Lymphocyte subsets as a predictor of severity and prognosis in COVID-19 patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) had become a worldwide health threat. Early prediction of the severity of COVID-19 patients was important for reducing death rate and controlling this disease. METHODS AND MATERIALS: A total of 301 patients confirmed with COVID-19 in Wuhan from 8 February to 10 April 2020 were included. Clinical data were collected and analyzed. Diagnostic and prognostic utility of blood cell counts and lymphocyte subsets in COVID-19 patients were investigated. The receiver operator characteristic curve (ROC) was used in discriminating the mild and severe/critical cases. RESULTS: There were difference in blood cell counts and lymphocyte subsets among mild, severe and critical patients, which were also influenced by comorbidities and duration of disease. The area under the ROC of lymphocyte, CD3+ T cells, CD4+ T cells, and CD8+ T cells were 0.718, 0.721, 0.718, and 0.670, which were higher than that of other hematological parameters. The optimal threshold was 1205, 691, 402, and 177 per µl, respectively. Patients with higher counts of lymphocyte, CD3+ T cells, CD4+ T cells, or CD8+ T cells were correlated with shorter length of stay in hospital (p < 0.05). Multivariable Cox regression analysis showed disease severity, CD3+ T cells counts and time when the nucleic acid turned negative were independent risk factors for in-hospital death of COVID-19 patients (p < 0.05). CONCLUSION: Blood cell counts and lymphocyte subsets correlated with severity of COVID-19.

[A 180-day mortality predictive score based on frailty syndrome in elderly patients with sepsis: a Logistic regression analysis model].

OBJECTIVE: To establish a 180-day mortality predictive score based on frailty syndrome in elderly sepsis patients [elderly sepsis score (ESS)]. METHODS: A prospective study for sepsis patients aged 60 years and above who were admitted to a medical intensive care unit of the General Hospital of Southern Theatre Command from January 1st, 2018 to December 31st, 2018 was conducted. Univariate analysis was performed on 19 independent variables including gender, age, body mass index (BMI), tumor, charlson comorbidity index (CCI), activity of daily living (ADL), instrumental activity of daily living (IADL), mini-mental state examination (MMSE), geriatric depression scale (GDS), clinical frail scale (CFS), sequential organ failure assessment (SOFA), Glasgow coma scale (GCS), acute physiology and chronic health evaluation (APACHE II, APACHE IV), modified NUTRIC score (MNS), multiple drug resistance (MDR), mechanical ventilation (MV), continuous renal replacement therapy (CRRT) and palliative care. Continuous independent variables were converted into classified variables. Multivariate binary regression analysis of risk factors was conducted to screen independent risk factors which affecting 180-day mortality in elderly sepsis patients. Then a 180-daymortality predictive score was established, and the discrimination of the mortality of patients using CFS, SOFA, GCS, APACHE II, APACHE IV, MNS scores were compared. RESULTS: A total of 257 patients were enrolled, with a 180-day mortality of 60.7%. Univariate analysis showed that age, tumor, CCI, ADL, IADL, MMSE, CFS, SOFA, GCS, APACHE II, APACHE IV, MNS, MDR, MV, CRRT, palliative care were risk factors of 180-day mortality in elderly sepsis patients [age: odds ratio (OR) = 1.027, 95% confidence interval (95%CI) was 1.005-1.050, P = 0.018; tumor: OR =2.001, 95%CI was 1.022-3.920, P = 0.043; CCI: OR = 1.193, 95%CI was 1.064-1.339, P = 0.003; ADL: OR = 0.851, 95%CI was 0.772-0.940, P = 0.001; IADL: OR = 0.894, 95%CI was 0.826-0.967, P = 0.005; MMSE: OR = 0.962, 95%CI was 0.937-0.988, P = 0.004; CFS: OR = 1.303, 95%CI was 1.089-1.558, P = 0.004; SOFA: OR = 1.112, 95%CI was 1.038-1.191, P = 0.003; GCS: OR = 0.918, 95%CI was 0.863-0.977, P = 0.007; APACHE II: OR = 1.098, 95%CI was 1.053-1.145, P < 0.001; APACHE IV: OR = 1.032, 95%CI was 1.020-1.044, P < 0.001; MNS: OR = 1.315, 95%CI was 1.159-1.493, P < 0.001; MDR: OR = 2.029, 95%CI was 1.197-3.437, P = 0.009; MV: OR = 6.408, 95%CI was 3.480-11.798, P < 0.001, CRRT: OR = 2.744, 95%CI was 1.529-4.923, P = 0.001, palliative care: OR = 5.760, 95%CI was 2.177-15.245, P < 0.001]. By binary regression analysis, CFS stratification (OR = 1.934, 95%CI was 1.267-2.953, P = 0.002), MV (OR = 4.531, 95%CI was 2.376-8.644, P < 0.001), CRRT (OR = 2.471, 95%CI was 1.285-4.752, P = 0.007), palliative care (OR = 6.169, 95%CI was 2.173-17.515, P = 0.001) were independent risk factors of 180-day mortality in elderly patients with sepsis. The model of "ESS = 0.660×CFS stratification+1.511×MV+0.905×CRRT+1.820×palliative care" was established. Receiver operating characteristic curve (ROC curve) analysis showed that the area under the ROC curve (AUC) for predicting 180-day mortality by ESS was 0.785 (95%CI was 0.730-0.834, P < 0.001). When the best cut-off value was 2.2 points, its sensitivity was 78.9%, specificity was 70.3%, the positive predictive value was 80.4%, and the negative predictive value was 68.3%. Simplified ESS was defined as "0.5×CFS stratification+1.5×MV+1×CRRT+2×palliative care". ROC curve analysis showed that AUC for predicting 180-day mortality by simplified ESS was 0.784 (95%CI was 0.729-0.833, P < 0.001). When the best cut-off value was 2.0 points, sensitivity was 76.9%, specificity was 70.3%, the positive predictive value was 80.0%, and the negative predictive value was 66.4%. Compared with CFS, SOFA, GCS, APACHE II, APACHE IV and MNS, ESS had a significant difference in discriminating 180-day mortality in elderly patients with sepsis (AUC was 0.785 vs. 0.607, 0.607, 0.600, 0.664, 0.702, 0.657, 95%CI: 0.730-0.734 vs. 0.537-0.678, 0.537-0.677, 0.529-0.671, 0.598-0.730, 0.638-0.766, 0.590-0.725, all P < 0.05). CONCLUSIONS: CFS, MV, CRRT, and palliative care are independent risk factors of 180-day mortality in elderly patients with sepsis. We established ESS based on these risk factors. The ESS model has good discrimination and can be used as a reference and assessment tool for prediction and treatment guidance in elderly patients with sepsis.

[Predictive value of SOFA score combined AGI grading system in elderly patients with sepsis: a retrospective analysis with 91 patients].

OBJECTIVE: To explore the predictive value of sequential organ failure assessment (SOFA) score combined the acute gastrointestinal injury (AGI) grading system in critical elderly patients with sepsis. METHODS: A retrospective analysis was conducted. Elderly patients with sepsis aged > 60 years admitted to medical intensive care unit (MICU) of General Hospital of Guangzhou Military Command from March 2014 to December 2015 and experiencing critical care over 48 hours were enrolled. Age, gender, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score and AGI score at admission (SOFAinitial, AGIinitial), the highest SOFA score and AGI score within the first week (SOFAmax, AGImax), serum procalcitonin (PCT), C-reactive protein (CRP), albumin (ALB), platelet (PLT), hemoglobin (Hb) and lactate (Lac) levels, length of ICU stay, usage of mechanical ventilation and renal replacement therapy were recorded. The primary end point was 28-day mortality. To extract factors affecting 28-day mortality, the risk factor of death of the senile sepsis patients were analyzed by binary logistic regression analysis (stepwise method). Fitness of the model was assessed by the Hosmer-Lemeshow test and calibration plot (P > 0.05). Receiver operating characteristic (ROC) analysis was performed for APACHE II score, SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and SOFAmax and combined AGImax score. RESULTS: Ninety-one patients were enrolled, the incidence of AGI in elderly patients with sepsis was 100%; 34 patients died 28 days after the admission, and the 28-day mortality rate was 37.4%. Non-survivors presented a higher APACHE II score, SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and longer usage of mechanical ventilation and renal replacement therapy. SOFAmax score [odds ratio (OR) = 1.576] and AGImax score (OR = 5.695) were associated with 28-day mortality in binary logistic regression analysis (both P < 0.01). The area under the curve (AUC) and 95% confidence interval (95%CI) of SOFAmax score combined AGImax score was significantly higher than that of SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and APACHE II score [0.806 (0.710-0.881) vs. 0.723 (0.619-0.812), 0.786 (0.688-0.865), 0.641 (0.533-0.739), 0.633 (0.526-0.881), 0.638 (0.531-0.736), all P < 0.05]. The Youden index (55.37) and positive predict value (5.51) of SOFAmax score combined AGImax score were the largest. When its cut-off value reached 14, the sensitivity and specificity was 67.65% and 87.72%, respectively. According to score of APACHE II, SOFAinitial, SOFAmax or AGImax, the higher of each score, the higher mortality rate could be. CONCLUSIONS: The combination of SOFAmax score and AGImaxscore enable accurate prediction in elderly patients with sepsis.

[Assessment of the value of acute physiology and chronic health evaluation II/IV prognostic models in elderly patients with sepsis].

OBJECTIVE: To assess and compare the performance of acute physiology and chronic health evaluation II/IV (APACHEII/IV) prognostic models in elderly patients with sepsis. METHODS: A totally of 82 elderly patients with sepsis were retrospectively assessed in geriatric intensive care unit of General Hospital of Guangzhou Military Command between July 2011 and December 2011. APACHEII/IV scores were recorded within 24 hours after admission. The prognosis accuracy of both scores was assessed by area under the receiver operating characteristic curve (AUC). Based on the best cutoff value corresponding with the highest accuracy, patients were divided into the low and high risk of hospital mortality group. The predictive power of APACHEII/IV in total population and subgroups was compared. RESULTS: Patients with severe sepsis constituted 57.3% (47/82) of all patients with sepsis, and hospital mortality was 61.0% (50/82). APACHEII/IV scores of the patients were 17.5±6.3 and 55.8±22.3, and mortality rate was 22.5% (18.4/82) and 17.9% (14.6/82) respectively, with significant differences compared with actual mortality (both P<0.01). Both APACHEII/IV scores showed underestimation of hospital mortality in total population [standardized mortality ratio (SMR) with APACHEII=2.71, 95% confidence interval (95%CI) 1.92-3.48 and SMR with APACHEIV=3.33, 95%CI 2.79-4.37]. APACHEII (AUC 0.664±0.066), and APACHEIV presented poor estimation(AUC 0.716±0.056). There was no difference in accuracy in prognosticating hospital death prognosis between the two APACHE models (Z=0.991, P=0.322). Cutoff values of APACHEII/IV were >11 and >59. According to the value, patients were divided into the low and high risk hospital mortality group. There was no significant difference between actual mortality and prognostic mortality in APACHEII low risk group [0-11, 20.0% (3/15) vs. 1.6% (0.2/15), Z=-1.023, P=0.306]. The actual mortality in high risk group with APACHEII (>11) was significantly higher than prognostic mortality [70.1% (47/67) vs. 27.2% (18.2/67), t=6.989, P=0.000]. In the high risk group, APACHEII underestimated mortality (SMR=2.58, 95%CI 2.22-3.51). The actual mortality of the low (0-59) and high (>59) risk group of APACHEIV were higher than prognostic mortality [lower risk group: 44.0% (22/50) vs. 7.5% (3.8/50), Z=-2.235, P=0.025; higher risk group: 87.5% (28/32) vs. 34.1% (10.9/32), Z=-4.712, P=0.000]. Two groups of patients with APACHEIV score, the mortality was underestimated (low risk group: SMR=5.90, 95%CI 5.19-7.07; high risk group: SMR=2.56, 95%CI 2.07-3.24). Mortality rate of the low risk group with APACHEIV score was prone to be underestimated. CONCLUSIONS: The accuracy of APACHEII/IV are not ideal in foretelling mortality rate. Hospital mortality was underestimated with APACHEII in high risk patients, and it was underestimated with APACHEIV both in low and high risk patients, and it is even more prone to be underestimated in low risk group of APACHEIV. More accurate prognostic modality is in need in elderly patients with sepsis.

[Changes of thyroxin and monocyte human leukocyte antigen-DR expression in senior patients with sepsis].

OBJECTIVE: To investigate the changes of thyroxin and monocyte human leukocyte antigen-DR expression in senior patients with sepsis and explore their clinical significance. METHODS: According to the 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions, 125 senior patients with sepsis free of thyroid conditions were divided into non-severe sepsis group (n=86) and severe sepsis group (n=39), with another 30 healthy subjects as the control. Thyroid function was assayed by chemoluminescence method in these patients and monocyte HLA-DR expression was determined by flow cytometry. RESULTS: Compared with the control group and non-severe sepsis cases, the levels of free T3 (FT3), free T4 (FT4), T3, T4 and monocyte HLA-DR expression were significantly lower in severe sepsis cases (P<0.05), but the levels of thyroid stimulating hormone (TSH) were comparable between the 3 groups (P>0.05). The non-severe sepsis cases showed significantly lower levels of FT3, FT4, T3, T4, TSH and monocyte HLA-DR expression than the control group (P<0.05). In severe sepsis group, the levels of FT3, FT4, T3, T4 and monocyte HLA-DR expression showed significant differences between the fatal cases and surviving cases (P<0.05). CONCLUSION: The levels of thyroxin and monocyte human leukocyte antigen-DR expression are obviously lower in senior patients with severe sepsis, and their detection may well indicate the severity of the condition and help make prognostic judgment.