Relationship Between Preoperative Inflammation Ratios Derived From Preoperative Blood Cell Count and Postoperative Pulmonary Complications in Patients Undergoing Lobectomy: A Single-Center Observational Study.

OBJECTIVE: Evaluation of the association of inflammatory cell ratios, especially neutrophil-to-lymphocyte ratio (NLR), based on preoperative complete blood counts, with postoperative complications in lobectomy surgery. DESIGN: This was a retrospective monocentric cohort study. SETTING: The study was conducted at Foch University Hospital in Suresnes, France. PARTICIPANTS: Patients having undergone a scheduled lobectomy from January 2018 to September 2021. INTERVENTIONS: There were no interventions. MEASUREMENTS AND MAIN RESULTS: The authors studied 208 consecutive patients. Preoperative NLR, monocyte-to-lymphocyte ratio, platelet-to-lymphocyte ratio, systemic inflammation index, systemic inflammation response index, and aggregate inflammation systemic index were calculated. Median and (IQR) of NLR was 2.67 (1.92-3.69). No statistically significant association was observed between any index and the occurrence of at least one major postoperative complication, which occurred in 37% of the patients. Median postoperative length of stay was 7 (5-10) days. None of the ratios was associated with prolonged length of stay (LOS), defined as a LOS above the 75th percentile. CONCLUSIONS: The results suggested that simple available inflammatory ratios are not useful for the preoperative identification of patients at risk of postoperative major complications in elective lobectomy surgery.

Interest in the new thromboelastometry device, Clot Pro®, for predicting thrombocytopenia and hypofibrinogenemia during lung transplantation.

INTRODUCTION: Lung transplantation is associated with high proportion of transfusion. Monitoring of coagulopathy using viscoelastic tests could aid in the perioperative management of bleeding. The aim of the study was to assess the predictive cut-off values for thrombocytopenia and hypofibrinogenemia using the new thromboelastography analyzer, ClotPro. METHODS: We retrospectively enrolled 65 patients who underwent lung transplantation and were sampled for both viscoelastic assays and conventional coagulation assays simultaneously during the procedure. We characterized the correlation between the EX-test (extrinsic pathway) and platelet count as well as between the FIB-test (extrinsic pathway after platelet inhibition) and fibrinogen concentration. Then, we used ROC curve analysis to determine the optimal EX-test and FIB-test values for predicting thrombocytopenia and hypofibrinogenemia. RESULTS: All the amplitude values of the EX-test (A5, A10, A20, MCF) showed correlation with platelets count (Spearman's rank correlation coefficient ranging from 0.75 to 0.77, all p < 0.0001). We also observed a strong correlation between the amplitude values of the FIB-test (A5, A10, A20 and MCF) and the fibrinogen concentration (Spearman's rank correlation coefficient ranging from 0.68 to 0.71, all p < 0.0001). The AUCs of the EX-test values for thrombocytopenia <100 G/L and <80 G/L ranged from 0.80 to 0.93. Similarly, the AUCs of the FIB-test values for hypofibrinogenemia <1.5 g/L and <2 g/L ranged from 0.74 to 0.83. These results indicate that only the five-minute parameter of thromboelastometry is sufficient for detecting thrombocytopenia and hypofibrinogenemia in patients undergoing lung transplantation. The proposed cut off values for the EX-test to predict thrombocytopenia <80 G/L showed high sensitivity (>86 %), high specificity (>89 %) and high negative predictive value (>95 %). FIB-test cut off values predictive of fibrinogen below 1.5 g/L showed sensitivity (>78 %), specificity (>55 %) and negative predictive value (>88 %). CONCLUSIONS: Our study provided preliminary results that are useful for developing a ClotPro-based algorithm to guide transfusion in lung transplantation. Future interventional studies will be necessary to validate these cut-off values of ClotPro for guiding transfusion.

Association between acute complications in PMM2-CDG patients and haemostasis anomalies: Data from a multicentric study and suggestions for acute management.

OBJECTIVES: Patients with PMM2-CDG develop acute events (stroke-like episodes (SLEs), thromboses, haemorrhages, seizures, migraines) associated with both clotting factors (factor XI) and coagulation inhibitors (antithrombin, protein C and protein S) deficiencies. The aim of the study was to correlate acute events to haemostasis and propose practical guidelines. METHODS: In this multicentric retrospective study, we evaluated clinical, radiological, haemostasis and electroencephalography data for PMM2-CDG patients hospitalized for acute events. Cerebral events were classified as thrombosis, haemorrhage, SLE, or "stroke mimic" (SM: normal brain imaging or evoking a migraine). RESULTS: Thirteen patients had a total of 31 acute episodes: 27 cerebral events with 7 SLEs, 4 venous thromboses, 4 haemorrhages (3 associated with thrombosis), 15 SMs at a mean age of 7.7 years; 4 non-cerebral thromboses, one of which included bleeding. A trigger was frequently involved (infection, head trauma). Although sometimes normal at baseline state, factor XI, antithrombin and protein C levels decreased during these episodes. No correlation between haemostasis anomalies and type of acute event was found. DISCUSSION: Acute events in PMM2-CDG are not negligible and are associated with haemostasis anomalies. An emergency protocol is proposed for their prevention and treatment (https://www.filiere-g2m.fr/urgences). For cerebral events, brain Magnetic Resonance Imaging with perfusion weight imaging and diffusion sequences, electroencephalogram and haemostasis protein levels guide the treatment: anticoagulation, antithrombin or fresh frozen plasma supplementation, antiepileptic therapy. Preventing bleeding and thrombosis is required in cases of surgery, prolonged immobilization, hormone replacement therapy. CONCLUSION: Acute events in PMM2-CDG are associated with abnormal haemostasis, requiring practical guidance.

Development of a Decision Support Tool for Anticoagulation in Critically Ill Patients Admitted for SARS-CoV-2 Infection: The CALT Protocol.

Severe COVID-19 infections are at high risk of causing thromboembolic events (TEEs). However, the usual exams may be unavailable or unreliable in predicting the risk of TEEs at admission or during hospitalization. We performed a retrospective analysis of two centers (n = 124 patients) including severe COVID-19 patients to determine the specific risk factors of TEEs in SARS-CoV-2 infection at admission and during stays at the intensive care unit (ICU). We used stepwise regression to create two composite scores in order to predict TEEs in the first 48 h (H0-H48) and during the first 15 days (D1-D15) in ICU. We then evaluated the performance of our scores in our cohort. During the period H0-H48, patients with a TEE diagnosis had higher D-Dimers and ferritin values at day 1 (D1) and day 3 (D3) and a greater drop in fibrinogen between D1 and D3 compared with patients without TEEs. Over the period D1-D15, patients with a diagnosis of a TEE showed a more marked drop in fibrinogen and had higher D-Dimers and lactate dehydrogenase (LDH) values at D1 and D3. Based on ROC analysis, the COVID-related acute lung and deep vein thrombosis (CALT) 1 score, calculated at D1, had a diagnostic performance for TEEs at H0-H48, estimated using an area under the curve (AUC) of 0.85 (CI95%: 0.76-0.93, p < 10-3). The CALT 2 score, calculated at D3, predicted the occurrence of TEEs over the period D1-D15 with an estimated AUC of 0.85 (CI95%: 0.77-0.93, p < 10-3). These two scores were used as the basis for the development of the CALT protocol, a tool to assist in the decision to use anticoagulation during severe SARS-CoV-2 infections. The CALT scores showed good performances in predicting the risk of TEEs in severe COVID-19 patients at admission and during ICU stays. They could, therefore, be used as a decision support protocol on whether or not to initiate therapeutic anticoagulation.

Hemostatic defects in congenital disorders of glycosylation.

A "state of the Art" lecture titled "Hemostatic Defects in Congenital Disorders of Glycosylation" was presented at the ISTH 2022 congress. Congenital disorders of glycosylation (CDGs) are rare, inherited, metabolic diseases. The diagnosis of CDG is often challenging due to the broad variety of disorders, the variable level of severity, and phenotypic heterogeneity. Most CDGs are multisystem disorders, and neurologic involvement is frequent. Patients with CDG often present coagulation abnormalities characterized by low levels of procoagulant or anticoagulant factors. Antithrombin deficiency is frequently associated with factor XI deficiency and less frequently with a protein C, protein S, or factor IX deficiency. This coagulation profile differs from those observed in liver failure, disseminated intravascular coagulation, and vitamin K deficiency, and so, should prompt the physician to consider a diagnosis of CDG. Coagulopathy can lead to thrombotic and/or hemorrhagic complications. In patients with phosphomannomutase 2 deficiency (the most common CDG), thrombotic events are more frequent than hemorrhagic events. In other types of CDGs, both hemorrhagic and thrombotic events have been described. Overall, the hemostatic balance in these patients is precarious and necessitates close monitoring in a setting of acute illness with greater metabolic needs. Here, we review the most relevant hemostatic defects observed in CDG and their clinical implications. Finally, we summarize relevant new data on this topic presented at the ISTH 2022 congress.

Prognostic value of cellular population data in patients with COVID-19.

Background and aims: Beckman Coulter hematology analysers identify leukocytes by their volume (V), conductivity (C) and scatter (S) of a laser beam at different angles. Each leukocyte sub-population [neutrophils (NE), lymphocytes (LY), monocytes (MO)] is characterized by the mean (MN) and the standard deviation (SD) of 7 measurements called "cellular population data" (@CPD), corresponding to morphological analysis of the leukocytes. As severe forms of infections to SARS-CoV-2 are characterized by a functional activation of mononuclear cells, leading to a cytokine storm, we evaluated whether CPD variations are correlated to the inflammation state, oxygen requirement and lung damage and whether CPD analysis could be useful for a triage of patients with COVID-19 in the Emergency Department (ED) and could help to identify patients with a high risk of worsening. Materials and method: The CPD of 825 consecutive patients with proven COVID-19 presenting to the ED were recorded and compared to classical biochemical parameters, the need for hospitalization in the ward or ICU, the need for oxygen, or lung injury on CT-scan. Results: 40 of the 42 CPD were significantly modified in COVID-19 patients in comparison to 245 controls. @MN-V-MO and @SD-V-MO were highly correlated with C-reactive protein, procalcitonin, ferritin and D-dimers. SD-UMALS-LY > 21.45 and > 23.92 identified, respectively, patients with critical lung injuries (>75%) and requiring tracheal intubation. @SD-V-MO > 25.03 and @SD-V-NE > 19.4 identified patients required immediate ICU admission, whereas a @MN-V-MO < 183 suggested that the patient could be immediately discharged. Using logistic regression, the combination of 8 CPD with platelet and basophil counts and the existence of diabetes or obesity could identify patients requiring ICU after a first stay in conventional wards (area under the curve = 0.843). Conclusion: CPD analysis constitutes an easy and inexpensive tool for triage and prognosis of COVID-19 patients in the ED.

Stratification of COVID-19 Severity Using SeptiCyte RAPID, a Novel Host Immune Response Test.

SeptiCyte® RAPID is a gene expression assay measuring the relative expression levels of host response genes PLA2G7 and PLAC8, indicative of a dysregulated immune response during sepsis. As severe forms of COVID-19 may be considered viral sepsis, we evaluated SeptiCyte RAPID in a series of 94 patients admitted to Foch Hospital (Suresnes, France) with proven SARS-CoV-2 infection. EDTA blood was collected in the emergency department (ED) in 67 cases, in the intensive care unit (ICU) in 23 cases and in conventional units in 4 cases. SeptiScore (0-15 scale) increased with COVID-19 severity. Patients in ICU had the highest SeptiScores, producing values comparable to 8 patients with culture-confirmed bacterial sepsis. Receiver operating characteristic (ROC) curve analysis had an area under the curve (AUC) of 0.81 for discriminating patients requiring ICU admission from patients who were immediately discharged or from patients requiring hospitalization in conventional units. SeptiScores increased with the extent of the lung injury. For 68 patients, a chest computed tomography (CT) scan was performed within 24 h of COVID-19 diagnosis. SeptiScore >7 suggested lung injury ≥50% (AUC = 0.86). SeptiCyte RAPID was compared to other biomarkers for discriminating Critical + Severe COVID-19 in ICU, versus Moderate + Mild COVID-19 not in ICU. The mean AUC for SeptiCyte RAPID was superior to that of any individual biomarker or combination thereof. In contrast to C-reactive protein (CRP), correlation of SeptiScore with lung injury was not impacted by treatment with anti-inflammatory agents. SeptiCyte RAPID can be a useful tool to identify patients with severe forms of COVID-19 in ED, as well as during follow-up.

Can Haematological Parameters Discriminate COVID-19 from Influenza?

Symptoms of COVID-19 are similar to the influenza virus, but because treatments and prognoses are different, it is important to accurately and rapidly differentiate these diseases. The aim of this study was to evaluate whether the analysis of complete blood count (CBC), including cellular population (CPD) data of leukocytes and automated flow cytometry analysis, could discriminate these pathologies. In total, 350 patients with COVID-19 and 102 patients with influenza were included between September 2021 and April 2022 in the tertiary hospital of Suresnes (France). Platelets were lower in patients with influenza than in patients with COVID-19, whereas the CD16pos monocyte count and the ratio of the CD16pos monocytes/total monocyte count were higher. Significant differences were observed for 9/56 CPD of COVID-19 and flu patients. A logistic regression model with 17 parameters, including among them 11 CPD, the haemoglobin level, the haematocrit, the red cell distribution width, and B-lymphocyte and CD16pos monocyte levels, discriminates COVID-19 patients from flu patients. The sensitivity and efficiency of the model were 96.2 and 86.6%, respectively, with an area under the curve of 0.862. Classical parameters of CBC are very similar among the three infections, but CPD, CD16pos monocytes, and B-lymphocyte levels can discriminate patients with COVID-19.

N-Glycosylation Deficiency Reduces the Activation of Protein C and Disrupts Endothelial Barrier Integrity.

Phosphomannomutase 2 (PMM2) deficiency is the most prevalent congenital disorder of glycosylation. It is associated with coagulopathy, including protein C deficiency. Since all components of the anticoagulant and cytoprotective protein C system are glycosylated, we sought to investigate the impact of an N-glycosylation deficiency on this system as a whole. To this end, we developed a PMM2 knockdown model in the brain endothelial cell line hCMEC/D3. The resulting PMM2low cells were less able to generate activated protein C (APC), due to lower surface expression of thrombomodulin and endothelial protein C receptor. The low protein levels were due to downregulated transcription of the corresponding genes (THBD and PROCR, respectively), which itself was related to downregulation of transcription regulators Krüppel-like factors 2 and 4 and forkhead box C2. PMM2 knockdown was also associated with impaired integrity of the endothelial cell monolayer-partly due to an alteration in the structure of VE-cadherin in adherens junctions. The expression of protease-activated receptor 1 (involved in the cytoprotective effects of APC on the endothelium) was not affected by PMM2 knockdown. Thrombin stimulation induced hyperpermeability in PMM2low cells. However, pretreatment of cells with APC before thrombin simulation was still associated with a barrier-protecting effect. Taken as a whole, our results show that the partial loss of PMM2 in hCMEC/D3 cells is associated with impaired activation of protein C and a relative increase in barrier permeability.

Comparison of two SARS-CoV-2 RT-PCR assays and implication of the instrument software on cycle threshold (Ct) value

The Cycle Threshold (Ct) value of SARS-CoV-2 RT-PCR are used as an indicator of viral load. Using a collection of 45 fresh nasopharyngeal samples collected on universal transport media, we compare the Ct value obtained with 2 RT-PCR assays, the Alinity M SARS-CoV-2 and the Alinity M RESP-4-Plex (Abbott Molecular, Des Plaines, Illinois, Etats-Unis) processed on an Alinity M device. The assays are highly correlated; however, the Ct values were in median lower of 4.54 with the Alinity M RESP-4-Plex. This difference could be attributed to earlier detection of positivity by the software of the Alinity M rather than a difference in RT-PCR performances. The Ct-value of SARS-CoV-2 RT-PCR should be interpreted with caution taking into account the clinical context, pre-analytical and analytical findings.

La valeur du cycle seuil (Ct) des RT-PCR positives pour le SARS-CoV-2 est utilisée pour évaluer si un patient est contagieux. Lors d'un changement de réactif, nous avons comparé les résultats de Ct obtenus pour 45 prélèvements positifs pour le SARS-CoV-2 avec 2 kits de réactifs : Alinity M SARS-CoV-2 et Alinity M RESP-4-Plex (Abbott Molecular, Des Plaines, Illinois, États-Unis) utilisée avec l'automate Alinity M. Les deux méthodes était corrélées mais les Ct étaient en médiane plus bas de 4,54 avec le réactif Alinity M RESP-4-Plex en comparaison du réactif Alinity M SARS-CoV-2. Cette différence semble liée à une détection plus précoce de la positivité par le logiciel de l'Alinity M qu'à une différence de performances. Nous alertons sur le fait que les valeurs de Ct doivent être interprétées avec prudence en prenant en compte le contexte clinique, les limites pré-analytiques et analytiques.

Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction.

OBJECTIVE: Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation. DESIGN: Retrospective monocentric cohort study. SETTING: Foch University Hospital, Suresnes, France. PARTICIPANTS: Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction). CONCLUSIONS: Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.

The Panbio COVID-19 Ag Rapid Test: Which Performances are for COVID-19 Diagnosis?

BACKGROUND: Rapid antigen detection assays are promising tools for the diagnosis of COVID-19. We assess the performances of the Panbio COVID-19 Ag Rapid Test. METHODS: The Panbio COVID-19 Ag Rapid test was compared to a reference RT-PCR performed on the same nasopharyngeal swab (NPS). Overall, 81 NPS were tested retrospectively and 330 healthcare workers (HCWs) were tested prospectively. RESULTS: Retrospective analyze. Of the 48 SARS-CoV-2 positive NPS, 19 (39.6%) were found positive with the Panbio COVID-19. There was no cross-reactivity with SARS-CoV-2 negative NPS. The Kappa value was 0.459. Prospective analyze. The prevalence of COVID-19 was 26.1% in symptomatic HCWs. The overall sensitivity and specificity of the Panbio COVID-19 were 47.2% and 100.0% respectively. The sensitivity was 55.2% and 14.3% in those tested within and after 4 days of diseases respectively. CONCLUSIONS: The Panbio COVID-19 Ag Rapid test displays low performance for the identification of SARS-CoV-2 infected patients.

SARS-CoV-2 screening of asymptomatic health care workers: experience of a General hospital.

Health care workers (HCWs) are at major risk to be infected by SARS-CoV-2 and transmit the virus to the patients. Furthermore, travels are a major factor in the diffusion of the virus. We report our experience regarding the screening of asymptomatic HCWs returning from holidays, following the issue of a national guideline on 08/20/2020. The organization of the occupational health department and the clinical laboratory was adapted in order to start the screening on August, 24, 2020. All HCWs tested for SARS-CoV-2 the week before and 4 weeks after the implementation of the screening were included. The mean number of tests was analyzed per working day and working week. Overall, 502 (31.4%) HCWs were tested for SARS-CoV-2 during the study period. The mean number of HCWs tested per working day was 27.1. HCWs accounted for 36.9% (n = 167) and 11.2% (n = 84) of the tests performed in the 1st and the 4th week following the implementation of the guidelines. The number of tests performed each week in HCWs increased by at least 20-fold after the implementation of the guidelines. No asymptomatic HCW was tested positive. Screening of asymptomatic HCWs was poorly effective in the context of low circulation of the virus. We suggest giving priority to infection prevention and control measures and screening of symptomatic subjects and asymptomatic contacts.

SLC37A4-CDG: New biochemical insights for an emerging congenital disorder of glycosylation with major coagulopathy.

SLC37A4-CDG is an emerging congenital disorder of glycosylation which is characterized by a dominant inheritance and a major coagulopathy originating from the liver. Recent studies took interest in the biochemical alterations found in this CDG and showed that they consisted of multiple glycosylation abnormalities, which result from mislocalization of the endoplasmic reticulum glucose-6-phosphate transporter and associated Golgi homeostasis defects. In this work, we highlight in six affected individuals abnormal patterns for various serum N-glycoproteins and bikunin proteoglycan isoforms, together with specific alterations of the mass spectra of endoglycosidase H-released serum N-glycans. Collectively, these data complement previous findings, help to better delineate SLC37A4-CDG and could present interest in diagnosing this disease.

A mutation in SLC37A4 causes a dominantly inherited congenital disorder of glycosylation characterized by liver dysfunction.

SLC37A4 encodes an endoplasmic reticulum (ER)-localized multitransmembrane protein required for transporting glucose-6-phosphate (Glc-6P) into the ER. Once transported into the ER, Glc-6P is subsequently hydrolyzed by tissue-specific phosphatases to glucose and inorganic phosphate during times of glucose depletion. Pathogenic variants in SLC37A4 cause an established recessive disorder known as glycogen storage disorder 1b characterized by liver and kidney dysfunction with neutropenia. We report seven individuals who presented with liver dysfunction multifactorial coagulation deficiency and cardiac issues and were heterozygous for the same variant, c.1267C>T (p.Arg423∗), in SLC37A4; the affected individuals were from four unrelated families. Serum samples from affected individuals showed profound accumulation of both high mannose and hybrid type N-glycans, while N-glycans in fibroblasts and undifferentiated iPSC were normal. Due to the liver-specific nature of this disorder, we generated a CRISPR base-edited hepatoma cell line harboring the c.1267C>T (p.Arg423∗) variant. These cells replicated the secreted abnormalities seen in serum N-glycosylation, and a portion of the mutant protein appears to relocate to a distinct, non-Golgi compartment, possibly ER exit sites. These cells also show a gene dosage-dependent alteration in the Golgi morphology and reduced intraluminal pH that may account for the altered glycosylation. In summary, we identify a recurrent mutation in SLC37A4 that causes a dominantly inherited congenital disorder of glycosylation characterized by coagulopathy and liver dysfunction with abnormal serum N-glycans.