Erythrocyte sedimentation rate is associated with severe coronavirus disease 2019 (COVID-19): a pooled analysis

Predictors of COVID-19 severity in autoimmune disease patients: A retrospective study during full epidemic decontrol in China

BACKGROUND

Early identification of risk factors for adverse COVID-19 progression in patients with autoimmune diseases is crucial for patient management, but data on the Chinese population are scarce.

OBJECTIVES

The purpose of this study was to identify predictors of severe COVID-19 in patients using blood cell ratios, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and other inflammatory markers.

METHODS

A retrospective study of 855 patients (746 females; median age 49 years) with autoimmune diseases and concurrent COVID-19 was conducted from December 2022 to February 2023 at the Rheumatology and Immunology Department of the First Affiliated Hospital of Nanchang University. Disease severity was assessed according to the 8th edition of the National Health Commission of the People's Republic of China's COVID-19 Diagnosis and Treatment Guidelines. The clinical classification criteria group mild and moderate cases as nonsevere cases and severe and critical cases as severe cases. A multivariate logistic regression model was established to evaluate the relationships between COVID-19 severity and demographic characteristics, comorbidities, medication use, and laboratory findings.

RESULTS

The PLR, NLR, and SII were significantly greater in the severe COVID-19 group than in the nonsevere group (all P < 0.05). In addition to classical independent clinical risk factors, increases in the PLR (OR: 1.004, 95 % CI: 1.001∼1.007, p = 0.001), NLR (OR: 1.180, 95 % CI: 1.041∼1.337, p = 0.010), and SII (OR: 0.999, 95 % CI: 0.998∼1.000, p = 0.005) were identified as risk factors for severe COVID-19 in patients with autoimmune diseases. After adjusting for clinical risk factors, the PLR (AUC: 0.592 vs. 0.865; P < 0.05), NLR (AUC: 0.670 vs. 0.866; P < 0.05), and SII (AUC: 0.616 vs. 0.864; P < 0.05) demonstrated higher predictive values.

CONCLUSION

Early prediction of severe COVID-19 in patients with autoimmune diseases can be achieved using the NLR, PLR, and SII.

Increased Erythrocyte Sedimentation Rate in Dogs: Frequency in Routine Clinical Practice and Association with Hematological Changes

(1) Background: the erythrocyte sedimentation rate (ESR) has been reported to increase in some infectious or inflammatory diseases in dogs, but no information on the frequency of increases in a routine clinical setting exists. The aim of this study was to assess the frequency of an increased ESR in dogs and to investigate its possible association with hematologic changes; (2) Methods: A total of 295 EDTA blood samples were randomly selected from the routine caseload of the Veterinary Teaching Hospital. Samples were grouped in controls and in pathologic groups based on the clinical presentation. A routine hemogram was performed, then the ESR was measured using the instrument MINI-PET; (3) Results: compared with controls, the ESR was significantly higher in all the pathologic groups, except for the hematological disorders group. The highest ESR was found in samples from dogs with chronic kidney disease or inflammation, followed by those from dogs with mild chronic disorders, severe/acute diseases, tumors and urinary disorders. The ESR negatively correlated with hematocrit and positively with neutrophil counts. (4) Conclusions: The ESR increases more frequently in dogs with clinically evident inflammation or CKD, but also in several other conditions, likely as a consequence of anemia and acute phase response.

Back to the Basics of SARS-CoV-2 Biochemistry: Microvascular Occlusive Glycan Bindings Govern Its Morbidities and Inform Therapeutic Responses

Consistent with the biochemistry of coronaviruses as well established over decades, SARS-CoV-2 makes its initial attachment to host cells through the binding of its spike protein (SP) to sialylated glycans (containing the monosaccharide sialic acid) on the cell surface. The virus can then slide over and enter via ACE2. SARS-CoV-2 SP attaches particularly tightly to the trillions of red blood cells (RBCs), platelets and endothelial cells in the human body, each cell very densely coated with sialic acid surface molecules but having no ACE2 or minimal ACE2. These interlaced attachments trigger the blood cell aggregation, microvascular occlusion and vascular damage that underlie the hypoxia, blood clotting and related morbidities of severe COVID-19. Notably, the two human betacoronaviruses that express a sialic acid-cleaving enzyme are benign, while the other three-SARS, SARS-CoV-2 and MERS-are virulent. RBC aggregation experimentally induced in several animal species using an injected polysaccharide caused most of the same morbidities of severe COVID-19. This glycan biochemistry is key to disentangling controversies that have arisen over the efficacy of certain generic COVID-19 treatment agents and the safety of SP-based COVID-19 vaccines. More broadly, disregard for the active physiological role of RBCs yields unreliable or erroneous reporting of pharmacokinetic parameters as routinely obtained for most drugs and other bioactive agents using detection in plasma, with whole-blood levels being up to 30-fold higher. Appreciation of the active role of RBCs can elucidate the microvascular underpinnings of other health conditions, including cardiovascular disease, and therapeutic opportunities to address them.

An Overview of the Impact of Bacterial Infections and the Associated Mortality Predictors in Patients with COVID-19 Admitted to a Tertiary Center from Eastern Europe

1.

BACKGROUND

Literature data on bacterial infections and their impact on the mortality rates of COVID-19 patients from Romania are scarce, while worldwide reports are contrasting. 2.

MATERIALS AND METHODS

We conducted a unicentric retrospective observational study that included 280 patients with SARS-CoV-2 infection, on whom we performed various microbiological determinations. Based on the administration or not of the antibiotic treatment, we divided the patients into two groups. First, we sought to investigate the rates and predictors of bacterial infections, the causative microbial strains, and the prescribed antibiotic treatment. Secondly, the study aimed to identify the risk factors associated with in-hospital death and evaluate the biomarkers' performance for predicting short-term mortality. 3.

RESULTS

Bacterial co-infections or secondary infections were confirmed in 23 (8.2%) patients. Acinetobacter baumannii was the pathogen responsible for most of the confirmed bacterial infections. Almost three quarters of the patients (72.8%) received empiric antibiotic therapy. Multivariate logistic regression has shown leukocytosis and intensive care unit admission as risk factors for bacterial infections and C-reactive protein, together with the length of hospital stay, as mortality predictors. The ROC curves revealed an acceptable performance for the erythrocyte sedimentation rate (AUC: 0.781), and C-reactive protein (AUC: 0.797), but a poor performance for fibrinogen (AUC: 0.664) in predicting fatal events. 4.

CONCLUSIONS

This study highlighted the somewhat paradoxical association of a low rate of confirmed infections with a high rate of empiric antibiotic therapy. A thorough assessment of the risk factors for bacterial infections, in addition to the acknowledgment of various mortality predictors, is crucial for identifying high-risk patients, thus allowing a timely therapeutic intervention, with a direct impact on improving patients' prognosis.

COVID-19 Infections and Inflammatory Markers in Patients Hospitalized During the First Year of the Pandemic

BACKGROUND

The clinical presentations in patients with SARS-CoV-2 (COVID-19) infections range from asymptomatic upper respiratory infections to acute respiratory failure with bilateral pulmonary infiltrates requiring mechanical ventilation. Clinicians often measured inflammatory markers in hospitalized patients to characterize the severity of the infection. Multiple studies published in 2020 reported information on the frequency of elevated inflammatory markers in hospitalized patients in various categories of disease severity.

METHODS

The PubMed database was searched using the terms "Inflammatory markers in COVID-19 patients" and "Clinical features of patients infected with COVID-19." Thirty-three publications were analyzed in detail to determine which inflammatory markers were increased and the frequency of these increases in various clinical classifications, including patients requiring hospitalization, patients with pneumonia, patients with severe infection, patients requiring intensive care unit admission, and patients who died.

RESULTS

C-reactive protein (CRP) was the most frequently elevated inflammatory marker in all categories. Ferritin, D-dimer, and erythrocyte sedimentation rate levels were also frequently elevated. In general, frequencies were higher in patients with more severe infections. For example, 24 out of 24 patients who died had an elevated CRP level.

CONCLUSION

This review provides concrete information about the frequency of various inflammatory markers in patients with COVID-19 infection who required hospitalization. It also provides us some insight into the approach clinicians took in the early phase of this pandemic in their efforts to characterize these patients and perhaps understand the disease process better. However, these results might suggest that clinicians and laboratory directors should develop protocols to optimize laboratory testing.

SARS-CoV-2 intra-host single-nucleotide variants associated with disease severity

Variants of severe acute respiratory syndrome coronavirus 2 frequently arise within infected individuals. Here, we explored the level and pattern of intra-host viral diversity in association with disease severity. Then, we analyzed information underlying these nucleotide changes to infer the impetus including mutational signatures and immune selection from neutralizing antibody or T-cell recognition. From 23 January to 31 March 2020, a set of cross-sectional samples were collected from individuals with homogeneous founder virus regardless of disease severity. Intra-host single-nucleotide variants (iSNVs) were enumerated using deep sequencing. Human leukocyte antigen (HLA) alleles were genotyped by Sanger sequencing. Medical records were collected and reviewed by attending physicians. A total of 836 iSNVs (3-106 per sample) were identified and distributed in a highly individualized pattern. The number of iSNVs paced with infection duration peaked within days and declined thereafter. These iSNVs did not stochastically arise due to a strong bias toward C > U/G > A and U > C/A > G substitutions in reciprocal proportion with escalating disease severity. Eight nonsynonymous iSNVs in the receptor-binding domain could escape from neutralization, and eighteen iSNVs were significantly associated with specific HLA alleles. The level and pattern of iSNVs reflect the in vivo viral-host interaction and the disease pathogenesis.

What hematological and endocrinal indicators are important in COVID-19 infection?

Background: Clinical evidence of endocrine involvement in coronavirus disease needs further investigation. The aim of the present study was to assess the relationship between hematology and endocrine parameters in coronavirus disease 2019 (COVID-19) infection. Methods: In the present cross-sectional study, a total of 320 patients (215 survivors and 105 non-survivors) with confirmed COVID-19 infection were enrolled. After isolation of serum samples, hematological, biochemical, and hormonal parameters were analyzed. Results: The mean age of survivors and non-survivors was 58.92 (SD: 15.28) and 63.65 (SD: 16.62) years, respectively. The results demonstrated significant differences in free triiodothyronine (FT3) [MD (95% CI): 0.40 (0.10, 0.71), P=0.009], total calcium [MD (95% CI): 0.53 (0.21, 0.86), P=0.003], vitamin D [MD (95% CI): 7.72 (6.38, 9.05), P=0.003], erythrocyte sedimentation rate (ESR) [MD (95% CI): 17.09 (9.38, 22.05), P=0.004) and serum ferritin [Median difference: -1091.9, P<0.001), between survivors and non-survivors, respectively. Conclusion: The results revealed that some hematological and endocrine factors play an important role in prognosis of COVID-19 infection. However, further studies with a larger population are required to clarify the exact effects of COVID-19 on the endocrine system.

Contribution of Erythrocyte Sedimentation Rate to Predict Disease Severity and Outcome in COVID-19 Patients

Aim

The use of erythrocyte sedimentation rate (ESR) in coronavirus disease 2019 (COVID-19) to determine disease severity and prognosis is limited. This study aimed to interrogate the diagnostic and prognostic role of ESR compared to other acute-phase reactants.

Method

This retrospective cross-sectional study included 493 confirmed and hospitalized adult COVID-19 patients. Pneumonia, radiological severity, oxygen, intensive care requirements, mortality, ESR, and other acute-phase reactant values were recorded. Logistic regression and ROC analysis identified the effect of ESR on mortality and the sensitivity and specificity of the optimal cutoff values of ESR for the prediction of pneumonia, intensive care needs, and mortality and compared these with values for CRP.

Results

Of patients, 346 (70.2%) had pneumonia, 98 (19.9%) required intensive care, 183 (37.1%) required oxygen support, and 62 (12.6%) died. ESR data were obtained for 278 patients. Among patients, 80.2% had ESR above 20 mm/h, with a median value of 53 (interquartile range: 49). ESR was higher among those with pneumonia (p < 0.001), requiring oxygen (p < 0.001), and requiring intensive care (p=0.003) compared to those without these, and in exitus patients (p=0.043) compared to survivors. Logistic regression analysis identified that ESR did not impact mortality. ROC analysis found the AUC, cutoff, sensitivity, and specificity results of ESR for pneumonia were 0.827, 37 mm/h, 77%, and 78%; for intensive care were 0.625, 50 mm/h, 74%, and 52; and for mortality were 0.606, 51 mm/h, 71%, and 49%, respectively. However, ROC analysis values for CRP were superior to ESR for all these categories.

Conclusion

ESR increased in COVID-19 patients in the presence of pneumonia and severe disease; however, it was not prognostic. Sensitivity and specificity values for pneumonia, intensive care requirements, and mortality were lower than those for CRP.

COVID-19 and Inflammatory Markers

Coronavirus disease-2019 (COVID-19) causes mild illness to serious infection with lung involvement, thrombosis, and other complications potentially resulting in fatal outcomes. Recognised inflammatory biomarkers play important roles in managing patients with COVID-19; for example, diagnosis, follow-up, assessment of treatment response, and risk stratification. Inflammatory markers in COVID-19 disease were analysed in two categories. Well-known inflammatory markers include complete blood count, C-reactive protein, albumin, cytokines, and erythrocyte sedimentation rate. Asymmetric dimethylarginine, endocan, pentraxin 3, serum amyloid A, soluble urokinase plasminogen activator receptor, total oxidant status and total antioxidant status, and galectin-3 are considered among the emerging inflammatory markers. This brief narrative review assesses the relationship between these inflammatory markers and COVID-19 infection.

Higher Intake of Dietary Magnesium Is Inversely Associated With COVID-19 Severity and Symptoms in Hospitalized Patients: A Cross-Sectional Study

Background and Aims

Magnesium is an anti-inflammatory mineral that plays a role in the innate immune system, and the relaxation of bronchial smooth muscle warrants additional attention in COVID-19. This study examined the association between magnesium intake and COVID-19 severity and related symptoms in hospitalized patients.

Methods

A cross-sectional study was done enrolling 250 COVID-19 patients aged 18 to 65 years. A validated 168-item online food frequency questionnaire (FFQ) was used to assess dietary magnesium intake. COVID-19 Treatment Guidelines were used to determine COVID-19 severity, and symptoms were evaluated using a standard questionnaire. Crude and adjusted analyses were performed (Model 1: age, sex, and energy intake; Model 2: Model 1 + physical activity, supplements, corticosteroids, and antiviral drugs; Model 3: Model 2 + body mass index).

Results

The mean age of participants was 44.1 ± 12.1 years, and 46% of them had severe COVID-19. Patients at the highest tertile of dietary magnesium intake had lower serum levels of inflammatory biomarkers, including CRP (11.8 ± 2.2 vs. 29.5 ± 2.1 mg/L, p < 0.001) and ESR (15.8 ± 2.4 vs. 34.7 ± 2.4 mm/hr, p < 0.001), than those at the lowest tertile. After controlling for potential confounders, we observed that a higher dietary magnesium intake was associated with a lower odds of severe COVID-19 (OR: 0.32; 95% CI: 0.15–0.70). Also, we found a significant inverse association between dietary magnesium intake and odds of COVID-19 symptoms.

Conclusion

We found that higher intake of dietary magnesium was inversely associated with COVID-19 severity and symptoms.

The VES-Matic 5 system: performance of a novel instrument for measuring erythrocyte sedimentation rate

OBJECTIVES

The VES-Matic 5 is an automated analyzer that assesses erythrocyte sedimentation rate based on a modified Westergren sedimentation technique. Instrument performance was established by addressing the recommendations of the International Council for Standardization in Haematology.

METHODS

Comparison against the reference Westergren method was performed for all samples, and further for the low, middle, and upper third of the analytical range. Intra-run precision, inter-run precision, and interference studies were further assessed. This study included the evaluation of reference ranges.

RESULTS

The comparison of methods by Passing-Bablok analysis has shown a good agreement without systematic or proportional differences. The regression equation was y=-0.646 + 0.979x. The mean bias of -0.542 was obtained by Bland-Altman analysis and the upper limit of 8.03 with the lower limit of -9.11 can be considered clinically acceptable. Intra-run and inter-run precision were good for each parameter and interference studies did not show any significant bias with exception of anemia samples, which showed a proportional difference when comparing high erythrocyte sedimentation rate values. Using the local adult reference population, we verified the reference ranges in comparison to those available in the literature, and according to the Clinical Laboratory Standards Institute (CLSI) EP28-A3C document. We determined the upper limit partitioned by gender and the following age groups: from 18 to 50, from 50 to 70, and over 70.

CONCLUSIONS

The VES-Matic 5 analyzer presented good comparability with the reference method. As there are commercial quality control and suitable external quality assessment (EQA) material and programs, the VES-Matic 5 can be employed appropriately for routine purposes.

[Biological activity of interferons in the novel coronavirus infection COVID-19]

INTRODUCTION

The immunopathogenesis of the novel coronavirus infection COVID-19 is usually associated with the development of imbalance in the immune response to its causative agent, SARS-CoV-2 virus (Coronaviridae: Coronavirinae: Betacoronavirus: Sarbecovirus). This is manifested, in particular, by interferons' (IFNs) deficiency at the beginning of the disease followed by hyperproduction of pro-inflammatory cytokines. The virus causes a decrease in IFN types I (α/β) and III (λ) levels; changes in IFN type II (γ) are less studied. In this regard, it is relevant to assess the functional bioactive IFN (interferon status) in COVID-19. The aim of the study was to assess the antiviral potential of the body by testing the biologically active IFNs in COVID-19.

MATERIAL AND METHODS

We used biological serum samples of COVID-19 patients taken in the acute phase (110 patients on the 1-5 days of the disease) and during rehabilitation (47 patients during 1-3 months after the disease onset). Assessment of interferon status was performed according to the technique developed by the authors and described earlier.

RESULTS

The IFN status of patients with COVID-19 in the acute period and in the phase of post-infection rehabilitation was studied вduring the observation period. It was found that SARS-CoV-2 causes a pronounced inhibition of biological activity of IFN types I and II compared to the reference values by more than 20 and 7 times, respectively. During the post-COVID period, incomplete recovery of the IFN system activity was registered, which proceeded very slowly. No cases of reaching physiological indicators of interferon status were identified during the observation period.

CONCLUSION

The obtained data on deficiency of the functional biologically active IFN confirm the hypothesis about the predominant role of impaired IFN production of different types in the immunopathogenesis of the novel coronavirus infection.

Epidemiological, Radiographical, and Laboratorial Characteristics of Chinese Asymptomatic Cases With COVID-19: A Systematic Review and Meta-Analysis

The comprehensive understanding of the characteristics of asymptomatic cases are helpful for the identification and management of patients with asymptomatic COVID-19 infection. Four electronic databases were searched from December 1, 2019 to February 8, 2022 for relevant articles. Data synthesis, subgroup analysis, and sensitivity analysis were performed on the included studies. I² and Q tests were applied to evaluate heterogeneity across studies. The risk of publication bias was assessed and visualized using a funnel plot. A total of 45 studies consisting of 2,655 patients with no symptoms at the screening point were included. Pooled results showed that in China, 65% of initial no-symptoms COVID-19 patients did not present any COVID-19-related symptom during follow-up or by end of disease course (asymptomatic infections). High proportions of initial no-symptoms COVID-19 patients (76%) and patients with asymptomatic infection (55%) had abnormal CT features at the screening point. High proportion of patients with asymptomatic infection had been detected Ig G⁺ (72%) and/or Ig M⁺ (57%) at the screening point. The chest CT scan and SARS-CoV-2-specific antibody testing could serve as effective supplementary methods to identify asymptomatic cases in the early stage of SARS-CoV-2 infection. However, the chest CT scan and the SARS-CoV-2-specific IgM and IgG testing should not replace reverse transcription–polymerase chain reaction (RT-PCR) for screening in asymptomatic patients. The combination of repeated RT-PCR, chest CT scans, and the SARS-CoV-2-specific IgM and IgG testing should be performed for those highly suspected SARS-CoV-2 infections.

Erythrocyte sedimentation: Effect of aggregation energy on gel structure during collapse

The erythrocyte (or red blood cell) sedimentation rate (ESR) is commonly interpreted as a measure of cell aggregation and as a biomarker of inflammation. It is well known that an increase of fibrinogen concentration, an aggregation-inducing protein for erythrocytes, leads to an increase of the sedimentation rate of erythrocytes, which is generally explained through the formation and faster settling of large disjoint aggregates. However, many aspects of erythrocyte sedimentation conform well with the collapse of a particle gel rather than with the sedimentation of disjoint aggregates. Using experiments and cell-level numerical simulations, we systematically investigate the dependence of ESR on fibrinogen concentration and its relation to the microstructure of the gel-like erythrocyte suspension. We show that for physiological aggregation interactions, an increase in the attraction strength between cells results in a cell network with larger void spaces. This geometrical change in the network structure occurs due to anisotropic shape and deformability of erythrocytes and leads to an increased gel permeability and faster sedimentation. Our results provide a comprehensive relation between the ESR and the cell-level structure of erythrocyte suspensions and support the gel hypothesis in the interpretation of blood sedimentation.

Hematological changes associated with COVID-19 infection

BACKGROUND

The unresolved COVID-19 pandemic considerably impacts the health services in Iraq and worldwide. Consecutive waves of mutated virus increased virus spread and further constrained health systems. Although molecular identification of the virus by polymerase chain reaction is the only recommended method in diagnosing COVID-19 infection, radiological, biochemical, and hematological studies are substantially important in risk stratification, patient follow-up, and outcome prediction.

AIM

This narrative review summarized the hematological changes including the blood indices, coagulative indicators, and other associated biochemical laboratory markers in different stages of COVID-19 infection, highlighting the diagnostic and prognostic significance.

METHODS

Literature search was conducted for multiple combinations of different hematological tests and manifestations with novel COVID-19 using the following key words: "hematological," "complete blood count," "lymphopenia," "blood indices," "markers" "platelet" OR "thrombocytopenia" AND "COVID-19," "coronavirus2019," "2019-nCoV," OR "SARS-CoV-2." Articles written in the English language and conducted on human samples between December 2019 and January 2021 were included.

RESULTS

Hematological changes are not reported in asymptomatic or presymptomatic COVID-19 patients. In nonsevere cases, hematological changes are subtle, included mainly lymphocytopenia (80.4%). In severe, critically ill patients and those with cytokine storm, neutrophilia, lymphocytopenia, elevated D-dimer, prolonged PT, and reduced fibrinogen are predictors of disease progression and adverse outcome.

CONCLUSION

Monitoring hematological changes in patients with COVID-19 can predict patients needing additional care and stratify the risk for severe course of the disease. More studies are required in Iraq to reflect the hematological changes in COVID-19 as compared to global data.

Association between serum inflammatory parameters and the disease severity in COVID-19 patients

Objective

Most patients infected with the novel coronavirus (SARS‐CoV‐2), as the causative agent of COVID‐19 disease, show mild symptoms, but some of them develop severe illness. The purpose of this study was to analyze the blood markers of COVID‐19 patients and to investigate the correlation between serum inflammatory cytokines and the disease severity.

Methods

In this prospective cross‐sectional study, 50 patients with COVID‐19 and 20 patients without COVID‐19 were enrolled. According to ICU admission criteria, patients were divided into two groups of non‐severe and severe. Differences in the serum levels of C‐reactive protein (CRP), IL‐6, and TNF‐α, as well as erythrocyte sedimentation rate (ESR), lymphocytes (LYM) count, and neutrophils (NEU) count between the two groups were determined and analyzed.

Results

Out of the 50 patients with COVID‐19, 14 were diagnosed as severe cases. There was no significant difference between the two groups of COVID‐19 patients in terms of gender and age. Blood tests of COVID‐19 patients showed a significant decrease and increase in NEU and LYM counts, respectively. There were significant differences in the serum levels of IL‐6, TNF‐α, and CRP between the severe and non‐severe groups, which were higher in the severe group.

Also, there was a significant correlation between the disease severity and CRP with ESR (r = 0.79), CRP with IL‐6 (r = 0.74), LYM with NEU (r = −0.97), and ESR with TNF‐α (r = 0.7).

Conclusion

The findings of this study, as the first study in Iran, suggest that the levels of IL‐6, TNF‐α, ESR, and CRP could be used to predict the severity of COVID‐19 disease.

Prognostic Value of Immune-Inflammatory Index in PSI IV-V Patients with COVID-19

Objective

Respiratory failure is the leading cause of mortality in COVID-19 patients, characterized by a generalized disbalance of inflammation. The aim of this study was to investigate the relationship between immune-inflammatory index and mortality in PSI IV-V patients with COVID-19.

Methods

We retrospectively reviewed the medical records of COVID-19 patients from Feb. to Apr. 2020 in the Zhongfa Xincheng Branch of Tongji Hospital, Wuhan, China. Patients who presented high severity of COVID-19-related pneumonia were enrolled for further analysis according to the Pneumonia Severity Index (PSI) tool.

Results

A total of 101 patients diagnosed with COVID-19 were identified at initial research. The survival analysis revealed that mortality of the PSI IV-V cohort was significantly higher than the PSI I-III group (p = 0.0003). The overall mortality in PSI IV-V patients was 32.1% (9/28). The fatal cases of the PSI IV-V group had a higher level of procalcitonin (p = 0.022) and neutrophil-to-lymphocyte ratio (p = 0.033) compared with the survivors. Procalcitonin was the most sensitive predictor of mortality for the severe COVID-19 population with area under receiver operating characteristic curve of 0.78, higher than the neutrophil-to-lymphocyte ratio (0.75) and total lymphocyte (0.68) and neutrophil (0.67) counts.

Conclusion

Procalcitonin and neutrophil-to-lymphocyte ratio may potentially be effective predictors for mortality in PSI IV-V patients with COVID-19. Increased procalcitonin and neutrophil-to-lymphocyte ratio were associated with greater risk of mortality.

The dynamics of inflammatory markers in coronavirus disease-2019 (COVID-19) patients: A systematic review and meta-analysis

BACKGROUND

Coronavirus disease-2019 (COVID-19) is a global pandemic and high mortality rate among severe or critical COVID-19 is linked with SARS-CoV-2 infection-induced hyperinflammation of the innate and adaptive immune systems and the resulting cytokine storm. This paper attempts to conduct a systematic review and meta-analysis of published articles, to evaluate the association of inflammatory parameters with the severity and mortality in COVID-19 patients.

METHODS

A comprehensive systematic literature search of medical electronic databases including Pubmed/Medline, Europe PMC, and Google Scholar was performed for relevant data published from January 1, 2020 to June 26, 2020. Observational studies reporting clear extractable data on inflammatory parameters in laboratory-confirmed COVID-19 patients were included. Screening of articles, data extraction and quality assessment were carried out by two authors independently. Standardized mean difference (SMD)/mean difference (MD/WMD) and 95% confidence intervals (CIs) were calculated using random or fixed-effects models.

RESULTS

A total of 83 studies were included in the meta-analysis. Of which, 54 studies were grouped by severity, 25 studies were grouped by mortality, and 04 studies were grouped by both severity and mortality. Random effect model results demonstrated that patients with severe COVID-19 group had significantly higher levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), interleukin-6 (IL-6), interleukin-10 (IL-10), interleukin-2R (IL-2R), serum amyloid A (SAA) and neutrophil-to-lymphocyte ratio (NLR) compared to those in the non-severe group. Similarly, the fixed-effect model revealed significant higher ferritin level in the severe group when compared with the non-severe group. Furthermore, the random effect model results demonstrated that the non-survivor group had significantly higher levels of CRP, PCT, IL-6, ferritin, and NLR when compared with the survivor group.

CONCLUSION

In conclusion, the measurement of these inflammatory parameters could help the physicians to rapidly identify severe COVID-19 patients, hence facilitating the early initiation of effective treatment.

PROSPERO REGISTRATION NUMBER

CRD42020193169.

Acute triiodothyronine treatment and red blood cell sedimentation rate (ESR) in critically ill COVID-19 patients: A novel association?

Sepsis and septic shock result in impaired microcirculation and red blood cell rheology which lead to tissue hypoxia and multi-organ failure. Early administration of triiodothyronine prevents tissue hypoxia in experimental sepsis. In this context, a clinical trial was initiated to test the efficacy of acute triiodothyronine administration to combat tissue hypoxia in critically ill COVID19 patients. Here, we provide preliminary data from interim analysis of this study showing a novel acute effect of triiodothyronine on erythrocyte sedimentation rate which may have an important therapeutic impact on red blood cell rheology and tissue hypoxia in sepsis and particular in COVID19 critical illness.Trial registration: ClinicalTrials.gov, NCT04348513. Registered 16 April 2020, https://clinicaltrials.gov/ct2/show/NCT04348513.

Associations of D-Dimer on Admission and Clinical Features of COVID-19 Patients: A Systematic Review, Meta-Analysis, and Meta-Regression

Background

Dynamic D-dimer level is a key biomarker for the severity and mortality of COVID-19 (coronavirus disease 2019). How aberrant fibrinolysis influences the clinical progression of COVID-19 presents a clinicopathological dilemma challenging intensivists.

Methods

We performed meta-analysis and meta regression to analyze the associations of plasma D-dimer with 106 clinical variables to identify a panoramic view of the derangements of fibrinolysis in 14,862 patients of 42 studies. There were no limitations of age, gender, race, and country. Raw data of each group were extracted separately by two investigators. Individual data of case series, median and interquartile range, and ranges of median or mean were converted to SDM (standard deviation of mean).

Findings

The weighted mean difference of D-dimer was 0.97 µg/mL (95% CI 0.65, 1.29) between mild and severe groups, as shown by meta-analysis. Publication bias was significant. Meta-regression identified 58 of 106 clinical variables were associated with plasma D-dimer levels. Of these, 11 readouts were negatively related to the level of plasma D-dimer. Further, age and gender were confounding factors. There were 22 variables independently correlated with the D-dimer level, including respiratory rate, dyspnea plasma K+, glucose, SpO2, BUN (blood urea nitrogen), bilirubin, ALT (alanine aminotransferase), AST (aspartate aminotransferase), systolic blood pressure, and CK (creatine kinase).

Interpretation

These findings support elevated D-dimer as an independent predictor for both mortality and complications. The identified D-dimer-associated clinical variables draw a landscape integrating the aggregate effects of systemically suppressive and pulmonary hyperactive derangements of fibrinolysis, and the D-dimer-associated clinical biomarkers, and conceptually parameters could be combined for risk stratification, potentially for tracking thrombolytic therapy or alternative interventions.

Comparison of Clinical Features and Outcomes of Medically Attended COVID-19 and Influenza Patients in a Defined Population in the 2020 Respiratory Virus Season

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which is causing the coronavirus disease-2019 (COVID-19) pandemic, poses a global health threat. However, it is easy to confuse COVID-19 with seasonal influenza in preliminary clinical diagnosis. In this study, the differences between influenza and COVID-19 in epidemiological features, clinical manifestations, comorbidities and pathogen biology were comprehensively compared and analyzed. SARS-CoV-2 causes a higher proportion of pneumonia (90.67 vs. 17.07%) and acute respiratory distress syndrome (12.00 vs. 0%) than influenza A virus. The proportion of leukopenia for influenza patients was 31.71% compared with 12.00% for COVID-19 patients (P = 0.0096). The creatinine and creatine kinase were significantly elevated when there were COVID-19 patients. The basic reproductive number (R0) for SARS-CoV-2 is 2.38 compared with 1.28 for seasonal influenza A virus. The mutation rate of SARS-CoV-2 ranges from 1.12 × 10-3 to 6.25 × 10-3, while seasonal influenza virus has a lower evolutionary rate (0.60-2.00 × 10-6). Overall, this study compared the clinical features and outcomes of medically attended COVID-19 and influenza patients. In addition, the S477N and N439K mutations on spike may affect the affinity with receptor ACE2. This study will contribute to COVID-19 control and epidemic surveillance in the future.

Myoglobin and C-reactive protein are efficient and reliable early predictors of COVID-19 associated mortality

Since the emergence of SARS-CoV-2, numerous studies have been attempting to determine biomarkers, which could rapidly and efficiently predict COVID-19 severity, however there is lack of consensus on a specific one. This retrospective cohort study is a comprehensive analysis of the initial symptoms, comorbidities and laboratory evaluation of patients, diagnosed with COVID-19 in Huoshenshan Hospital, Wuhan, from 4th February to 12th March, 2020. Based on the data collected from 63 severely ill patients from the onset of symptoms till the full recovery or demise, we found not only age (average 70) but also blood indicators as significant risk factors associated with multiple organ failure. The blood indices of all patients showed hepatic, renal, cardiac and hematopoietic dysfunction with imbalanced coagulatory biomarkers. We noticed that the levels of LDH (85%, P < .001), HBDH (76%, P < .001) and CRP (65%, P < .001) were significantly elevated in deceased patients, indicating hepatic impairment. Similarly, increased CK (15%, P = .002), Cre (37%, P = 0.102) and CysC (74%, P = 0.384) indicated renal damage. Cardiac injury was obvious from the significantly elevated level of Myoglobin (52%, P < .01), Troponin-I (65%, P = 0.273) and BNP (50%, P = .787). SARS-CoV-2 disturbs the hemolymphatic system as WBC# (73%, P = .002) and NEUT# (78%, P < .001) were significantly elevated in deceased patients. Likewise, the level of D-dimer (80%, P < .171), PT (87%, P = .031) and TT (57%, P = .053) was elevated, indicating coagulatory imbalances. We identified myoglobin and CRP as specific risk factors related to mortality and highly correlated to organ failure in COVID-19 disease.

Clinical longitudinal evaluation of COVID-19 patients and prediction of organ-specific recovery using artificial intelligence

Within COVID-19 there is an urgent unmet need to predict at the time of hospital admission which COVID-19 patients will recover from the disease, and how fast they recover to deliver personalized treatments and to properly allocate hospital resources so that healthcare systems do not become overwhelmed. To this end, we have combined clinically salient CT imaging data synergistically with laboratory testing data in an integrative machine learning model to predict organ-specific recovery of patients from COVID-19. We trained and validated our model in 285 patients on each separate major organ system impacted by COVID-19 including the renal, pulmonary, immune, cardiac, and hepatic systems. To greatly enhance the speed and utility of our model, we applied an artificial intelligence method to segment and classify regions on CT imaging, from which interpretable data could be directly fed into the predictive machine learning model for overall recovery. Across all organ systems we achieved validation set area under the receiver operator characteristic curve (AUC) values for organ-specific recovery ranging from 0.80 to 0.89, and significant overall recovery prediction in Kaplan-Meier analyses. This demonstrates that the synergistic use of an artificial intelligence (AI) framework applied to CT lung imaging and a machine learning model that integrates laboratory test data with imaging data can accurately predict the overall recovery of COVID-19 patients from baseline characteristics.

Is there a link between pre-existing antibodies acquired due to childhood vaccinations or past infections and COVID-19? A case control study

Background

There is growing evidence indicating that children are less affected from COVID-19. Some authors speculate that childhood vaccinations may provide some cross-protection against COVID-19. In this study, our aim was to compare the circulating antibody titers for multiple childhood vaccine antigens, as an indicator of the state of immune memory between patients with COVID-19 and healthy controls, with a specific aim to identify the association between disease severity and antibody titrations which may indicate a protective function related to vaccine or disease induced memory.

Methods

This study is a case-control study including 53 patients with COVID-19 and 40 healthy volunteers. COVID-19 severity was divided into three groups: asymptomatic, mild and severe. We measured the same set of antibody titers for vaccine antigens, and a set of biochemical and infection markers, in both the case and control groups.

Results

Rubella (p = 0.003), pneumococcus (p = 0.002), and Bordetella pertussis (p < 0.0001) titers were found to be significantly lower in the case group than the control group. There was a significant decline in pneumococcus titers with severity of disease (p = 0.021) and a significant association with disease severity for Bordetella pertussis titers (p = 0.014) among COVID patients. Levels of AST, procalcitonin, ferritin and D-dimer significantly increased with the disease severity.

Discussion

Our study supports the hypothesis that pre-existing immune memory, as monitored using circulating antibodies, acquired from childhood vaccinations, or past infections confer some protection against COVID-19. Randomized controlled studies are needed to support a definitive conclusion.

Biomarkers of acute respiratory distress syndrome in adults hospitalised for severe SARS-CoV-2 infection in Tenerife Island, Spain

OBJECTIVE

The dramatic spread of SARS-CoV-2 infections calls for reliable, inexpensive tools to quickly identify patients with a poor prognosis. In this study, acute respiratory distress syndrome (ARDS) was assessed within 72 h after admission of each of 153 consecutive, SARS-CoV-2 infected, adult patients to either of two hospitals in Tenerife, Spain, using suitable routine laboratory tests for lymphocyte counts, as well as ferritin, lactate dehydrogenase (LDH), and C-reactive protein levels. Results were correlated with the patients' respiratory function, defined through their pulse oximetric saturation/fraction of inspired oxygen (SpO2/FiO2) ratio.

RESULTS

Within 72 h from admission, criteria matched ARDS (SpO2/FiO2 < 235) in 13.1% of cases. We found a significant, negative correlation between SpO2/FiO2 ratios and D-dimer, ferritin, and LDH levels (- 0.31, - 0.32, and - 0.41; p = 0.004, 0.004, and < 0.0001, respectively). In patients with ARDS, the mean LDH was 373 U/L (CI95%: 300.6-445.3), but only 298 U/L (CI95%: 274.7-323.1) when they did not develop the syndrome (p = 0.015). None of the additionally evaluated biomarkers correlated with the SpO2/FiO2 ratios. Serum LDH levels in patients hospitalised for COVID-19 correlate with ARDS, as defined by their SpO2/FiO2 ratio, and might help to predict said complication.

Epidemiologic and Clinical Characteristics of COVID-19 Patients from a Quarantine Center in a Developing Community: A Retrospective Study

Purpose

Coronavirus disease 2019 (COVID-19) is an ongoing infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) agent, and is generally known as novel coronavirus. The impact of the disease has had apparent effects on health, social, and economic levels. This study aimed to investigate the epidemiologic features, clinical presentations, laboratory examination, and outcomes of COVID-19 patients in Jordan.

Patients and Methods

This retrospective study included all COVID-19 patients admitted to the quarantine center at King Abdullah University Hospital in Jordan between March 16 and May 21, 2020. Patient information was abstracted from hospital electronic records and included patient demographics, symptoms, comorbidities, laboratory tests, infection period, and outcome.

Results

Approximately 42% of the quarantined individuals were asymptomatic. The majority of symptomatic patients had mild to moderate symptoms of the disease. Only ten patients (9.3%) had severe symptoms, with one of them progressed to a critical stage and died 15 days after admission. Erythrocyte sedimentation rate (ESR), lactate dehydrogenase (LDH), and D-dimer levels were significantly elevated in many patients. More than two-thirds (69.8%) of the symptomatic patients were females. Elevated ESR and LDH levels, along with longer periods of infection, were significantly associated with symptomatic patients.

Conclusion

A large proportion of Jordanian patients were asymptomatic carriers of the virus. This finding emphasizes the importance of a continuous surveillance process to discover these contagious carriers to control the disease spread. Additionally, we suggest that future analyses should investigate for sexual variation in the inflammatory response to this viral infection since most of our symptomatic patients were females. Finally, the role of ESR and LDH biomarkers should be investigated further for the possibility of earlier identification of patients with greater risk.

IFCC Interim Guidelines on Biochemical/Hematological Monitoring of COVID-19 Patients

Routine biochemical and hematological tests have been reported to be useful in the stratification and prognostication of pediatric and adult patients with diagnosed coronavirus disease (COVID-19), correlating with poor outcomes such as the need for mechanical ventilation or intensive care, progression to multisystem organ failure, and/or death. While these tests are already well established in most clinical laboratories, there is still debate regarding their clinical value in the management of COVID-19, particularly in pediatrics, as well as the value of composite clinical risk scores in COVID-19 prognostication. This document by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Task Force on COVID-19 provides interim guidance on: (A) clinical indications for testing, (B) recommendations for test selection and interpretation, (C) considerations in test interpretation, and (D) current limitations of biochemical/hematological monitoring of COVID-19 patients. These evidence-based recommendations will provide practical guidance to clinical laboratories worldwide, underscoring the contribution of biochemical and hematological testing to our collective pandemic response.

Insufficient hyperfibrinolysis in COVID-19: a systematic review of thrombolysis based on meta-analysis and meta-regression

Background How aberrant fibrinolysis influences the clinical progression of COVID-19 presents a clinicopathological dilemma challenging intensivists. To investigate whether abnormal fibrinolysis is a culprit or protector or both, we associated elevated plasma D-dimer with clinical variables to identify a panoramic view of the derangements of fibrinolysis that contribute to the pathogenesis of COVID-19 based on studies available in the literature. Methods We performed this systematic review based on both meta-analysis and meta-regression to compute the correlation of D-dimer at admission with clinical features of COVID-19 patients in retrospective studies or case series. We searched the databases until Aug 18, 2020, with no limitations by language. The first hits were screened, data extracted, and analyzed in duplicate. We did the random-effects meta-analyses and meta-regressions (both univariate and multivariate). D-dimer associated clinical variables and potential mechanisms were schematically reasoned and graphed. Findings Our search identified 42 observational, or retrospective, or case series from six countries (n=14,862 patients) with all races and ages from 1 to 98-year-old. The weighted mean difference of D-dimer was 0.97 μg/mL (95% CI 0.65, 1.29) between relatively mild (or healthy control) and severely affected groups with significant publication bias. Univariate meta-regression identified 58 of 106 clinical variables were associated with plasma D-dimer levels, including 3 demographics, 5 comorbidies, 22 laboratory tests, 18 organ injury biomarkers, 8 severe complications, and 2 outcomes (discharge and death). Of these, 11 readouts were negatively associated with the level of plasma D-dimer. Further, age and gender were confounding factors for the identified D-dimer associated variables. There were 22 variables independently correlated with the D-dimer level, including respiratory rate, dyspnea plasma K+, glucose, SpO2, BUN, bilirubin, ALT, AST, systolic blood pressure, and CK. We thus propose that "insufficient hyperfibrinolysis (fibrinolysis is accelerated but unable to prevent adverse clinical impact for clinical deterioration COVID-19)" as a peculiar mechanism. Interpretation The findings of this meta-analysis- and meta-regression-based systematic review supports elevated D-dimer as an independent predictor for mortality and severe complications. D-dimer-associated clinical variables draw a landscape integrating the aggregate effects of systemically suppressive and locally (i.e., in the lung) hyperactive derangements of fibrinolysis. D-dimer and associated clinical biomarkers and conceptually parameters could be combined for risk stratification, potentially for tracking thrombolytic therapy or alternative interventions.

A Telemedicine Approach to Covid-19 Assessment and Triage

Covid-19 is a new highly contagious RNA viral disease that has caused a global pandemic. Human-to-human transmission occurs primarily through oral and nasal droplets and possibly through the airborne route. The disease may be asymptomatic or the course may be mild with upper respiratory symptoms, moderate with non-life-threatening pneumonia, or severe with pneumonia and acute respiratory distress syndrome. The severe form is associated with significant morbidity and mortality. While patients who are unstable and in acute distress need immediate in-person attention, many patients can be evaluated at home by telemedicine or videoconferencing. The more benign manifestations of Covid-19 may be managed from home to maintain quarantine, thus avoiding spread to other patients and health care workers. This document provides an overview of the clinical presentation of Covid-19, emphasizing telemedicine strategies for assessment and triage of patients. Advantages of the virtual visit during this time of social distancing are highlighted.

Coronavirus Disease 2019 (COVID-19): A Short Review on Hematological Manifestations

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a rapidly spreading and devastating global pandemic. Many researchers are attempting to clarify the mechanisms of infection and to develop a drug or vaccine against the virus, but there are still no proven effective treatments. The present article reviews the common presenting hematological manifestations of coronavirus disease 2019 (COVID-19). Elucidating the changes in hematological parameters in SARS-CoV-2 infected patients could help to understand the pathophysiology of the disease and may provide early clues to diagnosis. Several studies have shown that hematological parameters are markers of disease severity and suggest that they mediate disease progression.

Lactate dehydrogenase and C-reactive protein as predictors of respiratory failure in CoVID-19 patients

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COVID19 patients can develop severe acute respiratory distress syndrome (ARDS).

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ARDS is a fatal complication and the most common cause of death in COVID19 patients.

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Early detection of acute respiratory failure is mandatory to promplty identify critically ill COVID19 patients.

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Elevated LDH and CRP serum concentrations are associated to respiratory failure in CoVID-19 patients.

Objective

The dramatic worldwide CoVID-19 infection requires the identification of a reliable and inexpensive tool to quickly discriminate patients with a more unfavorable outcome.

Methods

We performed routine laboratory tests suitable to identify tissue damage and inflammatory status in 123 consecutive CoVID-19 patients admitted to the Emergency Department of the hospital of Piacenza (Emilia-Romagna, Northern Italy). The results were correlated with patients’ respiratory function evaluated by the partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2).

Results

The most common laboratory abnormalities were lymphocytopenia and elevated values of C-reactive protein (CRP) and lactate dehydrogenase (LDH). Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK) were also increased. The respiratory performance (PaO2/FiO2) showed a strong inverse correlation with LDH (r = 0.62, r² 0.38, p value < 0.0001) and CRP (r = 0.55, r² 0.31, p value < 0.0001). PaO2/FiO2 values also showed a significant inverse correlation with age (r = −0.37, p < 0.0001), AST (r = −0.31, p < 0.01), WBC (r = −0.49, p < 0.0001), neutrophils count (r = −0.5, p < 0.001). ROC curves showed a sensitivity of 75% and specificity of 70% for the LDH cut-off value of 450 U/L and a sensitivity of 72% and specificity of 71% for the CRP cut-off value of 11 mg/dl in identifying CoVID-19 with moderate-severe ARDS.

Conclusions

LDH and CRP may be related to respiratory function (PaO2/FiO2) and be a predictor of respiratory failure in CoVID-19 patients. LDH and CRP should be considered a useful test for the early identification of patients who require closer respiratory monitoring and more aggressive supportive therapies to avoid poor prognosis.