الفهرس 
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Abstract
Coronavirus disease-2019 (COVID-19) is a global health crisis. The clinical characteristics, disease progression and outcome in children appear significantly milder compared to older individuals. Symptoms, although variable, depend on the stage of the disease, the prior health status, and the presence of comorbidities and other individual features. The risk factors for morbidity and mortality include comorbidities such as diabetes, chronic pulmonary disease, and cardiac pathology. Thus, prompt diagnosis is vital, given the evolution of the disease, with ARDS potentially occurring at 1 week after symptom onset.
Arterial and venous thrombotic complications and coagulopathies including disseminated intravascular coagulopathy (DIC) have become a major cause of morbidity and mortality particularly in patients with comorbid conditions, prolonged hospitalization, intensive care unit (ICU) admission, and mechanical ventilation (MV). Excessive inflammation, platelet activation, endothelial dysfunction, and stasis play a significant role in the development of thrombotic complications.
D-dimer is the degradation product of fibrin and reflects the activation of both thrombotic and fibrinolytic pathways. D-dimer elevations are detected in plasma during the onset of thrombus formation and its elevation usually lasts about a week. For this reason, it is possible to find high levels of D-dimer during increased fibrinolytic activity. It occurs in high concentrations in
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many clinical conditions, such as deep vein thrombosis and pulmonary embolism. It may be also elevated in myocardial infarction, disseminated intravascular coagulation, pneumonia, heart failure, neoplasia and polytrauma.
We performed a retrospective observational study to investigate the prognostic value of D-dimer levels measured on admission in patients infected with novel Coronavirus Disease 2019 (COVID-19).
The study enrolled 80 consecutive critically ill patients with test confirmed COVID-19 status attending Ain Shams University Hospital, intensive care units (Dimerdash Hospital). We retrospectively collected demographic, clinical data, laboratory parameters and prognosis.
Each patient included in the study was subjected to epidemiological history, clinical manifestations, calculation of ARDS severity and nasal collection of PCR. Plasma level of D-dimer is measured by enzyme–linked immunosorbentassay (ELISA).
Age ranged from 28 to 87 years with mean of 59.08 years, 52.5% of our patients were males and 47.5% of them were females. Concerning comorbidities, 45% were diabetics, 37.5% were hypertensives, 12.5 had history of cardiac diseases and 5% were asthmatics.
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In our study, D dimer ranged from 38 to 2200 with median 100 on admission. According to Berlin Definition of ARDS, 28.7% had severe disease, 23.8% had moderate disease and 47.5% had mild disease. Patients stayed in ICU for 2 to 29 days with mean 12.38 days. About 29% of patients died.
There is statistically significant positive correlation between D dimer and all of neutrophil, C reactive protein and length of hospital stay. There is statistically significant negative correlation between D dimer and lymphocytes. There is non-significant correlation between D dimer and either age, hemoglobin or platelet count. Among factors significantly correlated with D dimer, lymphocytes, CRP at admission and neutrophil count significantly independently associated with it.
In our study, the median value of D-dimer of all patients was 100 for patients with mild disease, 185 for patients with moderate disease and 1000 for severe patients. There is statistically a significant relation between D dimer and disease severity among studied patients. On pairwise comparison, the difference is significant between each two individual groups where lowest value was reported in those with mild disease followed by moderate then severe disease (highest value). There is statistically a significant relation between D dimer and outcome of patients where non-survivors reported higher value of D dimer when compared to survivors.
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The best cutoff of D dimer in prediction of severe disease is ≥308 with area under curve of 0.897, sensitivity of 87%, specificity of 80.7%, positive predictive value (PPV) of 64.5%, negative predictive value of 93.9% and overall accuracy of 82.5% (p<0.001). Statistically, there is statistically significant association between D dimer (≥308) and disease severity where D dimer significantly increased risk of having severe disease by 27.9 folds.
The best cutoff of D dimer in prediction of mortality is ≥376 with area under curve of 0.839, sensitivity of 82.6%, specificity of 82.5%, positive predictive value (PPV) of 65.5%, negative predictive value of 92.2% and overall accuracy of 82.5% (p<0.001). Statistically, there is significant association between D dimer (≥376) and mortality where D dimer significantly increased risk of mortality by 22.4 folds.
In our study, there is statistically significant association between D dimer (≥376) and overall survival which was significantly higher in those with D dimer <376