Interleukin-6 (IL-6) as a Predictor of Clinical Outcomes in Patients with COVID-19.

BACKGROUND: Interleukin-6 (IL-6) has been known to be involved in immune regulation, inflammatory response, and metabolism. It is also recognized as the major cause to underscore the pathology of severe COVID-19 patients. However, it remains to be seen if IL-6 is superior to other inflammatory biomarkers in ascertaining clinical severity and mortality rate for COVID-19. This study aimed to determine the value of IL-6 as a predictor of severity and mortality in COVID-19 patients and compare it with other pro-inflammatory biomarkers in the South Asian region. METHODS: An observational study was conducted, including all adult SARS-CoV-2 patients who had undergone IL-6 testing from December 2020 to June 2021. The patients' medical records were reviewed to collect demographic, clinical, and biochemical data. Other pro-inflammatory biomarkers apart from IL-6 included Neutrophils to Lymphocyte Ratio (NLR), D-dimer, C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procal-citonin for analysis. SPSS version 22.0 was utilized. RESULTS: Out of the 393 patients who underwent IL-6 testing, 203 were included in the final analysis with a mean (SD) age of 61.9 years (12.9) and 70.9% (n = 144) were male. Fifty-six percent (n = 115) subjects had critical disease. IL-6 levels were elevated (> 7 pg/mL) in 160 (78.8%) patients. Levels of IL-6 significantly correlated with age, NLR, D-dimer, CRP, ferritin, LDH, length of stay, clinical severity, and mortality. All the inflammatory markers were significantly increased in critically ill and expired patients (p < 0.05). The receiver operator curve showed that IL-6 had the best area under the curve (0.898) compared to other pro-inflammatory biomarkers for mortality with comparable results for clinical severity. CONCLUSIONS: Study findings show that though IL-6 is an effective marker of inflammation and can be helpful for clinicians in recognizing patients with severe COVID-19. However, we still need further studies with larger sample size.

SARS-CoV-2 induced coagulopathy and potential role of anticoagulation: Scoping review of literature.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can vary on a spectrum of asymptomatic disease to rarer manifestations like hypercoagulability especially among elderly patients admitted in the intensive care unit (ICU) and those with preexisting comorbidities. The exact mechanism behind this phenomenon is still unclear, however studies have shown an association with elevated cytokines and severe inflammatory response which encompasses this disease. Hypercoagulability can be limited to the lungs, or present as systemic manifestations of arterial and venous thrombosis leading to mortal outcomes. Thus, careful evaluation of risk factors should be performed by physicians and treatment with anticoagulants should be modified accordingly. All Coronavirus Disease 2019 (COVID-19) in-patients should receive thromboprophylactic therapy, with increased dosages administered to patients with increased disease severity or those with a high risk. D-dimer levels and sepsis-induced coagulopathy (SIC) score aid in identifying high risk patients and predicting outcome. This article highlights the pathophysiology behind hypercoagulability, its clinical associations and discusses therapeutic modalities to combat this fatal consequence of SARS-CoV-2.

Factors predicting mortality among patients with COVID-19 associated hospital acquired pneumonia: Insights from a tertiary care center.

Hospital acquired pneumonia (HAP) is a severe and dangerous complication in patients admitted with COVID-19, causing significant morbidity and mortality globally. However, the early detection and subsequent management of high-risk cases may prevent disease progression and improve clinical outcomes. This study was undertaken in order to identify predictors of mortality in COVID-19 associated HAP. A retrospective study was performed on all patients who were admitted to a tertiary care center with COVID-19 associated HAP from July 2020 till November 2020. Data was collected on relevant demographic, clinical and laboratory parameters to determine their association with in-hospital mortality. 1574 files were reviewed, out of which 162 were included in the final study. The mean age of subjects was 59.4 ± 13.8 and a majority were male (78.4%). There were 71 (48.3%) mortalities in the study sample. Klebsiella pneumoniae (31.5%) and Pseudomonas aeruginosa (30.2%) were the most common organisms overall. Clinically significant growth of Aspergillus sp. was observed in 41 (29.0%) of patients. On univariate analysis, several factors were found to be associated with mortality, including male gender (p=0.04), D-dimers >1.3mg/L (p<0.001), ferritin >1000ng/mL (p<0.001), LDH >500I.U/mL (p<0.001) and procalcitonin >2.0ng/mL (p<0.001). On multivariate analysis, ferritin >1000ng/mL, initial site of care in Special Care Units or Intensive Care Units, developing respiratory failure and developing acute kidney injury were factors independently associated with mortality in our patient sample. These results indicate that serum ferritin levels may be a potentially useful biomarker in the management of COVID-19 associated HAP.

Association of Chest Xray (CXR) findings with outcomes in COVID-19 Patients.

Objective: To investigate chest radiography findings in suspected coronavirus disease-2019 patients in a tertiary care setting. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of coronavirus disease-2019 cases admitted to the tertiary care centre from March 1 to March 30, 2020. A predesigned proforma was used to gather data, including demographics, like age and gender, co-morbidities, presenting symptoms and chest radiography findings during the admission. Length of stay and mortality were the outcome measures. Data was analysed using SPSS 22. RESULTS: Of the 154 suspected cases, 46(29.8%) tested positive for coronavirus disease-2019; 29(63%) males and 17(37%) females with a mean age of 50.7±19.1 years. Abnormal chest radiography was noted in 25(54.3%) cases, with bilateral pulmonary infiltrates being the most common finding 19(41.3%). Mortality was the outcome in 7(28%) of these cases, and the mean length of hospital stay was 9.3±7.3 days. Abnormal chest radiography findings were associated with an increased risk of mortality (p=0.009) and a longer hospital stay (p=0.017). Conclusion: Abnormal chest radiography findings were frequently seen in coronavirus disease-2019 patients and were also associated with increased risk of mortality and prolonged hospital stay.

Predicting Development Of Critical Illness In Patients With Covid-19 Presenting To A Tertiary Care Hospital In A Developing Country.

BACKGROUND: With the increasing number of COVID-19 patients and limited resources available to accommodate them, there is a need for risk stratification tools to ensure better utilization of resources. METHODS: We conducted a retrospective observational cohort study in patients discharged from the COVID designated areas of a large tertiary care hospital in Karachi, Pakistan from the 1st of May to the 31st of July, 2020. 581 patients were included and the COVID GRAM score was calculated at the time of admission and patients developing critical disease as per COVID GRAM study criteria (need of intensive care unit admission, invasive ventilation or death) after 24 hours of admission were noted. RESULTS: The mean age of the study population was 56.3±14.8 years. Patients that developed critical illness (as per COVID GRAM study criteria) beyond 24 hours after admission had higher COVID GRAM scores at admission versus those that did not (183.2±80.7 versus 130.3±42.6). The Area under the Receiver Operator Curve for the COVID gram score to predict critical illness in the study population was 0.802 (95% confidence interval, 0.753-0.850). On binary logistic multivariable regression analysis, the COVID GRAM and SOFA scores on admission and need of ICU admission during hospitalization were significant predictors of mortality 24 hours after admission. CONCLUSIONS: The COVID GRAM score is a useful risk assessment tool and can be used for appropriate allocation and prioritization of resources where they are most needed.

Correlation Of Computerized Tomography (CT) Severity Score For COVID-19 Pneumonia With Clinical Outcomes.

BACKGROUND: Though various computerized tomography (CT) severity scores have been described for risk prognostication for coronavirus disease 2019 (COVID-19), most are challenging to calculate and have variable inter-observer agreement. The objective of this study was to develop a simple CT severity score (CT-SS) with good inter-observer agreement and assess its correlation with clinical outcome. METHODS: This retrospective study was conducted at the Aga Khan University Hospital (AKUH), from April-August 2020. All patients who were PCR positive for COVID-19 and underwent CT chest examination at AKUH were included. Severity of disease was described on the basis of a 10-point CT severity score (CT-SS) devised at our institution. CT-SS were categorized as Low (0-7) and High (8-10). Inter-observer reliability between radiologist and COVID-19 intensivist was assessed using the Kappa statistic. RESULTS: A total of 73 patients were included, the majority male (58.9%) with mean age 55.8±13.93 years. The CT-SS rated on 0-10 showed substantial inter-observer reliability between radiologist and intensivist with a Kappa statistic of 0.78. Patients with CT-SS 8-10 had a significantly higher ICU admission & intubation rate (53.8% vs. 23.5%) and mortality rate (35.9% vs. 11.8%; p=0.017), as compared to those with CT-SS 0-7. CONCLUSIONS: We conclude that the described CT severity score (CT-SS) is a quick, effective, and easily reproducible tool for prediction of adverse clinical outcome in patients with COVID 19 pneumonia. The tool shows good inter-observer agreement when calculated by radiologist and physician independently.

The association of chest radiographic findings and severity scoring with clinical outcomes in patients with COVID-19 presenting to the emergency department of a tertiary care hospital in Pakistan.

INTRODUCTION: While chest x-rays (CXRs) represent a cost-effective imaging modality for developing countries like Pakistan, their utility for the prognostication of COVID-19 has been minimally explored. Thus, we describe the frequency and distribution of CXR findings, and their association with clinical outcomes of patients with COVID-19. METHODS: All adult (≥ 18 years) patients presenting between 28th February-31st May to the emergency department of a tertiary care hospital in Pakistan, who were COVID-19 positive on RT-PCR with CXR done on presentation, were included. A CXR Severity Score (CXR-SS) of 0-8 was used to quantify the extent of pulmonary infection on CXR, with a score of 0 being negative and 1-8 being positive. The patients' initial CXR-SS and their highest CXR-SS over the hospital course were used for analysis, with cut-offs of 0-4 and 5-8 being used to assess association with clinical outcomes. RESULTS: A total of 150 patients, with 76.7% males and mean age 56.1 years, were included in this study. Initial CXR was positive in 80% of patients, and 30.7% of patients had an initial CXR-SS between 5-8. The mortality rate was 16.7% and 30.6% patients underwent ICU admission with intubation (ICU-Int). On multivariable analysis, initial CXR-SS (1.355 [1.136-1.616]) and highest CXR-SS (1.390 [1.143-1.690]) were predictors of ICU-Int, and ICU-Int was independently associated with both initial CXR-SS 5-8 (2.532 [1.109-5.782]) and highest CXR-SS 5-8 (3.386 [1.405-8.159]). Lastly, age (1.060 [1.009-1.113]), initial CXR-SS (1.278 [1.010-1.617]) and ICU-Int (5.047 [1.731-14.710]), were found to be independent predictors of mortality in our patients. CONCLUSION: In a resource-constrained country like Pakistan, CXRs may have valuable prognostic utility in predicting ICU admission and mortality. Additional research with larger patient samples is needed to further explore the association of CXR findings with clinical outcomes.

Risk factors for intensive care unit admission and mortality in hospitalized COVID-19 patients.

BACKGROUND: This study investigated the clinical features and outcome of hospitalized coronavirus disease 2019 (COVID-19) patients admitted to our quaternary care hospital. METHODS: In this retrospective cohort study, we included all adult patients with COVID-19 infection admitted to a quaternary care hospital in Pakistan from March 1 to April 15, 2020. The extracted variables included demographics, comorbidities, presenting symptoms, laboratory tests and radiological findings during admission. Outcome measures included in-hospital mortality and length of stay. RESULTS: Sixty-six COVID-19 patients were hospitalized during the study period. Sixty-one percent were male and 39% female; mean age was 50.6±19.1 years. Fever and cough were the most common presenting symptoms. Serial chest X-rays showed bilateral pulmonary opacities in 33 (50%) patients. The overall mortality was 14% and mean length of stay was 8.4±8.9 days. Ten patients (15%) required intensive care unit (ICU) care during admission, of which six (9%) were intubated. Age ≥60 years, diabetes, ischemic heart disease, ICU admission, neutrophil to lymphocyte ratio ≥3.3, and international normalized ratio ≥1.2 were associated with increased risk of mortality. CONCLUSIONS: We found a mortality rate of 14% in hospitalized COVID-19 patients. COVID-19 cases are still increasing exponentially around the world and may overwhelm healthcare systems in many countries soon. Our findings can be used for early identification of patients who may require intensive care and aggressive management in order to improve outcomes.