Association between Pan-Immune-Inflammation Value and Contrast-Induced Nephropathy with Coronary Angiography.

Background: Contrast-induced nephropathy (CIN) is one of the most important complications after invasive cardiovascular procedures. Considering the pivotal role of inflammation in CIN development, the use of peripheral blood-based indexes may be an easily available biomarker to predict CIN risk. Therefore, in the present study, we evaluated the association between the pan-immune-inflammation value (PIV) and the risk of CIN. Patients and Methods: A total of 1343 patients undergoing coronary angiography (CAG) were included. The PIV was calculated with the following equation: (neutrophil count × platelet count × monocyte count)/lymphocyte count. Multivariable regression analyses were used to determine the association between clinical and laboratory parameters and CIN development. Results: The median age of the cohort was 58 (IQR 50-67), and 48.2% of the patients were female. CIN developed in 202 patients (15%) in follow-up. In multivariate analyses, older age (OR: 1.015, 95% CI: 1.002-1.028, p = 0.020) and higher PIV levels (OR: 1.016, 95% CI: 1.004-1.028, p = 0.008) were associated with a higher CIN risk, while the use of antiplatelet agents was associated with a lower risk of CIN (OR: 0.670, 95% CI: 0.475-0.945, p = 0.022). Conclusions: We demonstrated that the risk of CIN was significantly higher in patients with higher PIV and older patients in a large cohort of patients undergoing CAG for stable ischemic heart disease. If supported with prospective evidence, PIV levels could be used as a minimally invasive reflector of CIN.

Ratios of Neutrophils and Platelets to Lymphocytes as Predictors of Postoperative Intensive Care Unit Admission and Length of Stay in Bariatric Surgery Patients: A Retrospective Study.

Background and Objectives: This study aimed to investigate the role of the pre- and postoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting intensive care unit (ICU) admission and postoperative length of stay (LOS) in bariatric surgery. Materials and Methods: We retrospectively analysed 96 patients who underwent bariatric surgery at our institution. The NLR and PLR were calculated in the pre- and postoperative stages. Changes in pre- and postoperative hematological ratios were compared using the Wilcoxon signed-rank test. The optimal cutoff values and area under the curve (AUC) for each ratio were calculated using receiver operating characteristic (ROC) analysis. Multivariate linear regression analysis was used to assess the relationship between each ratio and the postoperative LOS after adjusting for age, sex, and American Society of Anesthesiologists (ASA) score. Results: The median age of our patients was 35.50 years, and 54.2% were male. The preoperative NLR showed a significant increase from 1.44 to 6.38 postoperatively (p < 0.001). The PLR increased from 107.08 preoperatively to 183.58 postoperatively, p < 0.001). ROC analysis showed that the postoperative NLR was a moderate to high predictor of ICU admission (AUC = 0.700, optimal cutoff point = 5.987). The postoperative PLR had less predictive power for ICU admission (AUC = 0.641, optimal cutoff point = 170.950). Ratios that had a statistically significant relationship with the postoperative LOS were the preoperative NLR (standardized ß [95% CI]: 0.296 [0.115-0.598]), postoperative NLR (0.311 [0.034-0.161]), and postoperative PLR (0.236 [0.000-0.005]). Conclusions: The NLR and PLR demonstrated an independent relationship with the postoperative LOS after bariatric surgery and the predictive ability of ICU admission. Both ratios might be useful as simple markers to predict patient outcome after surgery.

Comprehensive analysis and insights gained from long-term experience of the Spanish DILI Registry.

BACKGROUND & AIMS: Prospective drug-induced liver injury (DILI) registries are important sources of information on idiosyncratic DILI. We aimed to present a comprehensive analysis of 843 patients with DILI enrolled into the Spanish DILI Registry over a 20-year time period. METHODS: Cases were identified, diagnosed and followed prospectively. Clinical features, drug information and outcome data were collected. RESULTS: A total of 843 patients, with a mean age of 54 years (48% females), were enrolled up to 2018. Hepatocellular injury was associated with younger age (adjusted odds ratio [aOR] per year 0.983; 95% CI 0.974-0.991) and lower platelet count (aOR per unit 0.996; 95% CI 0.994-0.998). Anti-infectives were the most common causative drug class (40%). Liver-related mortality was more frequent in patients with hepatocellular damage aged ≥65 years (p = 0.0083) and in patients with underlying liver disease (p = 0.0221). Independent predictors of liver-related death/transplantation included nR-based hepatocellular injury, female sex, higher onset aspartate aminotransferase (AST) and bilirubin values. nR-based hepatocellular injury was not associated with 6-month overall mortality, for which comorbidity burden played a more important role. The prognostic capacity of Hy's law varied between causative agents. Empirical therapy (corticosteroids, ursodeoxycholic acid and MARS) was prescribed to 20% of patients. Drug-induced autoimmune hepatitis patients (26 cases) were mainly females (62%) with hepatocellular damage (92%), who more frequently received immunosuppressive therapy (58%). CONCLUSIONS: AST elevation at onset is a strong predictor of poor outcome and should be routinely assessed in DILI evaluation. Mortality is higher in older patients with hepatocellular damage and patients with underlying hepatic conditions. The Spanish DILI Registry is a valuable tool in the identification of causative drugs, clinical signatures and prognostic risk factors in DILI and can aid physicians in DILI characterisation and management. LAY SUMMARY: Clinical information on drug-induced liver injury (DILI) collected from enrolled patients in the Spanish DILI Registry can guide physicians in the decision-making process. We have found that older patients with hepatocellular type liver injury and patients with additional liver conditions are at a higher risk of mortality. The type of liver injury, patient sex and analytical values of aspartate aminotransferase and total bilirubin can also help predict clinical outcomes.

Reduced sensitivity of PLASMIC and French scores for the diagnosis of thrombotic thrombocytopenic purpura in older individuals.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder characterized by thrombocytopenia, microangiopathic hemolysis, and ischemic organ failure. The PLASMIC and French TTP scores can help guide clinical decisions when ADAMTS13 testing is not immediately available. Older individuals often present atypically, but the impact of age on these tools is not known. STUDY DESIGN AND METHODS: We calculated the sensitivity and specificity of the PLASMIC and French TTP scores in patients enrolled in the Johns Hopkins thrombotic microangiopathy (TMA) registry. RESULTS: Of 257 patients with TMA enrolled in the registry, we excluded patients less than 18 years of age (n = 19), with prior TMA (n = 81) or who initially presented at another hospital (n = 25). The remaining 132 patients (75 with TTP and 57 with other TMA) were analyzed. Sensitivity of a French score of 2 decreased with age and was 72.2%, 61.5%, and 46.2% for ages 18 to 39, 40 to 59, and ≥ 60 years old, respectively. A PLASMIC score ≥ 5 had higher sensitivity than the French score but this also decreased with age; sensitivity was 91.4% (95% confidence interval [CI], 76.9-98.2), 78.3% (95% CI, 56.3-92.5), and 76.9% (95% CI, 46.2-95.0) for patients 18 to 39, 40 to 59, and ≥ 60 years old, respectively. Older patients had higher platelet counts and serum creatinine than the youngest group, contributing to the loss in sensitivity. CONCLUSION: The PLASMIC and French TTP scores have reduced sensitivity at age ≥ 60 years and are less reliable in identifying TTP in older patients. A high index of suspicion and availability of rapid ADAMTS13 assays is required to correctly diagnose all patients with TTP.

Platelet count trends and response to fondaparinux in a cohort of heparin-induced thrombocytopenia suspected patients after pulmonary endarterectomy.

A definitive diagnosis of heparin-induced thrombocytopenia (HIT) is difficult to make, especially in patients undergoing cardiac surgery. In this retrospective cohort study, we assessed the platelet count trends and the response to fondaparinux in a population of patients of suspected HIT after pulmonary endarterectomy (PEA). Patients enrolled in this study were over the age of 18 years, and survived longer than 7 days after PEA between January 1, 2011 and December 31, 2015. HIT likelihood was assessed by the 4 T's score and interpreted by our institutional algorithm. 54 patients were operated, and 49 patients met the inclusion criteria. Six patients met the criteria for suspected HIT and were treated with fondaparinux until the platelet recovered. No significant difference was observed of clinical characteristics between intermediate to high HIT likelihood patients (HIT SUSPECTED) and low HIT likelihood patients (NO HIT SUSPECTED). HIT SUSPECTED patients reached platelet count lowest later (about 5.5 days after PEA), while NO HIT SUSPECTED patients is about 4.0 days after PEA. Percentage of platelet counts decrease (> 50%) was larger than NO HIT SUSPECTED patients (< 50%). There was no difference in mortality or residual pulmonary hypertension between HIT SUSPECTED and NO HIT SUSPECTED patients. Two HIT SUSPECTED patients who used heparin after PEA died, the other four survived by replacing heparin or low molecular weight heparin with fondaparinux. Suspected HIT patients should be surveilled carefully. Platelet counts trends may have some hints in the prevention of HIT. Fondaparinux may be effective for patients with suspected HIT.

Utility of the 4Ts score in excluding heparin-induced thrombocytopenia in lung transplant recipients.

Heparin-induced thrombocytopenia (HIT) is a prothrombotic complication following heparin exposure. Data is limited on the incidence of HIT and validity of 4Ts score in the solid organ transplant population. This retrospective observational cohort included patients who underwent lung transplant between August 2015 and June 2018 and had a clinical suspicion of HIT with heparin-PF4 testing. The 4Ts score was correlated with the heparin-PF4 antibody and serotonin release assay (SRA) results, with positive SRA considered confirmed HIT. Of 146 patients evaluated, the overall incidence of HIT was low (2(1%)). Fifty-one patients had heparin-PF4 testing and were included in the cohort; 5 (10%) had positive heparin-PF4 and 1 (2%) had confirmed HIT. The median 4Ts score was 3 (3-4). Thirty (59%), 17 (33%), and 4 (8%) patients had low, intermediate, and high risk, respectively. The intermediate/high risk group compared to the low risk group had a higher use of alternative non-heparin anticoagulation [13 (62%) vs 7 (23%); p = 0.0086)] and a higher incidence of thrombosis [13 (62%) vs 1 (3%); p < 0.0001]. No patient with a low 4Ts score had confirmed HIT, supporting the utility of low 4Ts score to exclude HIT diagnosis in lung transplant recipients.

A pilot study of procoagulant platelet extracellular vesicles and P-selectin increase during induction treatment in acute lymphoblastic leukaemia paediatric patients: two new biomarkers of thrombogenic risk?

In paediatric acute lymphoblastic leukaemia (ALL), focus has shifted towards preventing treatment-related complications, including venous thromboembolism, the cause of significant mortality and morbidity. To better understand thrombogenic mechanisms during induction treatment, we studied the number, origin and procoagulant activity of extracellular vesicles (EVs) and P-selectin level throughout the induction course in 24 paediatric patients. EVs were mainly of platelet origin. We observed a significant increase in EV number, in platelet EV number and P-selectin level throughout the induction course. There was a correlation between higher EV and platelet EV number, P-selectin level, higher platelet count and leucocyte count. We also observed a correlation between higher EV procoagulant activity and higher platelet count and leucocyte count and higher P-selectin level. Older age and T phenotype were associated with a higher EV procoagulant activity. Platelet EV generation may play a role in thrombogenic complications in ALL patients and could serve as a biomarker to identify patients with a high risk of thrombosis. As a marker of platelet activation, P-selectin may be another relevant marker with the advantage of being easier to analyse in clinical practice.

Treatment and outcomes of heparin-induced thrombocytopenia (HIT) in patients with neoplasm, a case series.

Heparin-induced thrombocytopenia (HIT) is a highly thrombogenic condition. Cancer patients are already at high risk of thrombosis. The treatment and outcomes of HIT in cancer patients are not well established. We retrospectively identified patients with active cancer who were diagnosed with HIT at our institution. Only patients with a positive HIT assay and intermediate to high 4Ts score were included. We assessed patients for baseline characteristics, HIT characteristics, non-heparin agent usage, and outcomes (recurrent thrombosis, bleeding, and death) up to 180 days after diagnosis of HIT. Between November 1, 2006 and December 31, 2016, 39 patients with active cancer received a diagnosis of HIT. Of these, 35.9% had thrombotic complications at diagnosis. Gastrointestinal cancer was the most common solid organ malignancy while myeloproliferative neoplasm (MPN) was the most common hematological malignancy. Fondaparinux was the most often used parenteral agent at any point of follow-up (87.2%), followed by argatroban (41.0%). Less than half the patients transitioned to an oral agent. The recurrent thrombosis rate was 17.9%, the bleeding rate was 20.5%, the major bleeding rate was 10.3%, and the mortality rate was 15.4% in the entire cohort. HIT in cancer patients is associated with poor outcomes.

Distribution and reference interval establishment of neutral-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) in Chinese healthy adults.

BACKGROUND: Neutral-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) are associated with coronavirus disease 2019 (COVID-19) and many diseases, but there are few data about the reference interval (RI) of NLR, LMR, and PLR. METHODS: The neutrophil count, lymphocyte count, monocyte count, and platelet count of 404,272 Chinese healthy adults (>18 years old) were measured by Sysmex XE-2100 automatic hematology analyzer, and NLR, LMR, and PLR were calculated. According to CLSI C28-A3, the nonparametric 95% percentile interval is defined as the reference interval. RESULTS: The results of Mann-Whitney U test showed that NLR (p < .001) in male was significantly higher than that in female; LMR (p < .001) and PLR (p < .001) in male were significantly lower than that in female. Kruskal-Wallis H test showed that there were significant differences in NLR, LMR, and PLR among different genders and age groups (p < .001). The linear graph showed that the reference upper limit of NLR and PLR increased with age and the reference upper limit of LMR decreases with age in male population. In female population, the reference upper limit of NLR in 50-59 group, LMR in >80 group, and PLR in 70-79 group appeared a trough; the reference upper limit of NLR in >80 group, LMR in 50-59 group, and PLR in 40-49 group appeared peak. CONCLUSION: The establishment of RI for NLR, LMR, and PLR in Chinese healthy adults according to gender and age will promote the standardization of clinical application.

Combine effect of exposure to petrol, kerosene and diesel fumes: On hepatic oxidative stress and haematological function in rats.

Petroleum product fumes (PPFs) containing toxic organic components are pervasive in the environment, emanating from anthropogenic activities, including petroleum exploration and utilization by end-user activities from petrol-gasoline stations. Petrol station attendants are exposed to PPF through inhalation and dermal contact with consequent toxicological implications. We investigated the effects of chronic exposure (60 and 90 days) to petrol (P), kerosene (K) and diesel (D) alone and combined exposure to petrol, kerosene and diesel (PKD) fumes on hepatotoxicity, haematological function and oxidative stress in rats. Following sacrifice, we evaluated hepatic damage biomarkers, blood glucose, oxidative stress and haematological function. Chronic exposure to PPF significantly increased organo-somatic indices, blood glucose, biomarkers of hepatic toxicity and oxidative stress in an exposure duration-dependent manner. There was a simultaneous decrease in the protective capacity of antioxidants. Furthermore, exposure to PPF increased pro-inflammatory biomarkers in rats (90 > 60 days). Regardless of exposure duration, plateletcrit, mean platelet volume, platelet distribution width and red cell distribution width in the coefficient of variation increased, whereas red blood cell count, haemoglobin, packed cell volume, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, white blood cell, lymphocyte, monocyte-basophil-eosinophil mixed counts and platelet count decreased after 60 and 90 days exposure. Microscopic examination of the liver demonstrated hepatic pathological changes paralleling the duration of exposure to PKD fumes. However, the injury observed was lesser to that of rats treated with the diethylnitrosamine - positive control. Our results expanded previous findings and further demonstrated the probable adverse effect on populations' health occasioned by persistent exposure to PPF. Individuals chronically exposed by occupation to PPF may be at greater risk of developing disorders promoted by continuous oxido-inflammatory perturbation and suboptimal haematological-immunologic function - thereby enabling a permissive environment for pathogenesis notwithstanding the limitation of quantifying PPF absolute values in our model system.

Platelet-Derived PCSK9 Is Associated with LDL Metabolism and Modulates Atherothrombotic Mechanisms in Coronary Artery Disease.

Platelets play a significant role in atherothrombosis. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is critically involved in the regulation of LDL metabolism and interacts with platelet function. The effect of PCSK9 in platelet function is poorly understood. The authors of this article sought to characterize platelets as a major source of PCSK9 and PCSK9's role in atherothrombosis. In a large cohort of patients with coronary artery disease (CAD), platelet count, platelet reactivity, and platelet-derived PCSK9 release were analyzed. The role of platelet PCSK9 on platelet and monocyte function was investigated in vitro. Platelet count and hyper-reactivity correlated with plasma LDL in CAD. The circulating platelets express on their surface and release substantial amounts of PCSK9. Release of PCSK9 augmented platelet-dependent thrombosis, monocyte migration, and differentiation into macrophages/foam cells. Platelets and PCSK9 accumulated in tissue derived from atherosclerotic carotid arteries in areas of macrophages. PCSK9 inhibition reduced platelet activation and platelet-dependent thrombo-inflammation. The authors identified platelets as a source of PCSK9 in CAD, which may have an impact on LDL metabolism. Furthermore, platelet-derived PCSK9 contributes to atherothrombosis, and inhibition of PCSK9 attenuates thrombo-inflammation, which may contribute to the reported beneficial clinical effects.

Correlation between the variables collected at admission and progression to severe cases during hospitalization among patients with COVID-19 in Chongqing.

Mortality is high among severe patients with 2019 novel coronavirus-infected disease (COVID-19). Early prediction of progression to severe cases is needed. We retrospectively collected patients with COVID-19 in two hospital of Chongqing from 1st January to 29th February 2020. At admission, we collected the demographics and laboratory tests to predict whether the patient would progress to severe cases in hospitalization. Severe case was confirmed when one of the following criteria occurred: (a) dyspnea, respiratory rate ≥30 breaths/min, (b) blood oxygen saturation ≤93%, and (c) PaO2 /FiO2 ≤ 300 mm Hg. At admission, 348 mild cases were enrolled in this study. Of them, 20 (5.7%) patients progressed to severe cases after median 4.0 days (interquartile range: 2.3-6.0). Pulmonary inflammation index, platelet counts, sodium, C-reactive protein, prealbumin, and PaCO2 showed good distinguishing power to predict progression to severe cases (each area under the curve of receiver operating characteristics [AUC] ≥ 0.8). Age, heart rate, chlorine, alanine aminotransferase, aspartate aminotransferase, procalcitonin, creatine kinase, pH, CD3 counts, and CD4 counts showed moderate distinguishing power (each AUC between 0.7-0.8). And potassium, creatinine, temperature, and D-dimer showed mild distinguishing power (each AUC between 0.6-0.7). In addition, higher C-reactive protein was associated with shorter time to progress to severe cases (r = -0.62). Several easily obtained variables at admission are associated with progression to severe cases during hospitalization. These variables provide a reference for the medical staffs when they manage the patients with COVID-19.

Platelet count and mortality of H7N9 infected patients in Guangdong, China.

Avian influenza A (H7N9) is a serve zoonosis with a high mortality rate. Timely and effective diagnosis and early warning is crucial for the clinical treatment of H7N9 patients. The previous studies indicated that thrombocytopenia was associated with the prognosis of influenza cases, but the related evidence of platelet change within the course of the disease remains largely insufficient. A total of 130 laboratory-confirmed H7N9 cases and their corresponding medical records from August 2013 to March 2015 were collected from 23 hospitals of 13 cities in Guangdong, China. The results indicated that there was a significant difference between the outcome of H7N9 cases and their average platelet count (PC) including maximum, minimum, range, admission and discharge/death of the PC value. Furthermore, we built a classification and regression tree (CART) model to predict the fatality rate which varied with average PC. There was a 7% chance for a mortality from H7N9 if PC was over 207.0 × 10^9/L, while there was a 46.3% chance of a mortality from H7N9 when PC was between 123.9 × 10^9/L and 207.0 × 10^9/L, and 81.3% chance of a mortality from H7N9 when PC was less than 123.9 × 10^9/L. This study demonstrates that using platelet count to predict the fatality of H7N9 is significant, and lower platelet counts of H7N9 patients were associated with higher risk of mortality of H7N9 patients, which may need to be taken into consideration when planning clinical treatment.

Platelet Transfusion Practice and Related Outcomes in Pediatric Extracorporeal Membrane Oxygenation.

OBJECTIVE: To describe factors associated with platelet transfusion during pediatric extracorporeal membrane oxygenation and the relationships among platelet transfusion, complications, and mortality. DESIGN: Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014. SETTING: Eight Collaborative Pediatric Critical Care Research Network-affiliated hospitals. PATIENTS: Age less than 19 years old and treated with extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 511 children, 496 (97.1%) received at least one platelet transfusion during extracorporeal membrane oxygenation. Neonatal age, venoarterial extracorporeal membrane oxygenation, and various acute and chronic diagnoses were associated with increased average daily platelet transfusion volume (milliliters per kilogram body weight). On multivariable analysis, average daily platelet transfusion volume was independently associated with mortality (per 1 mL/kg; odds ratio, 1.05; CI, 1.03-1.08; p < 0.001), whereas average daily platelet count was not (per 1 × 10/L up to 115 × 10/L; odds ratio, 1.00; CI, 0.98-1.01; p = 0.49). Variables independently associated with increased daily bleeding risk included increased platelet transfusion volume on the previous extracorporeal membrane oxygenation day, a primary cardiac indication for extracorporeal membrane oxygenation, adolescent age, and an acute diagnosis of congenital cardiovascular disease. Variables independently associated with increased daily thrombotic risk included increased platelet transfusion volume on the previous extracorporeal membrane oxygenation day and venoarterial extracorporeal membrane oxygenation. Variables independently associated with decreased daily thrombotic risk included full-term neonatal age and an acute diagnosis of airway abnormality. CONCLUSIONS: Platelet transfusion was common in this multisite pediatric extracorporeal membrane oxygenation cohort. Platelet transfusion volume was associated with increased risk of mortality, bleeding, and thrombosis.

Prognostic Impact of Increased Perioperative Platelet Count in Gastric Cancer Patients.

BACKGROUND: Solid tumors are a common cause of secondary (reactive) thrombocytosis, a paraneoplastic syndrome that is also a prognostic factor for various cancers. However, cutoff values for platelet count specific to gastric cancer and their prognostic roles are unknown. METHODS: We retrospectively analyzed records of 4643 patients with gastric cancer who underwent radical surgery from 2007 to 2010. The minimum P-value approach was used with the log-rank test to determine the optimal prognosis predicting threshold for preoperative platelet count. Change in perioperative platelet count over time was evaluated with a generalized estimating equation. Clinicopathologic features and prognostic significance were analyzed according to platelet count. RESULTS: Thrombocytosis prevalence (platelet count ≥40 × 104/µL) was 1.6% (75 of 4643 patients). The platelet count cutoff value with the lowest P-value was ≥25.5 × 104/µL, and patients with higher platelet count had more advanced disease. Multivariate analysis showed that cutoff value was an independent prognostic factor of overall survival (hazard ratio 1.19, 95% confidence interval 1.03-1.37, P = 0.017). Patients who underwent adjuvant chemotherapy (n = 1300) and had a greater than 10% increase in platelet count at postoperative 1 y compared to before surgery had significantly poorer overall survival (hazard ratio 1.65, 95% confidence interval 1.11-2.45, P = 0.013). CONCLUSIONS: Elevated preoperative platelet count (≥25.5 × 104/µL) and increased platelet count (≥10%) at postoperative 1 y in an adjuvant chemotherapy group were unfavorable prognostic factors. Platelet count could be a cost-effective biomarker for screening and monitoring patients with unfavorable survival outcomes.

Effects of ABO Matching of Platelet Transfusions in Critically Ill Children.

OBJECTIVES: To determine if transfusing ABO compatible platelets has a greater effect on incremental change in platelet count as compared to ABO incompatible platelets in critically ill children. DESIGN: Secondary analysis of a prospective, observational study. Transfusions were classified as either ABO compatible, major incompatibility, or minor incompatibility. The primary outcome was the incremental change in platelet count. Transfusion reactions were analyzed as a secondary outcome. SETTING: Eighty-two PICUs in 16 countries. PATIENTS: Children (3 d to 16 yr old) were enrolled if they received a platelet transfusion during one of the predefined screening weeks. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five-hundred three children were enrolled and had complete ABO information for both donor and recipient, as well as laboratory data. Three-hundred forty-two (68%) received ABO-identical platelets, 133 (26%) received platelets with major incompatibility, and 28 (6%) received platelets with minor incompatibility. Age, weight, proportion with mechanical ventilation or underlying oncologic diagnosis did not differ between the groups. After adjustment for transfusion dose, there was no difference in the incremental change in platelet count between the groups; the median (interquartile range) change for ABO-identical transfusions was 28 × 10 cells/L (8-68 × 10 cells/L), for transfusions with major incompatibility 26 × 10 cells/L (7-74 × 10 cells/L), and for transfusions with minor incompatibility 54 × 10 cells/L (14-81 × 10 cells/L) (p = 0.37). No differences in count increment between the groups were noted for bleeding (p = 0.92) and nonbleeding patients (p = 0.29). There were also no differences observed between the groups for any transfusion reaction (p = 0.07). CONCLUSIONS: No differences were seen in the incremental change in platelet count nor in transfusion reactions when comparing major ABO incompatible platelet transfusions with ABO compatible transfusions in a large study of critically ill children. Studies in larger, prospectively enrolled cohorts should be performed to validate whether ABO matching for platelet transfusions in critically ill children is necessary.

L-statistics of absolute differences for quantifying the agreement between two variables.

In many clinical studies, Lin's (1989) concordance correlation coefficient (CCC) is a popular measure of agreement for continuous outcomes. Most commonly, it is used under the assumption that data are normally distributed. However, in many practical applications, data are often skewed and/or thick-tailed. King and Chinchilli (2001) proposed robust estimation methods of alternative CCC indices, and we propose an approach that extends the existing methods of robust estimators by focusing on functionals that yield robust L-statistics. We provide two data examples to illustrate the methodology, and we discuss the results of computer simulation studies that evaluate statistical performance.

Predictive value of the aspartate aminotransferase to platelet ratio index for parenteral nutrition associated cholestasis in extremely low birth weight infants.

BACKGROUND: Parenteral nutrition (PN) improves the survival of premature infants. However, prolonged PN increases the risk of PN-associated cholestasis (PNAC). OBJECTIVE: We aimed to evaluate the predictive value of aspartate aminotransferase (AST)-to-platelet ratio index (APRI) for PNAC in infants with extremely low birth weight (ELBW, birth weight < 1000 g) infants. METHODS: We retrospectively reviewed the medical records of ELBW infants from March 2010 to February 2017. Clinical data and the serial APRI, AST, alanine aminotransferase (ALT), AST-to-ALT ratio, and direct bilirubin (DB) were analyzed. PNAC was diagnosed in infants with a history of PN for at least 2 weeks and direct bilirubin concentrations > 2 mg/dL after other causes of neonatal cholestasis were excluded. RESULTS: Among the 179 eligible ELBW infants, 56 (31.3%) were diagnosed with PNAC. APRI significantly differed between infants with PNAC and those without PNAC. The best APRI cut-off point was 0.410 at 2 weeks after the start of PN (area under the receiver operating characteristic curve = 0.752, p < 0.05; positive predictive value, 50.6%; negative predictive value, 84.1%). CONCLUSION: APRI at 2 weeks after PN could be a reliable predictor of PNAC development in ELBW infants on PN.

The Effect of Mean Platelet Volume/Platelet Count Ratio on Dipper and Non-Dipper Blood Pressure Status.

Background and Objectives: The mean platelet volume (MPV) represents a possible marker of platelet activation. There is an association between the platelet count (PC) and inflammation and platelet reactivity. We assessed the association between the MPV/PC ratio and circadian alterations in blood pressure (BP). Material and Methods: One hundred and twenty subjects in total, 80 hypertensive subjects and 40 healthy subjects (controls), were enrolled in the study group. Twenty four hour ambulatory BP monitoring (ABPM) was applied to all subjects. According to ABPM results, the hypertensive subjects were separated into two groups, such as dippers (n = 40) and non-dippers (n = 40). In all subjects, the collection of venous peripheral blood samples was performed on admission for PC and MPV measurements. Results: The two groups exhibited similar clinical baseline characteristics. A significantly higher MPV/PC ratio was determined in non-dippers compared to that in dippers and normotensives. The higher MPV/PC ratio was observed in non-dippers in comparison with that in dippers and normotensives (0.046 ± 0.007 to 0.032 ± 0.004 fL/[109/L]; 0.046 ± 0.007 to 0.026 ± 0.004 fL/[109/L], p < 0.001, respectively). A receiver operating characteristic (ROC) curve analysis showed that the optimum cut-off value of the MPV/PC ratio for predicting non-dipping patterns in hypertensive patients was 0.036 (area under the curve [AUC]: 0.98, p < 0.001). According to the cut-off value, sensitivity and specificity were found to be 95% and 95%, respectively. Conclusions: The higher MPV/PC ratio was determined in non-dipper hypertensive subjects in comparison with that in dipper hypertensive subjects. An elevation of platelet activity and an increase in thrombus burden are reflected by an increase in the MPV/PC ratio. The MPV/PC ratio may underlie the increase in cardiovascular risk in non-dippers compared to that in dippers.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Complete Blood Count Components in the First Trimester Do Not Predict HELLP Syndrome.

Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), and other components of the routine complete blood count (CBC) were found to be sensitive biomarkers of preeclampsia and other inflammatory obstetric conditions in previous studies, with conflicting results. We speculated that the same associations existed with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in the first trimester of pregnancy. Materials and Methods: We conducted a retrospective case-control study at a tertiary care hospital in NY (USA), in the time frame between January 2016 and December 2018. Our population consisted of pregnant women in the first trimester: We compared patients with HELLP syndrome (cases) with healthy patients (controls) matched by age, body mass index (BMI), parity, and race. Patients with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up during the first prenatal visit in the first trimester, which includes a CBC. The main outcomes were NLR and PLR, and the secondary outcomes were hemoglobin, RDW, platelet count, MPV, neutrophils, and lymphocytes. Results: There were 10 patients in each group (Table 1). There were no differences in NLR and PLR levels and other CBC components between the two groups (Table 2). Conclusions: In our study NLR, PLR, and other CBC components did not predict HELLP syndrome. We speculate that HELLP syndrome has a sudden increase of tissue inflammation in the third trimester that is not manifested during the early phases of placentation. Larger studies are needed to evaluate the true ability of NLR, PLR, and CBC components to predict HELLP syndrome in the first trimester.