This blog post is a companion piece to a YouTube video, which you can access here.
In this blog post, you will be introduced to the most easily obtainable biomarker that is a proxy for chronic inflammation – the neutrophil-to-lymphocyte ratio.
Unlike specific markers of inflammation like C-reactive protein, fibrinogen, or malondialdehyde, your neutrophils and lymphocytes are regularly calculated as part of a standard metabolic panel. By dividing your absolute neutrophil count by your absolute lymphocyte count, you can quickly produce the highly predictive ratio that is a valuable indicator of systemic inflammation.
Below, we will take a brief tour through the various illnesses in which elevated NLRs are predictive, beginning with death in general.
The NLR
First suggested as a marker of systemic inflammation and stress in 2001, the neutrophil/lymphocyte ratio (NLR) is a predictive and easily obtainable marker of human health[i]. An average NLR is 1.65, with a healthy range from 0.78-3.53[ii].
Mortality
This year, it was shown that an elevated NLR is associated with increased all-cause mortality in the general US population – it is a predictor of death. It is associated with increased mortality from heart disease, cerebrovascular disease, lower respiratory disease, influenza, and kidney disease[iii].
The Brain
1. Adolescents:
a. An elevated NLR is found in children with ADHD[iv].
b. Adolescents with major depressive disorder (MDD) have higher NLRs[v].
c. Elevated NLRs are found among those with autism spectrum disorder (ASD)[vi].
2. Mental illness:
a. Among people with MDD, those with elevated NLRs are more likely to have exhibited suicidal behavior[vii].
b. Patients with bipolar disorder (BPD) exhibit elevated NLRs[viii], though it may be more pronounced in males[ix]. BPD patients exhibit higher NLRs than patients with MDD[x].
c. Patients with schizophrenia also exhibit elevated NLRs[xi] and elevated NLRs are associated with severity of symptoms[xii]. Antipsychotic treatment reduces the NLR among schizophrenics[xiii].
3. Addiction:
a. Methamphetamine abusers have lower NLRs than the average population, implying that methamphetamine use has some effect on the immune system[xiv].
4. Neurodegenerative disease:
a. In multiple sclerosis, NLR elevation is associated with severity of neurological disability[xv] and with disease activity[xvi].
i. Interestingly, in MS, HIT cardio lowers the NLR via a hormetic effect on inflammation modulation[xvii].
b. The NLR is elevated among those with Parkinson’s Disease[xviii].
c. Unlike in idiopathic Parkinson’s Disease, in Alzheimer’s Disease, average NLRs are similar to healthy controls[xix].
d. In the elderly, elevated NLRs are associated generally with cognitive impairment[xx].
Autoimmune Disease
1. Gastrointestinal:
a. In Crohn’s Disease, NLR associates with erythrocyte sedimentation rate (ESR), with CRP, with malondialdehyde, and with total white blood cell count (WBC). In ulcerative colitis, similar associations were found, in addition to fecal lactoferrin and fecal calprotectin (unless patients took an anti-TNF drug).
2. Thyroid:
a. An elevated NLR is associated with Hashimoto’s thyroiditis[xxi].
b. Elevated NLRs are associated with relapse in patients with Grave’s Disease being treated with antithyroid drugs[xxii].
3. Arthritis:
a. NLR is elevated in rheumatoid arthritics, though it does not associate closely with disease activity[xxiii].
b. NLR is a predictor of the severity of knee osteoarthritis[xxiv].
4. IgA nephropathy:
a. Elevated NLRs are associated with poorer outcomes in this autoimmune kidney disease[xxv].
5. Psoriasis:
a. People with psoriasis have increased risk of cardiovascular disease. NLR is a proxy for subclinical atherosclerosis among patients with psoriasis[xxvi].
Cardiovascular Disease
1. Heart failure:
a. NLR is inversely associated with left ventricular ejection fraction among patients with heart failure. A cut off of 3.0 predicted heart failure with 86% sensitivity and 78% specificity. NLR could also predict death with a 75% sensitivity and 62% specificity during a 13 month follow up if a cut off of 5.1 was used. PLR is a comparatively inferior biomarker for heart failure[xxvii].
2. Stroke:
a. A meta-analysis found that in both ischemic and hemorrhagic stroke, elevated baseline NLR is associated with worse outcomes. It is also associated with a higher recurrence of ischemic stroke[xxviii].
b. A meta-analysis found that it also predicts hemorrhagic transformation from ischemic cerebral infarction[xxix].
3. Calcific aortic valve disease (CAVD):
a. NLR is elevated among CAVD patients compared to controls. Among CAVD patients, tricuspid aortic valve (TAV) patients had higher NLR and lower CRPs than bicuspid aortic valve (BAV) patients[xxx].
4. Atherosclerosis:
a. Among the morbidly obese, NLR is associated with CRP, visceral adiposity, leptin and adiponectin, and the development of atherosclerosis[xxxi].
b. Among the elderly, NLR predicts carotid artery plaques better than CRP or fibrinogen[xxxii].
c. NLR (and PLR) are associated with symptomatic internal carotid artery stenosis[xxxiii].
5. Atrial fibrillation:
a. Patients with non-valvular atrial fibrillation had higher NLRs, with a cut off of 2.1 being predictive[xxxiv].
Cancer
1. A systematic review of studies using the NLR with cancer patients found that[xxxv]:
a. NLR was more prognostic for upper gastrointestinal cancers, for advanced or inoperable tumors, while it was less prognostic for operable cancers like colorectal cancer.
b. NLR associated well with CRP and hypoalbuminemia.
c. Threshold ratios of elevated NLR ranged from over 2.5 to over 5.
2. Liver cancer:
a. NLR predicts the likelihood of HCC recurrence consequent to liver transplantation[xxxvi].
i. Using a cut off of 4, patients with low NLRs had a 5-year survival rate of 89% while patients with high NLRs had a survival rate of 30%.
ii. While tumor expression of IL-17 was similar between groups, serum and peritumoral IL-17 was significantly higher in the high NLR group.
iii. While lymphocyte count was not associated with survival outcomes, the neutrophil count was.
iv. Because IL-18 (which promotes angiogenesis) was not associated with the NLR, but both IL-17 and CRP were, the authors concluded that the NLR predicts HCC recurrence via acting as a proxy for an inflammatory microenvironment, not angiogenesis.
3. Thyroid cancer:
a. Elevated NLR following treatment is associated with poor outcomes in differentiated thyroid cancers[xxxvii] and in the rarer, and much deadlier, undifferentiated thyroid cancers (i.e. anaplastic thyroid cancer)[xxxviii].
Metabolic Diseases
1. Type 1 diabetes (T1D):
a. There is relationship between NLR and aortic stiffness among T1D patients[xxxix].
2. Type 2 diabetes (T2D):
a. The NLR is found to be elevated in prediabetic and diabetic patients, while the platelet-to-lymphocyte (PLR) is decreased in prediabetic and early diabetic patients but elevated in late-stage diabetes[xl].
b. The combination of physical activity and a low NLR produce a synergistic effect on the quality of life of T2D patients[xli].
c. The NLR is a predictor of atrial fibrillation among diabetics[xlii].
3. NAFLD:
a. Elevated NLRs predict both steatohepatitis and fibrosis in patients with NAFLD[xliii], though it loses its prognostic value for higher levels of steatosis[xliv].
Kidney Health
1. Diabetic nephropathy:
a. NLR is associated with worsening renal function among diabetics[xlv].
2. Chronic kidney disease (CKD):
a. Elevated NLRs associate with the incidence of cardiovascular events among people with CKD[xlvi].
3. End stage renal disease (ESRD):
a. Among patients on hemodialysis, NLR (and PLR) associated with hs-CRP and inflammation[xlvii].
Organ Transplantation
1. Heart transplantation:
a. NLR predicts mortality from heart transplantation, with a cut off of 2.41 having an 86% sensitivity and a 67% specificity[xlviii].
2. Liver transplantation:
a. NLR predicts mortality from liver transplantation, with patients carrying NLRs north of 5 dying over 10x more frequently than those with NLRs less than 2[xlix].
Viruses and Bacteria
1. SARS-CoV-2:
a. NLR is an independent risk factor for mortality among COVID-19 patients. There is an 8% increase in mortality per unit increase in NLR[l].
2. Hepatitis:
a. While the NLR is associated with hepatitis C, the PLR is a superior predictor[li].
3. Bacterial infection:
a. An NLR cut off of 6.2 well-predicts bacterial infection[lii].
b. The NLR is associated with severity of gastritis due to H. pylori infection[liii].
Other Ailments
1. NLR has been suggested as a prognostic biomarker for severe tinnitus[liv].
2. Elevated NLRs are associated with mortality among critically ill patients[lv].
[i] Zahorec, R. (2001). Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill. Bratislavske lekarske listy, 102(1), 5-14. [ii] Forget, P., Khalifa, C., Defour, J. P., Latinne, D., Van Pel, M. C., & De Kock, M. (2017). What is the normal value of the neutrophil-to-lymphocyte ratio?. BMC research notes, 10(1), 1-4. [iii] Song, M., Graubard, B. I., Rabkin, C. S., & Engels, E. A. (2021). Neutrophil-to-lymphocyte ratio and mortality in the United States general population. Scientific Reports, 11(1), 1-9. [iv] Avcil, S. (2018). Evaluation of the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as inflammatory markers in children with attention‐deficit hyperactivity disorder. Psychiatry and clinical neurosciences, 72(7), 522-530. [v] Uçar, H. N., Eray, Ş., & Murat, D. (2018). Simple peripheral markers for inflammation in adolescents with major depressive disorder. Psychiatry and Clinical Psychopharmacology, 28(3), 254-260. [vi] Kulaksizoglu, S., & Koparan, C. (2019). High neutrophil to lymphocyte ratio and low mean platelet volume level in autism spectrum disorders. Annals of Medical Research, 26(10), 2382-2385. [vii] Ekinci, O., & Ekinci, A. (2017). The connections among suicidal behavior, lipid profile and low-grade inflammation in patients with major depressive disorder: a specific relationship with the neutrophil-to-lymphocyte ratio. Nordic journal of psychiatry, 71(8), 574-580. [viii]Inanli, I., Aydin, M., Çaliskan, A. M., & Eren, I. (2019). Neutrophil/lymphocyte ratio, monocyte/lymphocyte ratio, and mean platelet volume as systemic inflammatory markers in different states of bipolar disorder. Nordic journal of psychiatry, 73(6), 372-379. [ix] Fusar-Poli, L., Amerio, A., Cimpoesu, P., Grimaldi Filioli, P., Natale, A., Zappa, G., ... & Aguglia, A. (2021). Gender differences in complete blood count and inflammatory ratios among patients with bipolar disorder. Brain Sciences, 11(3), 363. [x] Dionisie, V., Filip, G. A., Manea, M. C., Movileanu, R. C., Moisa, E., Manea, M., ... & Ciobanu, A. M. (2021). Neutrophil-to-Lymphocyte Ratio, a Novel Inflammatory Marker, as a Predictor of Bipolar Type in Depressed Patients: A Quest for Biological Markers. Journal of Clinical Medicine, 10(9), 1924. [xi] Karageorgiou, V., Milas, G. P., & Michopoulos, I. (2019). Neutrophil-to-lymphocyte ratio in schizophrenia: A systematic review and meta-analysis. Schizophrenia research, 206, 4-12. [xii] Kovács, M. Á., Tényi, T., Kugyelka, R., Prenek, L., Hau, L., Magyar, É. E., ... & Simon, D. (2020). Elevated Osteopontin and Interferon Gamma Serum Levels and Increased Neutrophil-to-Lymphocyte Ratio Are Associated With the Severity of Symptoms in Schizophrenia. Frontiers in psychiatry, 10, 996. [xiii]Zhou, X., Wang, X., Li, R., Yan, J., Xiao, Y., Li, W., & Shen, H. (2020). Neutrophil-to-lymphocyte ratio is independently associated with severe psychopathology in schizophrenia and is changed by antipsychotic administration: a large-scale cross-sectional retrospective study. Frontiers in Psychiatry, 11. [xiv] Demir, B., Sahin, S. K., Ozsoy, F., Altindag, A., & Elboga, G. (2021). Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Methamphetamine Use Disorder. PSYCHIATRY AND CLINICAL PSYCHOPHARMACOLOGY, 31(1), 34-39. [xv] Hemond, C. C., Glanz, B. I., Bakshi, R., Chitnis, T., & Healy, B. C. (2019). The neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios are independently associated with neurological disability and brain atrophy in multiple sclerosis. BMC neurology, 19(1), 1-10. [xvi] D’Amico, E., Zanghì, A., Romano, A., Sciandra, M., Palumbo, G. A. M., & Patti, F. (2019). The neutrophil-to-lymphocyte ratio is related to disease activity in relapsing remitting multiple sclerosis. Cells, 8(10), 1114. [xvii]Joisten, N., Proschinger, S., Rademacher, A., Schenk, A., Bloch, W., Warnke, C., ... & Zimmer, P. (2021). High-intensity interval training reduces neutrophil-to-lymphocyte ratio in persons with multiple sclerosis during inpatient rehabilitation. Multiple Sclerosis Journal, 27(7), 1136-1139. [xviii]Muñoz‐Delgado, L., Macías‐García, D., Jesús, S., Martín‐Rodríguez, J. F., Labrador‐Espinosa, M. Á., Jiménez‐Jaraba, M. V., ... & Mir, P. (2021). Peripheral Immune Profile and Neutrophil‐to‐Lymphocyte Ratio in Parkinson's Disease. Movement Disorders. [xix] Kara, S. P., Altunan, B., & Unal, A. (2021). Investigation of the peripheral inflammation (neutrophil–lymphocyte ratio) in two neurodegenerative diseases of the central nervous system. Neurological Sciences, 1-9. [xx] Liu, J. H., Zhang, Y. J., Ma, Q. H., Sun, H. P., Xu, Y., & Pan, C. W. (2020). Elevated blood neutrophil to lymphocyte ratio in older adults with cognitive impairment. Archives of gerontology and geriatrics, 88, 104041. [xxi] Aktas, G., Sit, M., Dikbas, O., Erkol, H., Altinordu, R., Erkus, E., & Savli, H. (2017). Elevated neutrophil-to-lymphocyte ratio in the diagnosis of Hashimoto's thyroiditis. Revista da Associação Médica Brasileira, 63, 1065-1068. [xxii]Kim, M., Kim, B. H., Jang, M. H., Kim, J. M., Kim, E. H., Jeon, Y. K., ... & Kim, I. J. (2020). High neutrophil-to-lymphocyte ratio is associated with relapse in Graves’ disease after antithyroid drug therapy. Endocrine, 67(2), 406-411. [xxiii]Lee, Y. H. (2018). Association between the neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio and rheumatoid arthritis and their correlations with the disease activity: a meta-analysis. Journal of Rheumatic Diseases, 25(3), 169-178. [xxiv]Taşoğlu, Ö., Bölük, H., Onat, Ş. Ş., Taşoğlu, İ., & Özgirgin, N. (2016). Is blood neutrophil-lymphocyte ratio an independent predictor of knee osteoarthritis severity?. Clinical rheumatology, 35(6), 1579-1583. [xxv] Li, Q., Chen, P., Shi, S., Liu, L., Lv, J., Zhu, L., & Zhang, H. (2020). Neutrophil-to-lymphocyte ratio as an independent inflammatory indicator of poor prognosis in IgA nephropathy. International Immunopharmacology, 87, 106811. [xxvi]Yurtdaş, M., Yaylali, Y. T., Kaya, Y., Özdemir, M., Özkan, İ., & Aladağ, N. (2014). Neutrophil‐to‐lymphocyte ratio may predict subclinical atherosclerosis in patients with psoriasis. Echocardiography, 31(9), 1095-1104. [xxvii]Durmus, E., Kivrak, T., Gerin, F., Sunbul, M., Sari, I., & Erdogan, O. (2015). Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are predictors of heart failure. Arquivos brasileiros de cardiologia, 105, 606-613. [xxviii]Song, S. Y., Zhao, X. X., Rajah, G., Hua, C., Kang, R. J., Han, Y. P., ... & Meng, R. (2019). Clinical significance of baseline neutrophil-to-lymphocyte ratio in patients with ischemic stroke or hemorrhagic stroke: an updated meta-analysis. Frontiers in neurology, 10, 1032. [xxix]Zhang, R., Wu, X., Hu, W., Zhao, L., Zhao, S., Zhang, J., ... & Xu, Y. (2019). Neutrophil‐to‐lymphocyte ratio predicts hemorrhagic transformation in ischemic stroke: A meta‐analysis. Brain and behavior, 9(9), e01382. [xxx] Song, J., Zheng, Q., Ma, X., Zhang, Q., Xu, Z., Zou, C., & Wang, Z. (2019). Predictive roles of neutrophil-to-lymphocyte ratio and C-reactive protein in patients with calcific aortic valve disease. International heart journal, 60(2), 345-351. [xxxi]Suárez‐Cuenca, J. A., Ruíz‐Hernández, A. S., Mendoza‐Castañeda, A. A., Domínguez‐Pérez, G. A., Hernández‐Patricio, A., Vera‐Gómez, E., ... & Alcaráz-Estrada, S. L. (2019). Neutrophil‐to‐lymphocyte ratio and its relation with pro‐inflammatory mediators, visceral adiposity and carotid intima‐media thickness in population with obesity. European journal of clinical investigation, 49(5), e13085. [xxxii]Corriere, T., Di Marca, S., Cataudella, E., Pulvirenti, A., Alaimo, S., Stancanelli, B., & Malatino, L. (2018). Neutrophil-to-Lymphocyte Ratio is a strong predictor of atherosclerotic carotid plaques in older adults. Nutrition, Metabolism and Cardiovascular Diseases, 28(1), 23-27. [xxxiii]Massiot, N., Lareyre, F., Voury-Pons, A., Pelletier, Y., Chikande, J., Carboni, J., ... & Raffort, J. (2019). High neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are associated with symptomatic internal carotid artery stenosis. Journal of Stroke and Cerebrovascular Diseases, 28(1), 76-83. [xxxiv]Acet, H., Ertaş, F., Akıl, M. A., Oylumlu, M., Polat, N., Yıldız, A., ... & Ülgen, M. S. (2014). New inflammatory predictors for non-valvular atrial fibrillation: echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio. The international journal of cardiovascular imaging, 30(1), 81-89. [xxxv]Guthrie, G. J., Charles, K. A., Roxburgh, C. S., Horgan, P. G., McMillan, D. C., & Clarke, S. J. (2013). The systemic inflammation-based neutrophil–lymphocyte ratio: experience in patients with cancer. Critical reviews in oncology/hematology, 88(1), 218-230. [xxxvi]Motomura, T., Shirabe, K., Mano, Y., Muto, J., Toshima, T., Umemoto, Y., ... & Maehara, Y. (2013). Neutrophil–lymphocyte ratio reflects hepatocellular carcinoma recurrence after liver transplantation via inflammatory microenvironment. Journal of hepatology, 58(1), 58-64. [xxxvii]Lee, F., Yang, P. S., Chien, M. N., Lee, J. J., Leung, C. H., & Cheng, S. P. (2018). An increased neutrophil-to-lymphocyte ratio predicts incomplete response to therapy in differentiated thyroid cancer. International journal of medical sciences, 15(14), 1757. [xxxviii]Yamazaki, H., Sugino, K., Matsuzu, K., Masaki, C., Akaishi, J., Hames, K., ... & Ito, K. (2020). Inflammatory biomarkers and dynamics of neutrophil-to-lymphocyte ratio in anaplastic thyroid carcinoma. Endocrine, 70(1), 115-122. [xxxix]Ayhan, H., Kasapkara, H. A., Aslan, A. N., Durmaz, T., Keleş, T., Akçay, M., ... & Bozkurt, E. (2015). Relationship of neutrophil-to-lymphocyte ratio with aortic stiffness in type 1 diabetes mellitus. Canadian journal of diabetes, 39(4), 317-321. [xl] Mertoglu, C., & Gunay, M. (2017). Neutrophil-Lymphocyte ratio and Platelet-Lymphocyte ratio as useful predictive markers of prediabetes and diabetes mellitus. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11, S127-S131. [xli] Rias, Y. A., Kurniasari, M. D., Traynor, V., Niu, S. F., Wiratama, B. S., Chang, C. W., & Tsai, H. T. (2020). Synergistic effect of low neutrophil–lymphocyte ratio with physical activity on quality of life in type 2 diabetes mellitus: A community-based study. Biological research for nursing, 22(3), 378-387. [xlii]Sahin, S., Sarikaya, S., Alcelik, A., Erdem, A., Tasliyurt, T., Akyol, L., & Altunkas, F. (2013). Neutrophil to lymphocyte ratio is a useful predictor of atrial fibrillation in patients with diabetes mellitus. [xliii]Alkhouri, N., Morris‐Stiff, G., Campbell, C., Lopez, R., Tamimi, T. A. R., Yerian, L., ... & Feldstein, A. E. (2012). Neutrophil to lymphocyte ratio: a new marker for predicting steatohepatitis and fibrosis in patients with nonalcoholic fatty liver disease. Liver International, 32(2), 297-302. [xliv]Raksha, S. K., Desai, R. R., Chetan, V., & Chandrashekar, A. P. (2021). A Study on Association between Neutrophil to Lymphocyte Ratio and Steatohepatitis and Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease. Journal of Evolution of Medical and Dental Sciences, 10(25), 1876-1883. [xlv] Azab, B., Daoud, J., Naeem, F. B., Nasr, R., Ross, J., Ghimire, P., ... & El-Sayegh, S. (2012). Neutrophil-to-lymphocyte ratio as a predictor of worsening renal function in diabetic patients (3-year follow-up study). Renal failure, 34(5), 571-576. [xlvi]Solak, Y., Yilmaz, M. I., Sonmez, A., Saglam, M., Cakir, E., Unal, H. U., ... & Carrero, J. J. (2013). Neutrophil to lymphocyte ratio independently predicts cardiovascular events in patients with chronic kidney disease. Clinical and experimental nephrology, 17(4), 532-540. [xlvii]Ahbap, E., Sakaci, T., Kara, E., Sahutoglu, T., Koc, Y., Basturk, T., ... & Unsal, A. (2016). Neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in evaluation of inflammation in end-stage renal disease. Clinical nephrology, 85(4), 199-208. [xlviii]Seropian, I. M., Romeo, F. J., Pizarro, R., Vulcano, N. O., Posatini, R. A., Marenchino, R. G., ... & Belziti, C. A. (2018). Neutrophil‐to‐lymphocyte ratio and platelet‐to‐lymphocyte ratio as predictors of survival after heart transplantation. ESC heart failure, 5(1), 149-156. [xlix]Leithead, J. A., Rajoriya, N., Gunson, B. K., & Ferguson, J. W. (2015). Neutrophil‐to‐lymphocyte ratio predicts mortality in patients listed for liver transplantation. Liver International, 35(2), 502-509. [l] Liu, Y., Du, X., Chen, J., Jin, Y., Peng, L., Wang, H. H., ... & Zhao, Y. (2020). Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19. Journal of Infection, 81(1), e6-e12. [li] Meng, X., Wei, G., Chang, Q., Peng, R., Shi, G., Zheng, P., ... & Ming, L. (2016). The platelet-to-lymphocyte ratio, superior to the neutrophil-to-lymphocyte ratio, correlates with hepatitis C virus infection. International Journal of Infectious Diseases, 45, 72-77. [lii] Holub, M., Beran, O., Kaspříková, N., & Chalupa, P. (2012). Neutrophil to lymphocyte count ratio as a biomarker of bacterial infections. Open Medicine, 7(2), 258-261. [liii]Farah, R., & Khamisy‐Farah, R. (2014). Association of neutrophil to lymphocyte ratio with presence and severity of gastritis due to Helicobacter pylori infection. Journal of clinical laboratory analysis, 28(3), 219-223. [liv] Ozbay, I., Kahraman, C., Balikci, H. H., Kucur, C. Ü. N. E. Y. T., Kahraman, N. K., Ozkaya, D. P., & Oghan, F. (2015). Neutrophil-to-lymphocyte ratio in patients with severe tinnitus: prospective, controlled clinical study. The Journal of Laryngology & Otology, 129(6), 544-547. [lv] Dilektasli, E., Inaba, K., Haltmeier, T., Wong, M. D., Clark, D., Benjamin, E. R., ... & Demetriades, D. (2016). The prognostic value of neutrophil-to-lymphocyte ratio on mortality in critically ill trauma patients. Journal of Trauma and Acute Care Surgery, 81(5), 882-888.
