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BackgroundHow 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. MethodsWe 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. FindingsOur 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 g/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. InterpretationThe 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. FundingNational Institute of Health.
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Objective To discuss the clinical characteristics for lateral cervical lymph node metastasis in stage cN0 papillary thyroid microcarcinoma and significance and feasibility of preventive dissection,and provide reference for clinical treatment.Methods Reviewd the clinical data of 191 patients with stage cN0 papillary thyroid microcarcinoma patients from Jul.2011 to Dec.2016 underwent surgery in the Department of General Surgery of Lianyungang Oriental Hospital.Assessed the need for preventive cervical lymph node dissection.Chisquare test and logistic regression were used to analyze the relationship between cervical lymph node metastasis and gender,age,tumor number,tumor size,capsule infiltration,single and bilateral tumors,Hashimoto's disease,and central lymph node metastasis.Results The positive rate of cervical lymph node metastasis in papillary thyroid microcarcinoma was 27.9％ (50/191).Univariate analysis showed that the metastasis of the cervical lymph nodes was associated with infiltration of the capsule,Hashimoto disease,and CLN metastasis (all P ＜ 0.05).Multivariate logistic regression analysis showed that the capsule infiltration (OR =7.563,P =0.000),Hashimoto's disease (OR =4.635,P =0.003),and central lymph node metastasis (OR =3.075,P ＜ 0.001) were able to be independent risk factors for cervical lymph node metastasis.When the positive number of lymph node metastasis in the central region was ≥ 2,the positive rate of cervical lymph nodes was significantly increased (P ＜ 0.001).Eleven patients (5.8％) had temporary recurrent laryngeal nerve palsy,29 patients (15.1％) had transient hypoparathyroidism,and no patients with permanent recurrent laryngeal nerve palsy and hypoparathyroidism.Conclusions The removal of the cervical lymph nodes helps to accurately classify the tumor and assess the risk.It is important to choose the postoperative treatment follow-up plan for patients.For patients with capsule infiltration,Hashimoto's disease,and central lymph node metastasis,cervical lymph node dissection should be routinely performed.
