using the backward Wald method, severe COVID-19 (HR: 7.024; 95% CI: 3.971-12.744; p value: <0.0001), moderate COVID-19 infection (HR: 1.660; 95% CI: 1.048-2.629; p value: 0.031), liver cirrhosis (HR: 3.422; 95% CI: 1.208-9.691; p value: 0.021), female sex (HR: 1.738; 95% CI: 1.187-2.545; p value: 0.004), old age (HR: 2.139; 95% CI: 1.279-3.577; p value: 0.004), high leukocyte (HR: 11.502; 95% CI: 1.523-86.874; p value: 0.018), high NLR (HR: 1.720; 95% CI: 1.049-2.819; p value: 0.032), high CRP (HR: 1.906; 95% CI: 1.092-3.329; p value: 0.023), high procalcitonin (HR: 3.281; 95% CI: 1.780-6.049; p value: 0.001), and high creatinine (HR: 1.863; 95% CI: 1.240-2.800; p value: 0.003) were associated with 30-day mortality from COVID-19 infection. Subgroup analysis excluding cancer patients showed that age, D-Dimer, CRP, and PCT were associated with 30-day mortality in COVID-19 patients, while steroid therapy is protective. Conclusions: This study finds that COVID-19 severity, liver cirrhosis, sex, age, leukocyte, NLR, CRP, creatinine, and procalcitonin were associated with COVID-19 mortality within 30 days. These findings underscore the multifactorial nature of COVID-19 infection mortality. It is important, therefore, that patients which exhibit these factors should be treated more aggressively to prevent mortality.

Incidence of Thrombosis in COVID-19 Patients Compared to Non-COVID-19 Sepsis Patients in the Intensive Care Unit

Background/Objectives: The hypercoagulable state associated with COVID-19 infection is associated with adverse outcomes and mortality. Studies have also demonstrated high rates of venous thromboembolism (VTE) events among patients with sepsis. We aimed to evaluate how the increase in thrombotic events in critically ill patients with COVID-19 infection compares to that of critically ill patients with non-COVID-19 sepsis. Methods: A chart review was performed of patients 18 years or older admitted to the intensive care unit (ICU) at Tampa General Hospital between 1 January 2020 and 31 December 2020 diagnosed with COVID-19 or sepsis secondary to other pathogens. Non-COVID-19 sepsis patients and COVID-19 patients were propensity-matched 3:1 on the Charlson Comorbidity Index. Multivariate analyses adjusting for confounding were conducted to report odds ratio (OR) and 95% confidence intervals (95% CIs) of predictors for thrombotic events and overall mortality. Results: After propensity score matching, 492 sepsis patients and 164 COVID-19 patients were included in the analysis. COVID-19 patients were significantly older (p = 0.021) and showed higher BMI (p < 0.001) than sepsis patients. COVID-19 patients did not show significantly higher odds of thrombosis after adjustment for confounders (OR 0.85, 95% CI 0.42-1.72), but had significantly lower odds of mortality than sepsis patients (OR 0.33, 95% CI 0.16-0.66). Conclusions: Our results suggest that further study is required to lower the rate of VTE in COVID-19 and non-COVID-19 sepsis patients admitted to the ICU; it is also reasonable to consider similar thromboembolism practices between these two patient groups.

Vitamin D level in COVID-19 patients has positive correlations with autophagy and negative correlations with disease severity

Background and Objectives

There is still incomplete understanding of the pathogenesis of COVID-19. Calcitriol, the main form of vitamin D in serum, regulates immune responses and increases resistance to pathogens, but the mechanism by which it protects against COVID-19 is uncertain. Autophagy has antiviral effects and helps to maintain homeostasis, but its specific role in COVID-19 is also uncertain. Both vitamin D and autophagy have important functions in the lung microenvironment. This study examined the relationship of serum vitamin D and autophagy-related proteins in patients with COVID-19 and evaluated their potential use as biomarkers.

Methods

Blood samples from COVID-19 patients at the Second Hospital of Jilin University were collected. The levels of vitamin D, autophagy-related proteins (Becline 1 [BECN1] and autophagy-related 7 [ATG7]), and inflammatory markers (TNF-α and IL-1β) were measured using enzyme-linked immunosorbent assays.

Results

We examined 25 patients with mild/moderate COVID-19 and 27 patients with severe/critical COVID-19. The group with severe/critical COVID-19 had more abnormalities in many laboratory indicators, including lower levels of autophagy markers (BECN1 and ATG7) and vitamin D, and higher levels of inflammatory markers (TNF-α and IL-1β). Partial correlation analysis showed that vitamin D had strong positive correlations with ATG7 (r = 0.819, p < 0.001) and BECN1 (r = 0.900, p < 0.001).

Conclusion

Our results demonstrated that the vitamin D level had significant negative correlations with COVID-19 severity and strong positive correlations with autophagy. These findings enhance our understanding of the pathogenesis of COVID-19, and provide a theoretical basis for clinical interventions that target autophagy and vitamin D.

Impact of Sample Type on D-Dimer Screening

Background

The quality of laboratory test results depends on various factors, including sample type selection. Blood samples, such as whole blood, plasma and serum are commonly used for most clinical laboratory examinations. D-dimer parameters are frequently analysed in haematology laboratories and serve as biomarkers for coagulation activation and fibrinolysis. This study aimed to assess the impact of using different sample types on the quality of D-dimer test results.

Method

An observational analytical method was used. D-dimer examination was performed using the fluorescent lateral flow immunoassay method. The study sample consisted of 26 participants aged between 18 years old and 22 years old who had no blood disorders. Whole blood and ethylenediaminetetraacetic acid (EDTA) plasma samples were used for the examination of D-dimer levels.

Results

D-dimer levels in 26 participants using whole blood samples had a mean value of 0.23 mg/L (230 ng/mL), while plasma samples yielded a mean value of 0.14 mg/L (140 ng/mL). D-dimer levels obtained from whole blood samples were higher than plasma samples but remained within the normal range of 0 mg/L-0.5 mg/L (0 ng/mL-500 ng/mL).

Conclusion

The results showed that whole blood samples were more practical than plasma samples. Nevertheless, plasma samples gave results within the normal range of D-dimer values.

Laboratory biomarkers associated with COVID-19 mortality among inpatients in a Peruvian referral hospital

Aim

To evaluate the biochemical and hematological markers associated with the risk of death due to COVID-19 in a clinical cohort with a severe clinical profile.

Methods

A retrospective study was conducted among 215 anonymized inpatient records from the Hospital Nacional Almanzor Aguinaga Asenjo, Peru, between April and June 2020. The association between biomarkers and death due to COVID-19 was assessed using Cox regression, with a multivariable modeling of 1) biochemical and 2) hematological markers. Kaplan-Meier analyses and time-dependent receiver operating characteristic curves were calculated for each associated biomarker (p < 0.05).

Results

Data analysis of 215 inpatient records revealed an overall mortality rate of 51.30% (95% CI 44.70-58.50), a mean age of 63.90 ± 14.10 years, and a median oxygen saturation of 88% (interquartile range 82-92%). The best-fitted biochemical model included higher levels of C-reactive protein (CRP), D-dimer, fibrinogen, urea, and lactate dehydrogenase. Similarly, the best-fitted hematological model included higher absolute neutrophil and prothrombin time, and lower absolute platelet counts. The best area under the curve values in both models were found to be CRP and D-dimer values (>0.74) and the absolute neutrophil count (0.63).

Conclusions

Some specific biochemical markers outperformed hematological markers. Evaluated hematological counts analyzed in multivariable models proved to be better markers and could be useful to discriminate COVID-19 patients at high risk of death.

Diagnostic performance of plasma D-dimer, fibrinogen, and D-dimer to fibrinogen ratio as potential biomarkers to predict hypertension-associated acute ischemic stroke

Background

Ischemic stroke is a common type of stroke that leads to death and functional disability in hypertensive patients. However, there are no well-studied non-invasive and less expensive fluid biomarkers routinely used to detect ischemic stroke in hypertensive patients. Hence, this study aimed to tease out the performance of D-dimer, fibrinogen, and the D-dimer to fibrinogen ratio (DDFR) in predicting hypertension-associated acute ischemic stroke.

Methods

A hospital-based cross-sectional study was done from October 2022 to January 2022 at Yikatit 12 Hospital Medical College, Ethiopia. We recruited 55 hypertensive patients who had an ischemic stroke and 110 who did not. A ROC curve was used to calculate the areas under the curves (AUCs) and determine the diagnostic power of the D-dimer, fibrinogen, and DDFR. The Youden index was used to find the best cut-off points for biomarkers in detecting acute ischemic stroke. A De Long test was employed to show whether there was a significant difference between the AUCs of biomarkers in diagnosing ischemic stroke.

Results

D-dimer yielded the highest diagnostic power (AUC = 0.776) in detecting acute ischemic stroke, followed by DDFR (AUC = 0.763) and fibrinogen (AUC = 0.694), but there was no significant difference between them. At 0.52 μg/ml cut-off point, D-dimer had 82.9% sensitivity, 66.7% specificity, 62.5% PPV, and 85.3% NPV to diagnose acute ischemic stroke. Fibrinogen could detect acute ischemic stroke at 405.85 mg/dl level, with 70.0% sensitivity, 57.1% specificity, 41.2% PPV and 81.6% NPV. At a 1.83 ratio, DDFR might also identify ischemic stroke with 80.0% sensitivity, 67.1% specificity, 51.1% PPV, and 88.7% NPV.

Conclusion

We showed D-dimer, fibrinogen, and DDFR as promising, affordable, and non-invasive biomarkers for the detection of ischemic stroke among subjects with hypertension. This will help clinicians make an early diagnosis and better guide patient therapy.

Clinical Characteristics of Asymptomatic Thromboembolism in Psychiatric Inpatients: A Retrospective Study

Purpose

Venous thromboembolism (VTE) poses a significant threat to individuals' health, yet its correlation with mental disorders remains underappreciated. Here, we conducted a retrospective analysis to explore the characteristics of psychiatric patients presenting with VTE.

Methods

We retrospectively analyzed psychiatric inpatients with elevated plasma D-dimer levels at the Mental Health Center, First Affiliated Hospital, Zhejiang University School of Medicine, from January 2014 to January 2022. The inclusion criteria comprised comprehensive demographic and clinical profiles, including laboratory and imaging findings.

Results

A cohort of 33 eligible patients was included, with plasma D-dimer levels ranging from 880 to 10,700 μg/L FEU. Significantly higher D-dimer levels were observed in patients diagnosed with severe mental disorders (SMD), such as schizophrenia and bipolar disorder, compared to those with mild mental disorders (MMD), including depression and anxiety disorders (p = 0.007). Furthermore, individuals receiving antipsychotic medications for less than one year exhibited elevated D-dimer levels compared to those on treatment for over one year (p = 0.005). However, normalization of D-dimer levels did not demonstrate a significant association with psychiatric diagnosis or treatment duration (p > 0.05).

Conclusion

Our findings suggest that patients diagnosed with SMD or those undergoing antipsychotic treatment for less than one year may have elevated D-dimer levels, indicating a potential predisposition to VTE severity. This underscores the importance of recognizing VTE risk in individuals with severe mental disorders and warrants further investigation into the impact of antipsychotic treatment duration on thrombotic risk.

New Directions in Infection-Associated Ischemic Stroke

The relationship between infections and stroke has not been fully characterized, probably delaying the development of specific treatments. This narrative review addresses mechanisms of stroke linked to infections, including hypercoagulability, endothelial dysfunction, vasculitis, and impaired thrombolysis. SARS-CoV-2, the virus that causes COVID-19, may promote the development of stroke, which may represent its most severe neurological complication. The development of specific therapies for infection-associated stroke remains a profound challenge. Perhaps the most important remaining issue is the distinction between infections that trigger a stroke versus infections that are truly incidental. This distinction likely requires the establishment of appropriate biomarkers, candidates of which are elevated levels of fibrin D-dimer and anticardiolipin/antiphospholipid antibodies. These candidate biomarkers might have potential use in identifying pathogenic infections preceding stroke, which is a precursor to establishing specific therapies for this syndrome.

Quantitative sensory testing defines the trajectory of sensory neuropathy after severe COVID-19

AIMS

To assess sensory neuropathy development after severe COVID-19.

METHODS

Patients with severe COVID-19 underwent assessment of neuropathic symptoms, tendon reflexes, and quantitative sensory testing to evaluate vibration (VPT), cold (CPT), warm (WPT) and heat perception thresholds (HPT) within 1-3 weeks of admission and after 1-year.

RESULTS

32 participants with severe COVID-19 aged 68.6 ± 12.4 (18.8 % diabetes) were assessed. At baseline, numbness and neuropathic pain were present in 56.3 % and 43.8 % of participants, respectively. On the feet, VPT, WPT, and HPT were abnormal in 81.3 %, CPT was abnormal in 50.0 % and HPT on the face was abnormal in 12.5 % of patients. At 1-year follow-up, the prevalence of abnormal VPT (81.3 % vs 50.0 %, P < 0.01), WPT (81.3 % vs 43.8 %, P < 0.01), and HPT (81.3 % vs 50.0 %, P < 0.01) decreased, with no change in CPT (P = 0.21) on the feet or HPT on the face (P = 1.0). Only participants without diabetes recovered from an abnormal VPT, CPT, and WPT. Patients with long-COVID (37.5 %) had comparable baseline VPT, WPT and CPT with those without long-COVID (P = 0.07-0.69).

CONCLUSIONS

Severe COVID-19 is associated with abnormal vibration and thermal thresholds which are sustained for up to 1 year in patients with diabetes. Abnormal sensory thresholds have no association with long-COVID development.

Risk factors of early mortality in COVID-19 patients in Indonesia: A retrospective cohort study in a provincial referral hospital of Aceh

Some of coronavirus disease 2019 (COVID-19) patients died after being hospitalized and early mortality is a matter of concern during the pandemic; therefore, it is critical to determine which patients are the most vulnerable of having early mortality. The aim of this study was to determine the risk factors for early mortality among hospitalized COVID-19 patients in Indonesia. A retrospective cohort study was conducted on hospitalized COVID-19 patients from July 2020 to September 2021 at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. Demographic data, clinical characteristics, laboratory findings, and mortality were collected. Early mortality was defined as a death before seven days of the hospitalization. Multivariate regression analysis was employed to determine the risk factors associated with early mortality. We included the data of 624 COVID-19 patients who died during the study period. More than half of the patients were male and aged over 50 years old. The average hospitalization period was 10 days and most patients had more than two comorbidities. Chronic lung disease was the most common comorbidity (46.0%) followed by respiratory disease (26.8%) and heart disease (14.3%). Multiple comorbidities and elevated D-dimers exceeding 3376.92 ng/mL were associated with early mortality with OR: 7.029; 95%CI: 2.02-24.43 and OR: 1.000085, 95%CI: 1.000028-1.000142, respectively. In conclusion, early mortality in COVID-19 patients was associated with having multiple comorbidities and elevated D-dimer level. Therefore, it is crucial to assess the presence of comorbidities and routine laboratory test while managing COVID-19 patients in order to prevent the early mortality.

Role of biomarkers in prognostication of moderate and severe COVID-19 cases

Background

COVID-19 pandemic demanded upgrading of laboratory medicine to limit morbidity, disability and mortality from moderate and severe SARS-COV-2 infections.

Objective

To assess among moderate and severe COVID-19 patients, C-reactive protein (CRP), procalcitonin (PCT), ferritin, D-dimer, interleukin 6 (IL-6), lactate dehydrogenase (LDH), total and differential leucocyte count (TLC and DLC), neutrophil-to-lymphocyte ratio (NLR), absolute platelet count (APC), prothrombin time (PT), activated partial thromboplastin time (APTT) and international normalized ratio (INR) to find their interdependence and role in prognosis.

Methods

This open label analytical cross-sectional noninterventional study evaluated array of independent biochemical, haematological and coagulopathy markers, viz. CRP, PCT, ferritin, D-dimer, IL-6, LDH, TLC, DLC, NLR, absolute platelet count, PT, APTT and INR on consecutive 100 patients with diagnosis of moderate and severe COVID-19 from July to August 2021.

Results

In our study, on consecutive designated 100 cases (55 cases moderate and 45 cases severe), more severity were reported as the age progressed; gender difference was not noted. Among independent markers, CRP, PCT, ferritin, D-dimer, IL-6 and LDH had statistically significant relation in comparison with severity of the disease as Chi-square calculated value (P < 0.05). TLC, DLC and APC showed no significant relation in comparison with severity of the disease; NLR had highly significant relation. PT showed significant relation in comparison with severity, though APTT and INR did not show significant relation.

Conclusion

Our research group felt that CRP, PCT, ferritin, D-dimer, IL-6, LDH and NLR should be in included in clinical practice guidelines to prognosticate COVID-19 cases. Furthermore, translational researches are needed at all levels of healthcare to improve validity for practices of primary care physicians.

Inflammatory biomarkers to predict the prognosis of acute bacterial and viral infections

Mortality in acute infections is mostly associated with sepsis, defined as 'life-threatening organ dysfunction caused by a dysregulated host response to infection'. It remains challenging to identify the patients with increased mortality risk due to the high heterogeneity in the dysregulated host immune response and disease progression. Biomarkers reflecting different pathways involved in the inflammatory response might improve prediction of mortality risk (prognostic enrichment) among patients with acute infections by reducing heterogeneity of the host response, as well as suggest novel strategies for patient stratification and treatment (predictive enrichment) through precision medicine approaches. The predictive value of inflammatory biomarkers has been extensively investigated in bacterial infections and the recent COVID-19 pandemic caused an increased interest in inflammatory biomarkers in this viral infection. However, limited research investigated whether the prognostic potential of these biomarkers differs between bacterial and viral infections. In this narrative review, we provide an overview of the value of various inflammatory biomarkers for the prediction of mortality in bacterial and viral infections.

Multivariable Risk Modelling and Survival Analysis with Machine Learning in SARS-CoV-2 Infection

AIM

To evaluate the performance of a machine learning model based on demographic variables, blood tests, pre-existing comorbidities, and computed tomography(CT)-based radiomic features to predict critical outcome in patients with acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

METHODS

We retrospectively enrolled 694 SARS-CoV-2-positive patients. Clinical and demographic data were extracted from clinical records. Radiomic data were extracted from CT. Patients were randomized to the training (80%, n = 556) or test (20%, n = 138) dataset. The training set was used to define the association between severity of disease and comorbidities, laboratory tests, demographic, and CT-based radiomic variables, and to implement a risk-prediction model. The model was evaluated using the C statistic and Brier scores. The test set was used to assess model prediction performance.

RESULTS

Patients who died (n = 157) were predominantly male (66%) over the age of 50 with median (range) C-reactive protein (CRP) = 5 [1, 37] mg/dL, lactate dehydrogenase (LDH) = 494 [141, 3631] U/I, and D-dimer = 6.006 [168, 152.015] ng/mL. Surviving patients (n = 537) had median (range) CRP = 3 [0, 27] mg/dL, LDH = 484 [78, 3.745] U/I, and D-dimer = 1.133 [96, 55.660] ng/mL. The strongest risk factors were D-dimer, age, and cardiovascular disease. The model implemented using the variables identified using the LASSO Cox regression analysis classified 90% of non-survivors as high-risk individuals in the testing dataset. In this sample, the estimated median survival in the high-risk group was 9 days (95% CI; 9-37), while the low-risk group did not reach the median survival of 50% (p < 0.001).

CONCLUSIONS

A machine learning model based on combined data available on the first days of hospitalization (demographics, CT-radiomics, comorbidities, and blood biomarkers), can identify SARS-CoV-2 patients at risk of serious illness and death.

Platelet aggregates detected using quantitative phase imaging associate with COVID-19 severity

BACKGROUND

The clinical spectrum of acute SARS-CoV-2 infection ranges from an asymptomatic to life-threatening disease. Considering the broad spectrum of severity, reliable biomarkers are required for early risk stratification and prediction of clinical outcomes. Despite numerous efforts, no COVID-19-specific biomarker has been established to guide further diagnostic or even therapeutic approaches, most likely due to insufficient validation, methodical complexity, or economic factors. COVID-19-associated coagulopathy is a hallmark of the disease and is mainly attributed to dysregulated immunothrombosis. This process describes an intricate interplay of platelets, innate immune cells, the coagulation cascade, and the vascular endothelium leading to both micro- and macrothrombotic complications. In this context, increased levels of immunothrombotic components, including platelet and platelet-leukocyte aggregates, have been described and linked to COVID-19 severity.

METHODS

Here, we describe a label-free quantitative phase imaging approach, allowing the identification of cell-aggregates and their components at single-cell resolution within 30 min, which prospectively qualifies the method as point-of-care (POC) testing.

RESULTS

We find a significant association between the severity of COVID-19 and the amount of platelet and platelet-leukocyte aggregates. Additionally, we observe a linkage between severity, aggregate composition, and size distribution of platelets in aggregates.

CONCLUSIONS

This study presents a POC-compatible method for rapid quantitative analysis of blood cell aggregates in patients with COVID-19.

Assessing risk of major adverse cardiac event among COVID-19 patients using HEART score

Coronavirus disease 2019 (COVID-19) is known to be associated with cardiovascular complications, but whether the current validated HEART score for chest pain is still applicable for these patients is unknown. This study aims to identify the impact and association of COVID-19 co-infection in patients presenting with chest pain and a calculated HEART score to the emergency departments (ED) with 30-day of major adverse cardiac event (MACE). This is a multicenter, retrospective observational study that included adult (age ≥ 18 years) patients visiting 13 different EDs with chest pain and evaluated using a HEART score. The primary outcome was the percentage of 30-day MACE, which included acute myocardial infarction, emergency percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or death among patients who presented with chest pain and had COVID-19 co-infection. The sensitivity and specificity of the HEART score among COVID-19 co-infection for MACE were assessed by the receiver operating curve (ROC). We analyzed records of 46,210 eligible patients, in which 327 (0.7%) patients were identified as infected with COVID-19. Patients with COVID-19 had higher mean total HEART score of 3.3 (1.7), compared to patients who did not have COVID-19 (3.1, SD 1.8, P = 0.048). The rate of MACE was similar between both groups. There were only 2 (0.6%) COVID-19 patients who had MACE, compared to 504 (1.1%) patients in control group. Total HEART score was associated with an area under the ROC (AUROC) of 0.99, while the control group's was 0.78. History was associated with high AUROC in both COVID-19 (0.74) and control groups (0.76). Older age in COVID-19 had higher AUROC (0.89) than control patients (0.63). Among patients presenting to the ED with chest pain and having COVID-19 infection, HEART score had predictive capability for MACE, similar to patients without COVID-19 infection. Further studies with more COVID-19 patients are still necessary to confirm our observation.

Prevalence, pathogenesis and spectrum of neurological symptoms in COVID-19 and post-COVID-19 syndrome: a narrative review

Neurological symptoms are not uncommon during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and reflect a broad spectrum of neurological disorders of which clinicians should be aware. The underlying pathogenesis of neurological disease in coronavirus disease 2019 (COVID-19) may be due to four mechanisms of nervous system dysfunction and injury: i) direct viral neurological invasion; ii) immune dysregulation; iii) endothelial dysfunction and coagulopathy; and iv) severe systemic COVID-19 disease. Neurological manifestations of acute COVID-19 include headache, peripheral neuropathies, seizures, encephalitis, Guillain-Barré syndrome, and cerebrovascular disease. Commonly reported long term neurological sequelae of COVID-19 are cognitive dysfunction and dysautonomia, which despite being associated with severe acute disease are also seen in people with mild disease. Assessment of cognitive dysfunction after COVID-19 is confounded by a high prevalence of comorbid fatigue, anxiety, and mood disorders. However, other markers of neuroaxonal breakdown suggest no significant neuronal injury apart from during severe acute COVID-19. The long term impact of COVID-19 on neurological diseases remains uncertain and requires ongoing vigilance.

COVID severity test (CoST sensor)-An electrochemical immunosensing approach to stratify disease severity

With the evolution of the COVID-19 pandemic, there is now a need for point-of-care devices for the quantification of disease biomarkers toward disease severity assessment. Disease progression has been determined as a multifactor phenomenon and can be treated based on the host immune response within each individual. CoST is an electrochemical immunosensor point-of-care device that can determine disease severity through multiplex measurement and quantification of spike protein, nucleocapsid protein, D-dimer, and IL-2R from 100 μL of plasma samples within a few minutes. The limit of detection was found to be 3 ng/mL and 21 ng/mL for S and N proteins whereas for D-dimer and IL-2R it was 0.0006 ng/mL and 0.242 ng/mL, respectively. Cross-reactivity of all the biomarkers was studied and it was found to be <20%. Inter and intra-assay variability of the CoST sensor was less than <15% confirming its ability to detect the target biomarker in body fluids. In addition, this platform has also been tested to quantify all four biomarkers in 40 patient samples and to predict the severity index. A significant difference was observed between healthy and COVID-19 samples with a p-value of 0.0002 for D-dimer and <0.0001 for other proteins confirming the ability of the COST sensor to be used as a point of care device to assess disease severity at clinical sites. This device platform can be modified to impact a wide range of disease indications where prognostic monitoring of the host response can be critical in modulating therapy.

Comparison of circulating lipid profiles, D-dimer and fibrinogen levels between hypertensive patients with and without stroke

BACKGROUND

Stroke is one of the leading causes of global mortality and disability, particularly in hypertensive patients. This study aimed to compare lipid profile, fibrinogen, and D-dimer levels between hypertensive patient with and without stroke.

METHODS

This was a facility-based cross-sectional study conducted from November 2022 to January 2023 among 115 hypertensive patients (70 patients without stroke and 45 with stroke) who had follow-up at Yikatit 12 Hospital Medical College, Ethiopia. All data analyses were done using SPSS version 25.0 and comparisons of variables between groups were made using the Chi-square test, independent sample t-test, and Mann-Whitney U test. Multiple logistic regression analysis was done to identify predictors of stroke among hypertensive patients. A p-value <0.05 was assumed to be statistically significant for all statistical tests.

RESULTS

Significantly elevated levels of TC, LDL-C, D-DI, and fibrinogen were observed in the stroke group than in the non-stroke group (p-value<0.05). The mean values of TC, D-DI, and fibrinogen were significantly higher in patients with ischemic stroke compared to those with hemorrhagic stroke. Duration of hypertension (AOR: 1.21; CI: 1.10, 2.09), TC (AOR:1.07; CI: 1.01, 1.22), D-DI (AOR: 1.15; CI: 1.05, 1.69) and fibrinogen (AOR:1.19; CI: 1.10, 2.89) were identified to be independent predictors of stroke in hypertensive patients.

CONCLUSION

The circulating levels of TC, LDL-C, D-DI and fibrinogen in hypertensive patients with stroke were significantly higher than in those without stroke. But only TC, D-DI, and fibrinogen were found to be predictors of stroke in hypertensives. Considerably higher TC, D-DI, and fibrinogen levels were also seen in patients with ischemic stroke than in those with hemorrhagic stroke. This confirms the key roles of dyslipidemia (hypercholesterolemia) and aberrant hemostatic activation to stroke development, notably ischemic stroke.

The predictive role of biochemical markers on outcomes of severe COVID-19 patients admitted to intensive care unit

Background

The pandemic of severe acute respiratory syndrome by coronavirus 2 (SARS-CoV-2) is a multi-system disease caused by a diffuse systemic process involving a complex interaction of the inflammatory, immunological and coagulative cascades. This study aims to identify the most effective biomarkers to predict poor outcome in intensive care unit (ICU) patients with severe COVID-19 disease.

Methods

A single-centre retrospective observational study enrolled 69 deceased and 20 recovered patients treated in the ICU of the General Hospital Gradiska in the period from March 1, 2021. until April 1, 2022. We evaluated the leukocytes (WBC), lymphocytes (LYM), neutrophils (NEU), platelets (PLT), haemoglobin, neutrophil-lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). In addition, we evaluated the IL-6, ferritin, CRP, D-dimer, magnesium, bilirubin and lactate dehydrogenase.

ACE2, ACE, DPPIV, PREP and CAT L enzymatic activities in COVID-19: imbalance of ACE2/ACE ratio and potential RAAS dysregulation in severe cases

OBJECTIVE AND DESIGN

Circulating enzymatic activity and RAAS regulation in severe cases of COVID-19 remains unclear, therefore we measured the serum activity of several proteases as potential targets to control the SARS-CoV-2 infection.

MATERIAL OR SUBJECTS

152 patients with COVID-19-like symptoms were grouped according to the severity of symptoms (COVID-19 negative, mild, moderate and severe).

METHODS

Serum samples of COVID-19 patients and controls were subjected to biochemical analysis and enzymatic assays of ACE2, ACE, DPPIV, PREP and CAT L. One-way ANOVA and multivariate logistic regression analysis were used. Statistical significance was accepted at p < 0.05.

RESULTS

We detected a positive correlation among comorbidities, higher C-reactive protein (CRP) and D-dimer levels with disease severity. Enzymatic assays revealed an increase in serum ACE2 and CAT L activities in severe COVID-19 patients, while ACE, DPPIV and PREP activities were significantly reduced. Notably, analysis of ACE2/ACE activity ratio suggests a possible imbalance of ANG II/ANG(1-7) ratio, in a positive association with the disease severity.

CONCLUSION

Our findings reveal a correlation between proteases activity and the severity of COVID-19. These enzymes together contribute to the activation of pro-inflammatory pathways, trigger a systemic activation of inflammatory mediators, leading to a RAAS dysregulation and generating a significant damage in several organs, contributing to poor outcomes of severe cases.

A critical review on brain and heart axis response in COVID-19 patients: Molecular mechanisms, mediators, biomarkers, and therapeutics

Since the outbreak of highly virulent coronaviruses, significant interest was assessed to the brain and heart axis (BHA) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-affected patients. The majority of clinical reports accounted for unusual symptoms associated with SARS-CoV-2 infections which are of the neurological type, such as headache, nausea, dysgeusia, anosmia, and cerebral infarction. The SARS-CoV-2 enters the cells through the angiotensin-converting enzyme (ACE-2) receptor. Patients with prior cardiovascular disease (CVD) have a higher risk of COVID-19 infection and it has related to various cardiovascular (CV) complications. Infected patients with pre-existing CVDs are also particularly exposed to critical health outcomes. Overall, COVID-19 affected patients admitted to intensive care units (ICU) and exposed to stressful environmental constraints, featured with a cluster of neurological and CV complications. In this review, we summarized the main contributions in the literature on how SARS-CoV-2 could interfere with the BHA and its role in affecting multiorgan disorders. Specifically, the central nervous system involvement, mainly in relation to CV alterations in COVID-19-affected patients, is considered. This review also emphasizes the biomarkers and therapy options for COVID-19 patients presenting with CV problems.

Association between laboratory markers and Covid-19 disease severity and outcome: a retrospective cohort study in Saudi Arabia

Introduction

In Saudi Arabia, limited studies have evaluated factors including epidemiologic, clinical, and laboratory findings that are associated with COVID-19 disease. The aim of this paper was to identify laboratory parameters used in King Abdulaziz University Hospital which show an association with disease severity and patient outcome in the form of mortality.

Methods

Age, gender, medical history, and laboratory parameters were all retrospectively assessed concerning disease severity and disease outcome in a total of 111 COVID-19 patients at King Abdulaziz University Hospital between July 2020 and August 2020. Patients were categorized into mild disease if they did not require ward admission, moderate if they met the Ministry of Health criteria for isolation ward admition, and severe if they were admitted to the ICU.

Results

Age but not gender was associated with the disease severity X² (4, N = 110) = 27.2, p <0.001. Of all laboratory parameters on admission, only the levels of Albumin appeared to be significantly associated X² (2, N =70) = 6.6, p <0.05 with disease severity. Age but not gender was also significantly associated with disease outcome X² (2, N = 110) = 12.8, p < 0.01. Interestingly, RBC count also showed a significant relation with disease outcome X² (2, N = 71) = 6.1, p <0.05.

Discussion

This study provides more understanding of the laboratory characteristics in our part of the world to efficiently manage the disease.

Does follow-up D-dimer level help in predicting oxygenation status, ventilatory support requirement, lung fibrosis, and thromboembolic events in coronavirus disease 2019 pneumonia? A prospective observational study in a tertiary care setting in India

Introduction

Coronavirus disease 2019 (COVID-19) pneumonia is a heterogeneous disease with variable effects on lung parenchyma, airways, and vasculature, leading to long-term effects on lung functions.

Materials and Methods

This multicentric, prospective, observational, and interventional study included 1000 COVID-19 cases confirmed with reverse transcription-polymerase chain reaction. All cases were assessed with high-resolution computed tomography thorax, oxygen saturation, inflammatory marker as D-dimer at the entry point, and follow-up. Age, gender, comorbidity, use of bilevel positive airway pressure/noninvasive ventilation (BiPAP/NIV), and outcome as with or without lung fibrosis as per CT severity were key observations. In selected cases, we have performed lower limb venous Doppler and computed tomography (CT) pulmonary angiography to rule out deep-vein thrombosis (DVT) or pulmonary thromboembolism (PTE) respectively. Statistical analysis is performed by using Chi-square test.

Observations and Analysis

Age (<50 and >50 years) and gender (male vs. female) has a significant association with D-dimer level (P < 0.00001 and P < 0.010, respectively). CT severity score at the entry point with the D-dimer level has a significant correlation (P < 0.00001). The D-dimer level has a significant association with the duration of illness before hospitalization (P < 0.00001). Comorbidities have a significant association with D-dimer levels (P < 0.00001). D-dimer level has a significant association with oxygen saturation (P < 0.00001). BIPAP/NIV requirement has a significant association with the D-dimer level (P < 0.00001). Timing of BIPAP/NIV requirement during hospitalization has a significant association with D-dimer level (P < 0.00001). Follow-up D-dimer titer during hospitalization as compared to normal and abnormal to entry point level has a significant association with post-COVID lung fibrosis, DVT, and PTE (P < 0.00001).

Conclusions

D-dimer has documented a very crucial role in COVID-19 pneumonia in predicting the severity of illness and assessing response to treatment during hospitalization, and follow-up titers have a significant role in step-up or step-down interventions in a critical care setting.

Short-term exposure to ambient air pollution and COVID-19 severity during SARS-CoV-2 Delta and Omicron waves: A multicenter study

Air pollution may affect the clinical course of respiratory diseases, including COVID-19. This study aimed to evaluate the relationship between exposure of adult patients to mean 24 h levels of particulate matter sized <10 μm (PM₁₀ ) and <2.5 μm (PM_2.5 ) and benzo(a)pyrene (B(a)P) during a week before their hospitalization due to SARS-CoV-2 infection and symptomatology, hyperinflammation, coagulopathy, the clinical course of disease, and outcome. The analyses were conducted during two pandemic waves: (i) dominated by highly pathogenic Delta variant (n = 1440) and (ii) clinically less-severe Omicron (n = 785), while the analyzed associations were adjusted for patient's age, BMI, gender, and comorbidities. The exposure to mean 24 h B(a)P exceeding the limits was associated with increased odds of fever and fatigue as early COVID-19 symptoms, hyperinflammation due to serum C-reactive protein >200 mg/L and interleukin-6 >100 pg/mL, coagulopathy due to  d-dimer >2 mg/L and fatal outcome. Elevated PM₁₀ and PM_{2. 5} levels were associated with higher odds of respiratory symptoms, procalcitonin >0.25 ng/mL and interleukin >100 pg/mL, lower oxygen saturation, need for oxygen support, and death. The significant relationships between exposure to air pollutants and the course and outcomes of COVID-19 were observed during both pandemic waves. Short-term exposure to elevated PM and B(a)P levels can be associated with a worse clinical course of COVID-19 in patients requiring hospitalization and, ultimately, contribute to the health burden caused by SARS-CoV-2 variants of higher and lower clinical significance.

Clinical Characteristics and Serum Cytokines Profiling in Hospitalized COVID-19 Patients in Lebanon

Since its emergence, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains a public health threat worldwide. While the majority of patients recover in 3-4 weeks, complications in severely ill patients, including acute respiratory distress syndrome, cardiac injury, thrombosis, and sepsis, can lead to death. Several biomarkers, in addition to cytokine release syndrome (CRS), have been associated with severe and fatal outcomes in coronavirus disease 2019 (COVID-19) patients. The aim of this study is to assess clinical characteristics and cytokines profiles in hospitalized COVID-19 patients in Lebanon. A total of 51 hospitalized COVID-19 patients were recruited between February 2021 and May 2022. Clinical data and sera were collected at two time points: at hospital presentation (T0) and last collected results during hospitalization (T1). Our results showed that 49% of participants were >60 years with males accounting for the majority (72.5%). Hypertension, followed by diabetes and dyslipidemia, were the most frequent comorbid conditions among study participants accounting for 56.9% and 31.4%, respectively. Chronic obstructive pulmonary disease (COPD) was the only significantly different comorbid condition between intensive care unit (ICU) and non-ICU patients. Our results also showed that the median level of D-dimer was significantly elevated among patients in ICU and those who died compared to non-ICU patients and those who survived. Moreover, C-reactive protein (CRP) levels were significantly higher at T0 compared to T1 in ICU and non-ICU patients. The median level of IL-12p70 was significantly higher in patients >60 years compared to those ≤60 years (p = 0.0209). Our data are in agreement with previous reports suggesting the importance of IL-6, CRP, and IL-12p70 in the assessment of risk of severe disease and mortality.

Vitamin D, Albumin, and D-Dimer as Significant Prognostic Markers in Early Hospitalization in Patients with COVID-19

SARS-CoV-2 continues to pose a major challenge to scientists and clinicians. We examined the significance of the serum concentrations of vitamin D, albumin, and D-dimer for the severity of the clinical picture and mortality in COVID-19.

MATERIALS AND METHODS

A total of 288 patients treated for COVID-19 infection participated in the research. The patients were treated in the period from May 2020 to January 2021. All patients were divided based on the need for oxygen therapy (Sat > 94%) into patients with mild or severe clinical pictures. The biochemical and radiographic parameters of the patients were analyzed. Appropriate statistical methods were used in the statistical analysis.

RESULTS

In patients with COVID-19 with confirmed severe clinical pictures, lower values of serum albumin (p < 0.0005) and vitamin D (p = 0.004) were recorded, as opposed to elevated values of D-dimer (p < 0.0005). Accordingly, the patients with fatal disease outcomes had lower levels of albumin (p < 0.0005) and vitamin D (p = 0.002), while their D-dimer (p < 0.0005) levels were elevated. An increase in the radiographic score, as a parameter for assessing the severity of the clinical picture, was accompanied by a decrease in serum albumin (p < 0.0005) and a simultaneous increase in D-dimer (p < 0.0005), without a change in the vitamin D concentration (p = 0.261). We also demonstrated the interrelations of the serum levels of vitamin D, albumin, and D-dimer in patients with COVID-19 as well as their significance as predictors of the outcome of the disease.

CONCLUSION

The significance of the predictive parameters in our study indicates the existence of an important combined role of vitamin D, albumin, and D-dimer in the early diagnosis of the most severe patients suffering from COVID-19. Reduced values of vitamin D and albumin, in combination with elevated values of D-dimer, can be timely indicators of the development of a severe clinical picture and death due to COVID-19.

COVID-19 Biomarkers at the Crossroad between Patient Stratification and Targeted Therapy: The Role of Validated and Proposed Parameters

Clinical knowledge about SARS-CoV-2 infection mechanisms and COVID-19 pathophysiology have enormously increased during the pandemic. Nevertheless, because of the great heterogeneity of disease manifestations, a precise patient stratification at admission is still difficult, thus rendering a rational allocation of limited medical resources as well as a tailored therapeutic approach challenging. To date, many hematologic biomarkers have been validated to support the early triage of SARS-CoV-2-positive patients and to monitor their disease progression. Among them, some indices have proven to be not only predictive parameters, but also direct or indirect pharmacological targets, thus allowing for a more tailored approach to single-patient symptoms, especially in those with severe progressive disease. While many blood test-derived parameters quickly entered routine clinical practice, other circulating biomarkers have been proposed by several researchers who have investigated their reliability in specific patient cohorts. Despite their usefulness in specific contexts as well as their potential interest as therapeutic targets, such experimental markers have not been implemented in routine clinical practice, mainly due to their higher costs and low availability in general hospital settings. This narrative review will present an overview of the most commonly adopted biomarkers in clinical practice and of the most promising ones emerging from specific population studies. Considering that each of the validated markers reflects a specific aspect of COVID-19 evolution, embedding new highly informative markers into routine clinical testing could help not only in early patient stratification, but also in guiding a timely and tailored method of therapeutic intervention.

Increased D-dimer level was a poor predictor of neuroblastoma, especially in the high-risk group

PURPOSE

D-dimer levels are associated with tumor progression and prognosis in various cancers. However, there are few research about the relationship between D-dimer and neuroblastoma (NB). This study assessed the relationships of D-dimer levels with clinical features and overall survival (OS) in patients with NB.

METHODS

Information about the clinical features of 365 patients and the prognosis of 301 patients was collected. The relationship between D-dimer levels and clinical features or OS was analyzed. We constructed the risk score based on Cox regression analysis and verified the predictive efficacy of the model through ROC curve and calibration curve.

RESULTS

The results showed that D-dimer levels were significantly increased in patients with nonmediastinal tumor, tumor larger than 10 cm, stage 3-4 disease, bone marrow metastasis, unfavorable histology, bone metastasis, NMYC amplification, and the high-risk group (all P < 0.05). The Kaplan-Meier survival analysis showed that there were significant differences in 3- and 5-year OS (87.4% vs. 32.3%, 79.3% vs. 32.3%, P < 0.0001) between the low D-dimer and high D-dimer groups. In the high-risk group, the OS of high D-dimer was significantly lower than that of low D-dimer (P < 0.0001). All cases were divided into the training cohort (N = 211) and the validation cohort (N = 90). Multivariate analysis further suggested that D-dimer level, bone metastasis, and NMYC status were independent prognostic factors for OS (all P < 0.05). Based on the above three factors, we constructed the risk score in the training cohort. Survival analysis showed that compared with the other groups, the group with 11 scores had the worst prognosis (3-year OS 0%, P < 0.0001). The time-dependent ROC analysis and calibration curve indicated that the risk score had good accuracy.

CONCLUSIONS

Patients with high D-dimer levels tended to have unfavorable clinical characteristics and poor prognosis.

An eye to the future: Acute and long-term neuro-ophthalmological and neurological complications of COVID-19

COVID-19 has had a significant impact on the global population and has produced compelling evidence of non-pulmonary organ dysfunction, including the nervous system. It is vital that specialists in ophthalmology and neurology are informed of the potential complications of COVID-19 and gain a deeper understanding of how COVID-19 can cause diseases of the nervous system. In this review we detail four possible mechanisms by which COVID-19 infection may result in neurological or neuro-ophthalmological complications: (1) Toxic and metabolic effects of severe pulmonary COVID-19 disease on the neural axis including hypoxia and the systemic hyper-inflammatory state, (2) endothelial dysfunction, (3) dysimmune responses directed again the neuroaxis, and (4) direct neuro-invasion and injury by the virus itself. We explore the pathological evidence for each of these and how they may link to neuro-ophthalmological disorders. Finally, we explore the evidence for long-term neurological and neuro-ophthalmological complications of COVID-19, with a focus on neurodegeneration.

Study of Coagulation Disorders and the Prevalence of Their Related Symptoms among COVID-19 Patients in Al-Jouf Region, Saudi Arabia during the COVID-19 Pandemic

Introduction: The coronavirus (COVID-19) has affected millions of people around the world. COVID-19 patients, particularly those with the critical illness, have coagulation abnormalities, thrombocytopenia, and a high prevalence of intravascular thrombosis. Objectives: This work aims to assess the prevalence of coagulation disorders and their related symptoms among COVID-19 patients in the Al-Jouf region of Saudi Arabia. Subjects and methods: We conducted a retrospective study on 160 COVID-19 patients. Data were collected from the medical records department of King Abdulaziz Specialist Hospital, Sakaka, Al-Jouf, Saudi Arabia. The socio-demographic data, risk factors, coagulation profile investigation results, symptom and sign data related to coagulation disorders, and disease morbidity and mortality for COVID-19 patients were extracted from medical records, and the data were stored confidentially. Results: Males represented the highest prevalence of COVID-19 infection at 65%; 29% were aged 60 or over; 28% were smokers; and 36% were suffering from chronic diseases, with diabetes mellitus representing the highest prevalence. Positive D-dimer results occurred in 29% of cases, with abnormal platelet counts in 26%. Conclusion: Our findings confirm that the dysregulation of the coagulation cascade and the subsequent occurrence of coagulation disorders are common in coronavirus infections. The results show absolute values, not increases over normal values; thus, it is hard to justify increased risk and presence based on the presented data.

The second wave of COVID-19 wreaked havoc: A look at clinical and laboratory parameters of survivors and non-survivors admitted to Intensive Care Unit, a single-centered retrospective study

Background

The second wave of COVID-19 was disastrous and claimed many lives in India and abroad. The most challenging task was to provide the required treatment as per the patient's condition, within a limited span of time. The lack of prognostic predictors at the time of admission led to failure in prioritizing the patient's need for intensive care.

Aim

This study was conducted to find out the clinical and laboratory parameters at the time of admission to ICU as predictors of outcomes in COVID-19 patients, which can help in judicious utilization of the available resources for better patient care.

Subjects and Methods

Study comprises of 161 ICU admitted patients. Study of clinical traits, comorbidities, test results, and demographic variables were carried out among survivors and non-survivor.

Result

Maximum death were patients of age group 21-30 years and male gender. Mortality in hypertensives, diabetics, and patients with sepsis were found to be statistically significant. Patients who developed ARDS and pneumonia or needed ventilation died invariably. High levels of laboratory parameters like IL-6, LDH, PT, INR, aPTT, ferritin, WBC count, and D-dimer were significantly associated with poor outcomes and at a particular cutoff had optimum sensitivity and specificity to predict mortality in ICU admitted COVID-19 patients. At the same time, low lymphocyte count and PaO2/FiO2 ratio was significantly associated with bad prognosis (P < 0.05).

Conclusion

This paper will help in prioritizing patients in ICU who need special attention especially at the time of meager supply of resources.

D-dimer levels in non-COVID-19 ARDS and COVID-19 ARDS patients: A systematic review with meta-analysis

BACKGROUND

Hypercoagulability and thrombo-inflammation are the main reasons for death in COVID-19 patients. It is unclear whether there is a difference between D-dimer levels in patients without or with COVID-19 acute respiratory distress syndrome (ARDS).

METHODS

We searched PubMed, EMBASE, and ClinicalTrails.gov databases looking for studies reporting D-dimer levels in patients without or with COVID-19 ARDS. Secondary endpoints included length of hospital stay, and mortality data at the longest follow-up available.

RESULTS

We included 12 retrospective and 3 prospective studies with overall 2,828 patients, of whom 1,404 (49.6%) had non-COVID-19 ARDS and 1,424 had COVID-19 ARDS. D-dimer levels were not significantly higher in non-COVID-19 ARDS than in COVID-19 ARDS patients (mean 7.65 mg/L vs. mean 6.20 mg/L MD 0.88 [CI: -0.61 to 2.38] p = 0.25; I² = 85%) while the length of hospital stay was shorter (non-COVID-19 mean 37.4 days vs. COVID-19 mean 48.5 days, MD -10.92 [CI: -16.71 to -5.14] p < 0.001; I² = 44%). No difference in mortality was observed: non-COVID-19 ARDS 418/1167 (35.8%) vs. COVID-19 ARDS 467/1201 (38.8%).

CONCLUSIONS

We found no difference in the mean D-dimer levels between non-COVID-19 ARDS and COVID-19 ARDS patients.

Study to Determine a Prognostic Cutoff Values of the Coagulation Analyte D-dimer for ICU Admission among COVID-19 Patients

Introduction

The measured D-dimer levels in coronavirus disease-2019 (COVID-19) patients have no specific cutoff to find the progression of coagulopathy and severity.

Aim

This study aimed to determine prognostic cutoff values of D-dimer for intensive care unit (ICU) admission among COVID-19 patients.

Materials and methods

This cross-sectional study was conducted in Sree Balaji Medical College and Hospital, Chennai, during a period of 6 months. This study included 460 COVID-19-positive individuals.

Results

The mean age was 52.2 ± 12.53 years. Patients with mild illness have D-dimer value 461.8 ± 221, whereas moderate and severe COVID illness patients have D-dimer values of 1915.2 ± 699.9 and 7937.6 ± 2045.2, respectively. D-dimer cutoff value of 1036.9 is shown to be a prognostic cutoff value for COVID-19 patients admitted in the ICU with 99% sensitivity and 17% specificity. The area under curve (AUC) was considered excellent (AUC = 0.827, 95% Cl: 0.78-0.86, p-value < 0.0001) indicative of high sensitivity.

Conclusion

The D-dimer value of 1036.9 ng/mL was found to be the optimum cutoff for the patients to predict the severity of the COVID-19-positive patients admitted in the ICU.

How to cite this article

Anton MC, Shanthi B, Vasudevan E. Study to Determine a Prognostic Cutoff Values of the Coagulation Analyte D-dimer for ICU Admission among COVID-19 Patients. Indian J Crit Care Med 2023;27(2):135-138.