ABSTRACT
Background : Hospitalized COVID-19 patients often show a hypercoagulable profile, mainly elevated fibrinogen and D-dimer, associated with worse outcomes in terms of ICU admission, thrombotic events and mortality. Increased clot stiffness on whole blood viscoelastic testing (VET) is another hypercoagulable profile observed in COVID-19 patients. Sonic Estimation of Elasticity by Resonance (SEER) sonorheometry (Quantra ® system) is a novel ultrasound based VET technology. Aims : To characterize the hemostatic status of COVID-19 patients with standard and viscoelastic testings and its association with disease severity. Methods : Blood samples from adult COVID-19 patients at hospital admission were analyzed with a panel of tests including markers of inflammation, coagulation and Quantra VET parameters. Fisher ' s exact test was used to statistically compare the moderate and severe/ critical disease groups. Results : The cohort of 37 patients showed a mean age (SD) of 59.6 (16) years, with 23 of them in the moderate disease group and 14 in the severe/critical disease group. Markers of inflammation were elevated in 44-84% of patients, while of coagulation tests, only fibrinogen (79%) and D-dimer (60%) levels were elevated. Clot stiffness (CS), as well as the contribution of platelets (PCS) and fibrinogen (FCS) measured by Quantra, were also above normal values at 64.3, 50 and 78.6%, respectively. These parameters were the only ones significantly associated with the severe/critical disease group (Table 1), where most of the adverse outcome were observed. According to this result, the median of these parameters was significantly different between the two groups ( P = 0.011/0.029/0.008). TABLE 1 Parameters of coagulation in COVID-19 patients at hospital admission: proportion (%) above the upper limit of normal (ULN). Test ULN All (%) Moderate (%) Severe/Critical (%) P value Platelet count (×10 3 /μL) 450 1/37 (2.7) 0/23 (0.0) 1/14 (7.1) 0.378 Fibrinogen (mg/dL) 400 27/34 (79.4) 14/20 (70.0) 13/14 (92.9) 0.198 D-dimer (μg/L) 500 22/37 (59.5) 12/23 (52.2) 10/14 (71.4) 0.314 CT (s) 164 1/37 (2.7) 1/23 (4.3) 0/14 (0.0) 1.000 CSL (%) 99 8/26 (30.8) 2/13 (15.4) 6/13 (46.2) 0.202 CS (hPa) 33.2 12/37 (32.4) 3/23 (13.0) 9/14 (64.3) 0.003 PCS (hPa) 29.8 9/36 (25.0) 2/22 (9.1) 7/14 (50.0) 0.014 FCS (hPa) 3.7 21/37 (56.8) 10/23 (43.5) 11/14 (78.6) 0.048 Conclusions : The study of global hemostatic status using Quantra can be a powerful tool for the analysis of COVID-19 patients at admission, helping in risk stratification and triage decisions of patients. This profile, characterized by incresased clot stiffness from both platelet and fibrinogen contribution, was most prevalent in patients with severe/critical disease, and could therefore be established as a new prognostic marker.
ABSTRACT
Background: COVID-19 is a severe respiratory disease caused by the SARS-CoV-2 that manifests severely in a high number of patients, leading to hospitalization of many of them and in the worst case to death. Recent studies have shown a high incidence of thrombotic complications in these patients, especially in those with poor prognosis, and confer special interest to D-dimer as an indicator of poor prognosis. However, the diagnostic value of D-dimer is limited by the long analysis times and that it only reflects the final part of the physiological process of hemostasis. Therefore, the identification of other parameters is needed to allow a rapid and reliable characterization of the hemostatic status of the patient. Viscoelastic testing allows a global analysis of coagulation and have already proven their usefulness in the study of other infectious diseases. The application of viscoelastic tests in COVID-19 patients would therefore be very useful to quickly determine the hemostatic status of patients and thus identify predictors of poor prognosis. Aims: To characterize the hemostatic status of COVID-19 patients with standard and viscoelastic testings, and identification of poor prognosis variables. Methods: Prospective, observational, single-centre study. A total of 50 patients requiring hospitalization were included in the study. The next-generation viscoelastic testing "Quantra Hemostasis Analyzer" (HemoSonics) was used to determine the coagulation profile of patients. Blood samples at the time of hospitalization were taken to determine the parameters reported by Quantra (QStat and QPlus cartridges). Correlation study using a heat map of our Spearman partial correlation matrix with a confidence interval of 95%. Results: As described, a high percentage of COVID-19 patients admitted to hospital showed increased levels of fibrinogen (81.6%), D-dimer (61.9%), IL-6 (70.3%) and increased clot stiffness measured by CS, FCS and PCS parameters (63.6%), while clotting times were normal in almost 100% of patients. Age (>65 years), together with elevated levels of D-dimer, LDH and clot firmness were associated with the presence of an adverse event during admission, including the need for mechanical ventilation, ICU admission or death (p=0.007/0.030/0.010/0.002). Increased D-dimer levels were significantly recurrent in patients >65 years (p=0.031). A significant difference was observed between the median of these parameters between patients who experienced an adverse event and those who did not: fibrinogen (750 vs 532, p=0.010), D-dimer (779 vs 560, p=0.005), LDH (309 vs 227, p=0.027), CTH (131.5 vs 123, p=0.042), CS (38.15 vs 25, p=0.042), PCS (30.85 vs 20.7, p=0.042) and FCS (7.45 vs 3.9, p=0.027). Multiple correlation study using HeatMap representation revealed independence between clot firmness, age, LDH and D-dimer levels. Summary/Conclusion: The study of global hemostatic status using Quantra can be a powerful tool for the analysis of COVID-19 patients at admission and thereby predict risk by identifying markers of poor prognosis. Increased levels of parameters measuring clot stiffness are associated with the presence of an adverse event in patients and can be considered as new independent prognostic markers.
ABSTRACT
BACKGROUND: We aimed to describe the epidemiology, risk factors, and clinical outcomes of co-infections and superinfections in onco-hematological patients with COVID-19. METHODS: International, multicentre cohort study of cancer patients with COVID-19. All patients were included in the analysis of co-infections at diagnosis, while only patients admitted at least 48 h were included in the analysis of superinfections. RESULTS: 684 patients were included (384 with solid tumors and 300 with hematological malignancies). Co-infections and superinfections were documented in 7.8% (54/684) and 19.1% (113/590) of patients, respectively. Lower respiratory tract infections were the most frequent infectious complications, most often caused by Streptococcus pneumoniae and Pseudomonas aeruginosa. Only seven patients developed opportunistic infections. Compared to patients without infectious complications, those with infections had worse outcomes, with high rates of acute respiratory distress syndrome, intensive care unit (ICU) admission, and case-fatality rates. Neutropenia, ICU admission and high levels of C-reactive protein (CRP) were independent risk factors for infections. CONCLUSIONS: Infectious complications in cancer patients with COVID-19 were lower than expected, affecting mainly neutropenic patients with high levels of CRP and/or ICU admission. The rate of opportunistic infections was unexpectedly low. The use of empiric antimicrobials in cancer patients with COVID-19 needs to be optimized.