Comment on "Inflawell, neutrophil-to-lymphocyte ratio and COVID-19".

Dear Editor,

We would like to share ideas on the publication “Inflawell() improves neutrophil-to-lymphocyte ratio and shortens hospitalization in patients with moderate COVID-19, in a randomized double-blind placebo-controlled clinical trial [1]”. Barzin et al. (2022) concluded that “the treatment with Inflawell resulted in shorter hospital stay, alleviation of COVID-19 clinical symptoms and decline in the level of pro-inflammatory cytokines.” We agree that Inflawell® might useful for management of COVID-19. However, there are many confounding factors that might affect the measured outcome in the present report. In the present report, Barzin et al. (2022) set inclusion criteria for recruit COVID-19 patients. They used history of liver, kidney, and/or heart failure for exclusion. Therefore, it cannot rule out the case with asymptomatic abnormality such as cases with chronic silent asymptomatic hepatitis carrier status or cases with underlying hemoglobin disorder, which might further affect the measured outcome parameters such as complete blood count.

In this work, Barzin et al. (2022) reported on hospital stay as a main outcome. The hospital stay of COVID-19 case depends on several factors. The alternative therapy, quality of local supportive care and the local bed availability have to be considered. Another important reported parameter by Barzin et al. (2022) is neutrophil-to-lymphocyte ratio. This parameter is a possible usefulness clinical marker for monitoring case with COVID-19 (Lagunas-Rangel 2020). There are no data on the analysis of this parameter in the present report. Basically, neutrophil-to-lymphocyte ratio is based on the basic complete blood count parameters, which are derived from automated hematology analyzer. The specification and quality control of the analysis using automated hematology analyzer should be mentioned. The variation among different analyzer might occur. Regarding neutrophil-to-lymphocyte ratio, it can be affected by different hematological analyzers as well as other confounding personal illness (Health Devices 1992; Takubo et al. 2002).