The Association Between Neutrophil/Lymphocyte Ratio and Disease Activity in Rheumatoid Arthritis and Ankylosing Spondylitis

The effectiveness of tocilizumab in treating refractory adult-onset Still's disease with dichotomous phenotypes: IL-18 is a potential predictor of therapeutic response

OBJECTIVE

Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder with clinical heterogeneity. Although tocilizumab (TCZ), an interleukin (IL)-6 receptor inhibitor, is an effective treatment for AOSD, the evidence regarding its efficacy on systemic or articular subtypes is conflicting. Furthermore, the predictors of therapeutic response are still elusive and worthy of exploration.

METHODS

This two-center retrospective study analyzed the effectiveness and safety profile of TCZ treatment in 28 patients with refractory AOSD. The 28-joint disease activity score (DAS28) and systemic activity score were assessed before and during TCZ treatment period at weeks 12, 24, 36, and 48. Plasma levels of proinflammatory cytokines at baseline were determined using ELISA method.

RESULTS

Among the systemic subtype patients, 10 (58.8%), 13 (76.5%), 14 (82.4%), and 15 (88.2%) patients achieved complete remission at week 12, 24, 36, and 48, respectively, in comparison to 2 (22.2%), 5 (55.6%), 6 (66.7%), and 7 (77.8%) who achieved disease remission (DAS28 < 2.6) at weeks 12, 24, 36, and 48, respectively, among articular subtype patients. The systemic activity scores and inflammatory parameters were significantly decreased after 12-week TCZ therapy, and TCZ could significantly reduce corticosteroid dose in AOSD patients. Multivariate analysis reveals that baseline IL-18 level is a significant predictor of poor therapeutic response at week 24 (odds ratio 7.86, p < 0.05).

CONCLUSION

AOSD patients refractory to high-dose corticosteroids and methotrexate may respond well to TCZ treatment with a steroid-sparing effect and an acceptable safety. A high baseline IL-18 level may be a predictor of poor therapeutic response. Key Points • Tocilizumab may be effective and well-tolerated in refractory AOSD patients regardless of disease subtypes. • High plasma levels of IL-18 may predict poor response to tocilizumab in AOSD patients.

Prognostic Value of Neutrophil:Lymphocyte and Platelet:Lymphocyte Ratios for 28-Day Mortality of Patients with AECOPD

Objective

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the most common cause of hospitalization and death among COPD patients. Clinicians are seeking simple, inexpensive, and easily obtained biomarkers for prognostic evaluation. The aim of this study was to evaluate the association of the neutrophil:lymphocyte ratio (NLR), platelet:lymphocyte ratio (PLR) and lymphocyte:monocyte ratio (LMR) with 28-day mortality and assess the clinical prognostic utility of the NLR, PLR, and LMR in patients with AECOPD.

Methods

A retrospective study was conducted from January 2017 to April 2020 at Ningbo First Hospital. Clinical characteristics, NLR, PLR, LMR, serum levels of CRP, and other data were collected. Relationships between the NLR/PLR/LMR and CRP were evaluated with Pearson’s correlation test. Receiver-operating characteristic curves and area under the curve were used to assess the ability of NLR/PLR/LMR to predict 28-day mortality in patients with AECOPD. Optimal cutoff values were determined by the Youden index. Univariate and multivariate logistic regression analysis were used to identify risk factors for 28-day mortality in patients with AECOPD.

Results

By reviewing the medical case records, we collected 533 cases diagnosed with AECOPD for analysis. Death had occurred in 48 (9%) patients within 28 days. Univariate analysis identified age, smoking history, FEV₁% predicted, neutrophil count, lymphocyte count, NLR, PLR, CRP and blood-urea nitrogen as being associated with increased 28-day mortality. Multivariate analysis demonstrated that elevated NLR and PLR were significantly associated with death at 28 days. Receiver-operating characteristic analysis showed that the NLR had the highest area under the curve (0.801), with optimal cutoff of 6.74, sensitivity of 82.54%, and specificity of 71.38%. At a cutoff of 203.6, the corresponding sensitivity, specificity, and area under the curve of the PLR were 76.86%, 65.27%, and 0.75. The LMR failed to show prognostic significance.

Conclusion

Our results indicated that the NLR and PLR were associated with 28-day mortality in patients with AECOPD. These ratios may serve as prognostic biomarkers for short-term mortality in patients hospitalized with AECOPD.

Neutrophil to Lymphocyte Ratio in Maternal Blood: A Clue to Suspect Amnionitis

There is no information about whether maternal neutrophil to lymphocyte ratios (NLRs) progressively increase with respect to the progression of acute histologic chorioamnionitis (acute-HCA) and increased maternal NLR is a risk factor for amnionitis, known as advanced acute-HCA, in pregnant women at risk for spontaneous preterm birth (PTB). The objective of the current study is to examine this issue. The study population included 132 singleton PTB (<34 weeks) due to either preterm labor or preterm-PROM with both placental pathology and maternal CBC results within 48 h before delivery. We examined maternal NLRs according to the progression of acute-HCA in extra-placental membranes (EPM) (i.e., group-0, inflammation-free EPM; group-1, inflammation restricted to decidua; group-2, inflammation restricted to the membranous trophoblast of chorion and the decidua; group-3, inflammation in the connective tissue of chorion but not amnion; group-4, amnionitis). Maternal NLRs significantly and progressively increased with the progression of acute-HCA (Spearman’s rank correlation test, γ = 0.363, p = 0.000019). Moreover, the increased maternal NLR (≥7.75) (Odds-ratio 5.56, 95% confidence-interval 1.26-24.62, p < 0.05) was a significant independent risk factor for amnionitis even after the correction for potential confounders. In conclusion, maternal NLRs significantly and progressively increased according to the progression of acute-HCA and the increased maternal NLR (≥7.75) was an independent risk factor for amnionitis in spontaneous PTB. The evaluation of the performance of NLR should clearly require a prospective description of this parameter in a cohort of patients with either threatened PTL or preterm-PROM.

Neutrophil-to-lymphocyte ratio and CRP as biomarkers in multiple sclerosis: A systematic review

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system, which causes demyelination and neuroaxonal damage. Low-grade systemic inflammation has been suggested to contribute to the pathogenesis due to amplification of pathogenic immune activation. However, there is a lack of reliable biomarkers of systemic inflammation predicting disease activity and progression in MS. The neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) have been identified as biomarkers of severity and disease activity in various disorders. In September 2020, we conducted a systematic literature search on multiple databases on studies reporting NLR values or CRP levels in MS. The aim of this systematic review was to highlight the current knowledge about the potential of NLR and CRP as biomarkers in MS. A total of nineteen articles qualified for inclusion. Data on CRP were included in fourteen studies and NLR in nine studies. The results regarding CRP were inconsistent, and present literature does not support the use of CRP as a diagnostic or prognostic biomarker in MS. In contrast, NLR values were increased in MS patients compared with healthy controls in all case-control studies. Furthermore, NLR was associated with disease activity in untreated patients. Our systematic review therefore indicates that NLR might serve as a potential biomarker of disease activity. Given that the results of NLR are mainly drawn from retrospective case-control or cross-sectional studies, future prospective studies with long-term follow-up are required to accurately determine optimal timing and cutoff values that may be used in the clinical setting.

The serum C-reactive protein to prealbumin ratio and fibrinogen to prealbumin ratio are two relevant indicators for evaluating the disease activity of ankylosing spondylitis

The C-reactive protein to prealbumin ratio (CPR) and fibrinogen to prealbumin ratio (FPR) in serum are two emerging biomarkers. The purpose of this study is to explore the relationship between these two markers and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Scores (ASDAS). A total of 163 patients with AS and 120 healthy examinees were included in this study. The t-test and Mann-Whitney U ranking test were used to analyze the differences between groups. The spearman-test was used to analyze the correlation between erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), fibrinogen (Fib), prealbumin (PAlb), CPR, FPR, and AS disease activity in the test group. We generated the receiver operating characteristic curves (ROC) of CPR and FPR and determined the discriminating ability by calculating the area under the curve (AUC). Compared with the healthy group, ESR ( p < 0.001), CRP ( p < 0.001), Fib ( p < 0.001), CPR ( p < 0.001), and FPR ( p < 0.001) of AS patients were significantly increased, while PAlb was significantly reduced. CPR and FPR were more correlated to ASDAS-CRP. CPR was positively correlated with CRP, ESR, BASDAI, and ASDAS-CRP in AS patients ( r = 0.959, p < 0.001, r = 0.717, p < 0.001, r = 0.704, p < 0.001, r = 0.763, p < 0.001). FPR was positively correlated with CRP, ESR BASDAI, and ASDAS-CRP in AS patients ( r = 0.779, p < 0.001, r = 0709, p < 0.001, r = 0.551, p < 0.001, r = 0.763, p < 0.001). ROC showed that the AUC levels of CPR and FPR were high (AUC = 0.952 and AUC = 0.893). CPR and FPR are two promising new biological indicators for assessing disease activity in AS patients.

Correlation Between Diagnostic Imaging Findings of Sacroiliitis and Inflammation Parameters

Objectives Sacroiliitis is an inflammation of the sacroiliac joints. Diagnostic imaging has a very important role in the diagnosis of sacroiliac involvement in the disease process. In addition, laboratory parameters can also be useful for the detection of inflammation. This study aims to investigate the relationship between active sacroiliitis and subclinical inflammation parameters in patients who underwent MRI and 99mTc-methylene diphosphonate (MDP) bone scintigraphy.

Material and Methods This study includes 65 patients with suspected spondyloarthritis (SpA). Patients who had a sacroiliac MRI, a 99mTc-MDP bone scintigraphy and a complete blood count (CBC) within 3 months were reviewed retrospectively. Sacroiliac joints were evaluated bilaterally by using bone scintigraphy and MRI. Blood inflammation parameters were further assessed regarding evidence of probable sacroiliitis.

Results Significant differences were reported between MRI groups for sacroiliac indices (SII) (p=0.003), neutrophil-to-lymphocyte ratio (NLR) (p=0.008), C-reactive protein (CRP) (p = 0.037), and white blood cell (WBC) count (p=0.031). A significant correlation was found between active sacroiliitis and SII (p=0.001), CRP (p=0.000), erythrocyte sedimentation rate (ESR) (p=0.000), and NLR (p=0.001). Based on the ROC curve analysis, SII was found to have a sensitivity of 64.3% and specificity of 69.8%; NLR was found to have a sensitivity of 64.3% and specificity of 73.3% for diagnosing active sacroiliitis.

Conclusions Subclinical inflammation indices obtained from CBC and, particularly, NLR may contribute to disease activity assessment like acute-phase reactants. However, this needs to be confirmed in further studies.

Potential of neutrophil to lymphocyte ratio in predicting sustained remission in rheumatoid arthritis compared to other immune activation markers

Background & objectives:

Cells and cell proportions may indicate the equilibrium status of the immune system. The present study was conducted to evaluate the role of cytokines and the immunocompetent cells as biomarkers of remission in rheumatoid arthritis (RA) patients intended to withdraw or reduce disease-modifying anti-rheumatic drug (DMARD) treatment.

Methods:

This prospective observational study involved newly diagnosed and treated RA patients who fulfilled 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria. The patients were classified based on disease activity score (DAS)28-C-reactive protein (CRP)(3) score into remission (≤2.6) and treatment-naïve/active (>2.6) groups. Remission patients were followed up for six months and were reclassified into those in sustained remission (≤2.6) and relapse (>2.6) based on the DAS28-CRP(3) score. Various cytokines and cell surface markers were quantitated using whole blood samples, and the CD3⁺/CD19⁺ and FOXP3⁺/CD4⁺ ratios were calculated. The clinical, demographic, cytokine and cellular phenotype characteristics were compared between remission and treatment-naïve groups. The factors associated with sustained remission were verified.

Results:

Of the 72 patients, 52 were in remission and 20 were DMARD naïve and had active disease. Duration of illness, interleukin-6 (IL-6) and IL-10 were significantly different between remission and treatment naïve/active disease patients. Increased likelihood for achieving sustained remission was noted in RA patients with baseline NLR ≤2. Other demographic/clinical variables and cell phenotypes, namely age, gender, duration of illness, CD3⁺, CD4⁺, FOXP3⁺, CD19⁺, CD3⁺/CD19⁺, FOXP3⁺/CD4⁺ and cytokines - IL-6 and IL-10 were not associated with sustained remission.

Interpretation & conclusions:

The present preliminary study highlighted the potential of NLR in predicting sustained remission in RA patients with a cut-off <2. Further study with a large sample size should be done to confirm this finding.

Novel approaches to develop biomarkers predicting treatment responses to TNF-blockers

Introduction: Chronic inflammatory diseases (CIDs) cause significant morbidity and are a considerable burden for the patients in terms of pain, impaired function, and diminished quality of life. Important progress in CID treatment has been obtained with biological therapies, such as tumor-necrosis-factor blockers. However, more than a third of the patients fail to respond to these inhibitors and are exposed to the side effects of treatment, without the benefits. Therefore, there is a strong interest in developing tools to predict response of patients to biologics. Areas covered: The authors searched PubMed for recent studies on biomarkers for disease assessment and prediction of therapeutic responses, focusing on the effect of TNF blockers on immune responses in spondyloarthritis (SpA), and other CID, in particular rheumatoid arthritis and inflammatory bowel disease. Conclusions will be drawn about the possible development of predictive biomarkers for response to treatment. Expert opinion: No validated biomarker is currently available to predict treatment response in CID. New insight could be generated through the development of new bioinformatic modeling approaches to combine multidimensional biomarkers that explain the different genetic, immunological and environmental determinants of therapeutic responses.

The relationship between neutrophil-lymphocyte ratio and early renal fibrosis and renal prognosis in patients with lupus nephritis

OBJECTIVE

To explore the relationship between neutrophil-lymphocyte ratio (NLR) and early renal fibrosis and renal prognosis in patients with lupus nephritis.

METHODS

A total of 186 patients with lupus nephritis admitted to our hospital were enrolled and grouped according to the standard of "NLR=3.175". There were 90 patients in the higher NLR group and 96 patients in the lower NLR group. The correlation and independent relationship between NLR/estimated glomerular filtration rate (eGFR) and pathological indicators were explored by comparing the differences of physiological indicators between the two groups. The correlation between NLR/eGFR and renal insufficiency and renal prognosis were explored.

RESULTS

The higher NLR group showed increased levels of hs-CRP, white blood cells, neutrophils, platelets, PLR values, eGFR, D-dimer, crescent compared with the lower NLR group, while lymphocyte count in the higher NLR group was lower than that in the lower NLR group. Platelets, neutrophils, white blood cells, serum anhydride, serum C4 and vascular cellulose had positive correlations with NLR. eGFR, age, systolic blood pressure, diastolic blood pressure, neutrophils, leukocytes, NLR, blood uric acid, triglycerides, crescent ratio, endothelial hyperplasia, spherical sclerosis ratio, intraglomerular leukocyte infiltration, platinum loop, microthrombus, nuclear fragmentation, interstitial inflammatory cell infiltration, renal tubular atrophy, interstitial fibrosis, and mesangial cell showed negative correlation with matrix hyperplasia, arteriolar wall thickening and pathological activity scores, but showed positive correlation with hemoglobin and low-density lipoprotein.

CONCLUSION

NLR affects some important renal functions to a certain extent and is not the only risk factor for renal prognosis in patients with LN.

IL-33 promotes anemia during chronic inflammation by inhibiting differentiation of erythroid progenitors

An important comorbidity of chronic inflammation is anemia, which may be related to dysregulated activity of hematopoietic stem and progenitor cells (HSPCs) in the bone marrow (BM). Among HSPCs, we found that the receptor for IL-33, ST2, is expressed preferentially and highly on erythroid progenitors. Induction of inflammatory spondyloarthritis in mice increased IL-33 in BM plasma, and IL-33 was required for inflammation-dependent suppression of erythropoiesis in BM. Conversely, administration of IL-33 in healthy mice suppressed erythropoiesis, decreased hemoglobin expression, and caused anemia. Using purified erythroid progenitors in vitro, we show that IL-33 directly inhibited terminal maturation. This effect was dependent on NF-κB activation and associated with altered signaling events downstream of the erythropoietin receptor. Accordingly, IL-33 also suppressed erythropoietin-accelerated erythropoiesis in vivo. These results reveal a role for IL-33 in pathogenesis of anemia during inflammatory disease and define a new target for its treatment.

Haematologic indices and disease activity index in primary Sjogren's syndrome

BACKGROUND

The present study was conducted to investigate the association between haematologic indices, neutrophil/lymphocyte ratio (NLR), mean platelet volume (MPV), platelet/lymphocyte ratio (PLR), disease activation, organ involvement, and inflammatory markers in the SS.

METHODS

The study was conducted with newly diagnosed and treatment-naive 41 primary SS patients who met ACR-2012 criteria and 96 healthy volunteers. Blood tests obtained before treatment were evaluated. Lymphocyte, neutrophil and platelet counts, mean corpuscular volume (MCV), platelet distribution width (PDW), plateletcrit (PCT), haematocrit (HCT), MPV, white blood cell count (WBC) values were harvested from CBC of the subjects and NLR, PLR were calculated over these values. The values were compared between groups and correlation with EULAR SS disease activity index (ESSDAI) was evaluated.

RESULTS

The study included a total of 41 patients with a mean age of 40.73 ± 12.0 years and 96 healthy subjects with a mean age of 40.0 ± 9.2 years. In inter-group comparisons, lymphocyte, platelet counts, and MPV values were significantly lower in the SS group compared with the control group (P < .01), and NLR was significantly higher in the SS group (P = .026). The mean ESSDAI scores in SS patients were 5.65 ± 0.86 SE. These scores were significantly higher in patients with neurological involvement. There was a positive correlation between ESSDAI and PLR.

CONCLUSION

NLR, PLR, and MPV may be used as indicators or with activity index in SS. ESSDAI scores were found to be high in patients with neurological involvement, and it was also found to be correlated with PLR.

IL-17A expressed on neutrophil extracellular traps promotes mesenchymal stem cell differentiation toward bone-forming cells in ankylosing spondylitis

Ankylosing spondylitis (AS) is an inflammatory disease characterized by excessive bone formation. We investigated the presence of neutrophil extracellular traps (NETs) in AS and how they are involved in the osteogenic capacity of bone marrow mesenchymal stem cells (MSCs) through interleukin-17A (IL-17A). Peripheral neutrophils and sera were obtained from patients with active AS and healthy controls. NET formation and neutrophil/NET-associated proteins were studied using immunofluorescence, immunoblotting, qPCR, and ELISA. In vitro co-culture systems of AS NET structures and MSCs isolated from controls were deployed to examine the role of NETs in the differentiation of MSCs toward osteogenic cells. Analysis was performed using specific staining and qPCR. Neutrophils from patients with AS were characterized by enhanced formation of NETs carrying bioactive IL-17A and IL-1β. IL-17A-enriched AS NETs mediated the differentiation of MSCs toward bone-forming cells. The neutrophil expression of IL-17A was positively regulated by IL-1β. Blocking IL-1β signaling on neutrophils with anakinra or dismantling NETs using DNase-I disrupted osteogenesis driven by IL-17A-bearing NETs. These findings propose a novel role of neutrophils in AS-related inflammation, linking IL-17A-decorated NETs with the differentiation of MSCs toward bone-forming cells. Moreover, IL-1β triggers the expression of IL-17A on NETs offering an additional therapeutic target in AS.

The role of lymphocyte-monocyte ratio on axial spondyloarthritis diagnosis and sacroiliitis staging

Background

Axial spondyloarthritis (axial SpA) is a chronic inflammatory disorder could lead to disability due to the failure of timely treatment. The role of lymphocyte-to-monocyte ratio (LMR) in axial SpA remains unclear. The aim of this study was to investigate the role of LMR in axial SpA diagnosis, disease activity classification and sacroiliitis staging.

Methods

Seventy-eight axial SpA patients [51males and 27 females; mean age 41.0 (29–52) years] and 78 healthy controls (HCs) [55males and 23 females; mean age 40 (30–53) years] were enrolled in this study. The diagnosis of axial SpA was performed according to the New York criteria or the Assessment of Spondyloarthritis international Society (ASAS) classification criteria, whereas the staging of sacroiliitis in axial SpA patients was determined by X-ray examination. Comparisons of LMR levels between groups were performed using t test. Pearson or Spearman correlation analysis were used to assess correlations between LMR and other indicators. Receiver operating characteristic (ROC) curves were used to determine the role of LMR in the diagnosis of axial SpA.

Results

Higher neutrophil-to-lymphocyte ratio(NLR), red blood cell distribution width(RDW), platelet-to-lymphocyte ratio(PLR), mean platelet volume(MPV), erythrocyte sedimentation rate (ESR), and C-reactive protein(CRP) levels and lower red blood cell (RBC), hemoglobin (Hb), Hematocrit (Hct), LMR, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin/globulin (A/G) levels were noted in axial SpA patients compared to HCs. Positive correlations were observed between LMR and RBC, Hb, Hct and A/G, whereas negative correlations were found between LMR and NLR, PLR, AST, and TBIL (P < 0.05). ROC curves showed that the area under the curve (AUC) for LMR in the diagnosis of ankylosing spondylitis was 0.803 (95% CI = 0.734–0.872) with a sensitivity and specificity of 62.8 and 87.2%, respectively, and the AUC (95% CI) for the combination of ESR, CRP and LMR was 0.975 (0.948–1.000) with a sensitivity and specificity of 94.9 and 97.4%, respectively. LMR levels were lower (P < 0.05) and significant differences in LMR values were observed among different stages (P < 0.05).

Conclusions

Our study suggested that LMR might be an important inflammatory marker to identify axial SpA and assess disease activity and X-ray stage of sacroiliitis.

Peripheral Immune Cell Ratios and Clinical Outcomes in Seropositive Autoimmune Encephalitis: A Study by the Australian Autoimmune Encephalitis Consortium

Objective

To examine the utility of the peripheral blood neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) as biomarkers of prognosis in seropositive autoimmune encephalitis (AE).

Methods

In this multicenter study, we retrospectively analyzed 57 cases of seropositive AE with hospital admissions between January 2008 and June 2019. The initial full blood examination was used to determine each patients’ NLR and MLR. The modified Rankin Scale (mRS) was utilized to assess the patients’ follow-up disability at 12 months and then at final follow-up. Primary outcomes were mortality and mRS, while secondary outcomes were failure of first line treatment, ICU admission, and clinical relapse. Univariate and multivariable regression analysis was performed.

Results

During initial hospital admission 44.7% of patients had unsuccessful first line treatment. After a median follow-up of 700 days, 82.7% had good functional outcome (mRS ≤2) while five patients had died. On multivariable analysis, high NLR was associated with higher odds of first line treatment failure (OR 1.32, 95% CI 1.03–1.69, p = 0.029). Increased MLR was not associated with any short or long-term outcome.

Conclusions

NLR on initial hospital admission blood tests may be provide important prognostic information for cases of seropositive AE. This study demonstrates the potential use of NLR as a prognostic marker in the clinical evaluation of patients with seropositive AE.

Clinical significance of the monocyte:lymphocyte ratio for ankylosing spondylitis patients with thoracolumbar kyphotic deformities

Purpose

This study aimed to determine the clinical significance of the monocyte:lymphocyte ratio (MLR) in ankylosing spondylitis (AS) patients with thoracolumbar kyphotic deformity.

Methods

Ninety AS patients and 45 healthy controls were retrospectively enrolled. AS patients were divided into thoracolumbar kyphotic deformity (AS deformity) and spine normal (AS normal) groups. Blood parameters including C-reactive protein and erythrocyte sedimentation rate were determined. Receiver operating characteristic (ROC) curves and binary logistic regression analysis were conducted.

Results

Counts of white blood cells, neutrophils, and monocytes, and the neutrophil:lymphocyte ratio, platelet:lymphocyte ratio, and MLR were significantly higher in the AS than the control group. ROC curve results showed that the MLR yielded a higher area under the curve (AUC) value than other parameters, compared with controls. The MLR and monocyte count were higher in the AS deformity group than the AS normal group. ROC curve results indicated that the MLR yielded a higher AUC value than other parameters, compared with the AS normal group. Logistic regression suggested that the MLR was an independent predictor for thoracolumbar kyphotic deformity.

Conclusions

The MLR was elevated in AS patients, and was shown to be an independent predictor for thoracolumbar kyphotic deformity.

Clinical impact of monocyte distribution width and neutrophil-to-lymphocyte ratio for distinguishing COVID-19 and influenza from other upper respiratory tract infections: A pilot study

The coronavirus disease 2019 (COVID-19) has become a pandemic. Rapidly distinguishing COVID-19 from other respiratory infections is a challenge for first-line health care providers. This retrospective study was conducted at the Taipei Medical University Hospital, Taiwan. Patients who visited the outdoor epidemic prevention screening station for respiratory infection from February 19 to April 30, 2020, were evaluated for blood biomarkers to distinguish COVID-19 from other respiratory infections. Monocyte distribution width (MDW) ≥ 20 (odds ratio [OR]: 8.39, p = 0.0110, area under curve [AUC]: 0.703) and neutrophil-to-lymphocyte ratio (NLR) < 3.2 (OR: 4.23, p = 0.0494, AUC: 0.673) could independently distinguish COVID-19 from common upper respiratory tract infections (URIs). Combining MDW ≥ 20 and NLR < 3.2 was more efficient in identifying COVID-19 (AUC: 0.840). Moreover, MDW ≥ 20 and NLR > 5 effectively identified influenza infection (AUC: 0.7055). Thus, MDW and NLR can distinguish COVID-19 from influenza and URIs.

Diagnostic accuracy of different blood cells-derived indexes in rheumatoid arthritis: A cross-sectional study

To evaluate the performance of different blood cells-derived indexes in the diagnosis of rheumatoid arthritis (RA).Neutrophil-to-lymphocyte ratio (NLR), lymphocyte to monocyte ratio, platelet to lymphocyte ratio (PLR), systemic inflammation response index (SIRI), and aggregate inflammation systemic index were calculated in 199 consecutive RA patients and 283 sex and age-matched controls (147 healthy donors and 136 patients with other rheumatic diseases). Area under the curve (AUCs), sensitivity and specificity were calculated to evaluate the accuracy of indexes in discriminating between RA and controls. Association between indexes and RA variables was explored by multiple linear regression analyses.Blood cells-derived indexes did not demonstrate good accuracy in differentiating RA from controls with lymphocyte to monocyte ratio, the index with the best diagnostic performance, having 63.6% of sensitivity and 65.3% specificity [AUC (95%CI) = 0.67 (0.62-0.72]. The accuracy of the indexes in differentiating RA from healthy donors was significantly higher than that (AUCs < 0.6 for all comparisons) differentiating RA from rheumatic diseases. In RA, SIRI and aggregate inflammation systemic index showed significant association with C-reactive protein and erythrocyte sedimentation rate.Our results do not support the use of blood cells-derived indexes for the diagnosis of RA, suggesting that they might reflect chronic inflammatory burden in rheumatic diseases rather than, specifically, in RA.

The value of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as complementary diagnostic tools in the diagnosis of rheumatoid arthritis: A multicenter retrospective study

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have drawn attention in recent years as novel non-specific inflammatory markers; however, only a few studies have been conducted to investigate their value in RA.

OBJECTIVE

To investigate the value of the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) as complementary diagnostic tools in rheumatoid arthritis (RA).

METHOD

This study included 1009 patients with RA, 170 patients with other rheumatic diseases, and 245 healthy individuals from four medical centers. The patients' general data, including complete blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF), were retrospectively analyzed, and the NLR and PLR were calculated. Potential effective indicators were screened by logistic regression analysis, and a receiver operating characteristic (ROC) curve was plotted to evaluate their diagnostic value for RA.

RESULTS

(a) The NLR and PLR were significantly higher in the RA group than in the non-RA group and the control group (P < .05). (b) Spearman's Rho showed that the NLR was positively correlated with the PLR (r = .584, P < .05), RF (r = .167, P < .01), and CRP (r = .280, P < .01) but was not significantly correlated with ESR (r = .100, P > .05). The PLR was positively correlated with RF (r = .139, P < .01), CRP (r = .297, P < .01), and ESR (r = .262, P < .05). (c) Logistic analysis showed that RF, CRP, ESR, and the NLR had diagnostic value for RA. (d) For the NLR, the area under the curve (AUC) of the ROC curve was 0.831; at the cutoff value of 2.13, the diagnostic sensitivity, specificity, accuracy, and Youden index were 76.7%, 75.9%, 76.4%, and 0.5424, respectively.

CONCLUSION

The NLR was less effective than CRP and RF but was superior to ESR in the diagnosis of RA. The NLR can thus be used as a complementary diagnostic indicator in the diagnosis of RA.

Red cell distribution width and neutrophil-lymphocyte ratio in rheumatoid arthritis

Red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) are potential low-cost markers for detecting rheumatoid arthritis (RA) disease activity, but evidence on their accuracy for this purpose is conflicting. We aimed to determine the relationship between these and the Disease Activity Score of 28 joints (DAS-28) among Filipino RA patients, and to evaluate their ability to discriminate between patients with active RA and those in remission. This was a cross-sectional study done through a 7-year review of medical records of 134 adult patients with RA in a tertiary government hospital. Correlations were analyzed using Spearman analysis, and the receiver operating characteristic (ROC) curve was used to derive the sensitivity, specificity, and optimal cut-off values of RDW and NLR. Most patients were females with a mean disease duration of 7 years. Eighty-one percent (81%) had active disease using DAS-28 ESR. A weak positive correlation was found between NLR and DAS-28 and between NLR and ESR, but RDW did not correlate with either DAS-28 or ESR. The ROC analysis showed that in the differentiation of active RA and inactive RA, both RDW (area under the curve [AUC] 0.516, cut-off of ≥ 14.2% with 55.6% sensitivity and 42.3% specificity) and NLR (AUC 0.629, cut-off of ≥ 2.32 with 54.6% sensitivity and 76.9% specificity) had poor performance. NLR, but not RDW, was positively but weakly correlated with DAS-28 and ESR, making it a helpful marker of disease activity and inflammation in RA. Both NLR and RDW had low sensitivity and specificity for active RA and may not be useful in detecting disease activity.

Cut off point of neutrophil-to-lymphocyte ratio as a marker of active disease in systemic lupus erythematosus

AIM

We aimed to measure sensitivity, specificity, and to determine the cut-off value (COV) ratio of neutrophil-to-lymphocyte (NLR) in patients with active systemic lupus erythematosus (SLE).

METHODS

A cross sectional study was conducted using the retrospective data from Hasan Sadikin Lupus Registry (HSLR). The inclusion criteria were SLE patients aged 18 years or older who had documented data of neutrophil, lymphocyte, and SLE disease activity index (SLEDAI). Patients with infections, malignancies, and other inflammatory diseases recorded in registry were excluded. SLEDAI with a score of ≤ 4 is considered inactive and score of > 4 is considered active. The neutrophil-to-lymphocyte ratio was calculated by dividing the absolute number of neutrophils by the absoulte number of lymphocytes. Receiver Operating Characteristic (ROC) curve was used to analyze and determine optimal COV of NLR.

RESULTS

The total sample in this study were 112 subjects with a dominant of female (95.54%) and the mean age of 34.45 ± 9.40 years. The median of SLEDAI was 4.5 with a range from 0 to 16, while the median of NLR was 2.68 with a range of 0.59 to 19.02. The ROC analysis showed the optimal cut-off in this study was 2.94 with sensitivity and specificity as high as 60.71% and 76.79%, respectively.

CONCLUSION

Neutrophil-to-lymphocyte ratio with cut off value of 2.94 can be used to determine active disease of systemic lupus eythematousus.

Prognostic Impact of the Neutrophil-to-Lymphocyte Ratio in Borderline Resectable Pancreatic Ductal Adenocarcinoma Treated with Neoadjuvant Chemoradiotherapy Followed by Surgical Resection

BACKGROUND

Increasing evidence suggests that cancer-associated inflammation, as indicated by markers such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and modified Glasgow Prognostic Score (mGPS), predicts poor outcomes in pancreatic cancer. In this study, the associations between systemic inflammation markers and survival were examined in borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) patients who underwent neoadjuvant chemoradiotherapy (NACRT) followed by surgical resection.

METHODS

From April 2009 to December 2017, 119 patients diagnosed with BR-PDAC and receiving NACRT followed by radical surgery were included in this retrospective study. The associations between the pre- and post-NACRT NLR, PLR, mGPS, and clinicopathological characteristics, as well as their predictive values for survival outcomes, were analyzed. This study was approved by an institutional review board at Yokohama City University (B180600049).

RESULTS

On multivariate analysis with a Cox's proportional hazards regression model, post-NACRT NLR ≥3 (p = 0.040; hazard ratio, 2.24; 95% CI 1.28-3.91) and lymph node metastasis (p = 0.002; hazard ratio, 2.33; 95% CI 1.36-3.99) were significantly associated with shorter overall survival. The median survival time was 22.0 months for patients with post-NACRT NLR ≥3 and 45.0 months for patients with post-NACRT NLR <3 (p = 0.028).

CONCLUSIONS

The NLR following NACRT might predict survival in BR-PDAC patients. Patients with an elevated post-NACRT NLR or positive lymph node metastasis may be candidates for stronger adjuvant therapies.

Predicting postoperative pain with neutrophil/ lymphocyte ratio after arthroscopic rotator cuff repair

Background

Postoperative pain is well known and usually disturbing complication of arthroscopic shoulder surgery. Inflammation plays an important role in the development and progression of postoperative pain. The aim of this study was to evaluate the predictability of postoperative pain through the correlation of neutrophil/lymphocyte ratio (NLR) with inflammation. In addition, the correlation of parameters such as operative time, tear size, age and gender with postoperative pain was evaluated.

Methods

Sixty three patients, who underwent arthroscopic rotator cuff repair, were evaluated in this single-center-based retrospective study. The American Society of Anaesthesiologists I and II risk groups were determined as the inclusion criteria. NLR was calculated using preoperative one day hemogram values in all patients. The amounts of analgesic use and Numerical Rating Scale (NRS) scores at the 12th, 24th and 48th hours and on the 3rd and 7th days were recorded. Multivariate linear regression analysis was used to correlate postoperative NRS scores with multiple independent factors, including preoperative NLR, sex, age, tear size, repair type, operative time, block time, postoperative analgesic intake and length of hospital stay.

Results

Sixty three patients with a mean age of 59.4 years (range, 40-72 years) were evaluated. The mean tear size was 2.8 cm (range, 1-5 cm), the mean operative time was 84.1 min (range, 35-135 min), the mean duration of block was 7.6 hours (range, 4-12 hours) and the mean length of hospital stay was 1.7 days (range, 1-3 days). There was no significant correlation between age, sex, tear size, repair type, operative time and postoperative NRS (p > 0.2). The preoperative NLR was found to be a strong predictor of postoperative NRS (p < 0.001, rho = 0,864). There was a correlation between the NLR and mean analgesic intake (p = 0,03). The duration of block was decreased in patients with a NLR above 2, while it was prolonged in patients with a NLR below 2 (p = 0.04, rho = -0,725).

Conclusion

The preoperative NLR was found to be a strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Likewise, NLR was also predictive of postoperative block time and analgesic consumption.

The role of fibrinogen to albumin ratio in ankylosing spondylitis: Correlation with disease activity

BACKGROUND

This study aimed to assess the role of fibrinogen (Fib) to albumin (ALB) ratio (FAR) in ankylosing spondylitis (AS) and its association with disease activity.

METHODS

135 AS patients and 76 age - and gender - matched healthy controls were collected in this retrospective study. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score was used to divide the AS patients into remission group (BASDAI < 4) and active group (BASDAI ≥ 4). The association between FAR and BASDAI was evaluated by Spearman correlation. Receiver operating characteristic (ROC) curve was made to determine the area under curve (AUC) value. The prognostic value of FAR in the AS disease activity was tested by multivariate logistical regression analyses.

RESULTS

AS patients showed higher FAR levels than the controls (P < 0.001). FAR was also increased in active group of AS patients than those in inactive group (P < 0.001). Spearman analyses showed that FAR was positively related with BASDAI (r = 0.594, P < 0.001) in AS patients. ROC curve analyses revealed that the AUC of FAR was higher than ALB and Fib. In addition, the optimal cutoff value of FAR for AS diagnosis was 78.84, with a specificity of 88.2% and sensitivity of 77.0%. Logistical regression analyses showed that FAR (odds ratio = 13.091, 95% confidence interval: 4.686-36.571, P < 0.001) was a predictor for AS disease activity.

CONCLUSIONS

FAR was increased in AS and may act as a novel inflammatory parameter for mirroring disease activity in AS.

Neutrophil/lymphocyte and platelet/lymphocyte ratios as potential markers of disease activity in patients with Ankylosing spondylitis: a case-control study

Background

The neutrophil/ lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have the potential to be inflammatory markers that reflect the activity of many inflammatory diseases. The aim of this study was to evaluate the NLR and PLR as potential markers of disease activity in patients with ankylosing spondylitis.

Methods

The study involved 132 patients with ankylosing spondylitis and 81 healthy controls matched in terms of age and gender. Their sociodemographic data, disease activity scores using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), and white blood cell, neutrophil, lymphocyte and platelet counts were recorded. The patients with ankylosing spondylitis were further divided according to their BASDAI scores into patients with inactive disease (BASDAI < 4) and patients with active disease (BASDAI ≥4). The correlations between the NLR, PLR and disease activity were analysed.

Results

There was a statistically significant difference in the NLR and PLR between the active and inactive ankylosing spondylitis patients (2.31 ± 1.23 vs. 1.77 ± 0.73, p = 0.002), (142.04 ± 70.98 vs. 119.24 ± 32.49, p <  0.001, respectively). However, there was no significant difference in both the NLR and PLR between the healthy control group and ankylosing spondylitis patients (p > 0.05). In addition, the PLR was significantly higher in both the active and inactive groups compared to those in the healthy control group (142.04 ± 70.98 vs. 99.32 ± 33.97, p = 0.014), (119.24 ± 32.49 vs. 99.32 ± 33.97, p = 0.019). The BASDAI scores were positively correlated with the PLR (r = 0.219, p = 0.012) and the NLR, but they were not statistically significant with the later (r = 0.170, p = 0.051). Based on the ROC curve, the best NLR cut-off value for predicting severe disease activity in ankylosing spondylitis patients was 1.66, with a sensitivity of 61.8% and a specificity of 50.6%, whereas the best PLR cut-off value was 95.9, with a sensitivity of 70.9% and a specificity of 55.5%.

Conclusion

The PLR may be used as a useful marker in the assessment and monitoring of disease activity in AS together with acute phase reactants such as the ESR.

GM-CSF drives dysregulated hematopoietic stem cell activity and pathogenic extramedullary myelopoiesis in experimental spondyloarthritis

Dysregulated hematopoiesis occurs in several chronic inflammatory diseases, but it remains unclear how hematopoietic stem cells (HSCs) in the bone marrow (BM) sense peripheral inflammation and contribute to tissue damage in arthritis. Here, we show the HSC gene expression program is biased toward myelopoiesis and differentiation skewed toward granulocyte-monocyte progenitors (GMP) during joint and intestinal inflammation in experimental spondyloarthritis (SpA). GM-CSF-receptor is increased on HSCs and multipotent progenitors, favoring a striking increase in myelopoiesis at the earliest hematopoietic stages. GMP accumulate in the BM in SpA and, unexpectedly, at extramedullary sites: in the inflamed joints and spleen. Furthermore, we show that GM-CSF promotes extramedullary myelopoiesis, tissue-toxic neutrophil accumulation in target organs, and GM-CSF prophylactic or therapeutic blockade substantially decreases SpA severity. Surprisingly, besides CD4+ T cells and innate lymphoid cells, mast cells are a source of GM-CSF in this model, and its pathogenic production is promoted by the alarmin IL-33.

Relationship between Neutrophil-to-Lymphocyte Ratio and Systemic Lupus Erythematosus: A Meta-analysis

Systemic lupus erythematosus (SLE) is a chronic systematic autoimmune disease. Current methods of diagnosing SLE or evaluating its activity are complex and expensive. Numerous studies have suggested that neutrophil-to-lymphocyte ratio (NLR) is closely correlated with the presence of SLE and its activity, suggesting that it may serve as a diagnostic and monitoring indicator for SLE. Therefore, we performed a meta-analysis to systematically assess the association between NLR and SLE. We performed a literature search until 12 April 2019 in the PubMed, Web of Science, and China National Knowledge Infrastructure databases. Cross-sectional studies comparing the NLR of SLE patients versus those of healthy controls, of active versus inactive SLE patients, and of SLE patients with versus without lupus nephritis were considered for inclusion. Mean intergroup NLR differences were estimated using standardized mean differences and their 95% confidence intervals. Study quality was assessed using the Agency for Healthcare Research and Quality instrument for cross-sectional studies. Fourteen studies with 1,781 SLE patients and 1,330 healthy controls were included in this meta-analysis. The pooled results showed that the NLR was significantly higher in SLE patients than in healthy controls, in active SLE patients than in inactive SLE patients, and in SLE patients with lupus nephritis than in those without lupus nephritis. NLR may be an indicator for monitoring disease activity and reflecting renal involvement in SLE patients. Nevertheless, more high-quality studies are warranted to further validate our findings.

Anti-Arthritic Activities of Supercritical Carbon Dioxide Extract Derived from Radiation Mutant Perilla Frutescens Var. Crispa in Collagen Antibody-Induced Arthritis

We investigated the anti-arthritic effects of the radiation mutant Perilla frutescens var. crispa leaf extract (SFE-M) and wild type leaf extract (SFE-W), both prepared by supercritical carbon dioxide (SC-CO2) extraction, on collagen antibody-induced arthritis (CAIA) in Balb/c mice. Animals were randomly divided into four groups: control, CAIA, CAIA + SFE-M (100 mg/kg/day), and CAIA + SFE-W (100 mg/kg/day). The mice were subjected to the respective treatments via oral gavage once daily for 4 days. Mice treated with SFE-M developed less severe arthritis than the CAIA mice. They showed significantly improved arthritic score, paw volume, and paw thickness compared to the CAIA mice from days 3 through 7. Furthermore, histopathological analysis of ankle for inflammation showed that SFE-M treatment reduced inflammatory cell infiltration and edema formation. Similarly, the neutrophil-to-lymphocyte ratio (NLR) in the whole blood was 37% lower in mice treated with SFE-M compared with the CAIA mice. However, treatment with SFE-W did not result in any significant difference compared with the CAIA group. In conclusion, SFE-M treatment delays the onset of arthritis and alleviates its clinical manifestations in CAIA mice.

The Role of the Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Markers of Disease Activity in Ankylosing Spondylitis

Background Ankylosing spondylitis (AS) is a chronic rheumatological condition affecting sacroiliac joint and spine and occurs more often in younger patients than in the elderly population. Objective The purpose of the study was to determine the association of the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) with the disease activity of AS. Methodology This case-control study was conducted in the rheumatology department at the Pakistan Institute of Medical Sciences (PIMS) hospital in Islamabad from September 2018 to July 2019. The study consisted of two groups of 59 patients per group. We assessed a full blood count with erythrocyte sedimentation rate (ESR) for each participant using the PIMS hospital laboratory. NLR and PLR were calculated. Results The mean age of the participants in the control group and the cases group was the same (32 ± 4 years). The control group NLR was 1.30 ± 0.16, the PLR was 94.98 ± 17.96, and the ESR was 16.88 ± 3.76 mm/hour. For the cases group, the NLR was 3.08 ± 0.91, the PLR was 171.50 ± 38.06, and the ESR was 29.30 ± 9.20 mm/hour. There was a significant increase in cases for NLR, PLR, and ESR as compared to control samples (p<0.05). The mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of participants with active diseases was 5.91±1.28. In the same group, the mean ESR was 27.65 ± 9.07 mm/hour, the NLR was 3.46 ± 0.80, and the PLR was 184.39 ± 36.13. For those in the inactive disease group, the mean BASDAI score was 2.84 ± 0.46, the ESR was 33.42 ± 8.48 mm/hour, the NLR was 2.17 ± 0.37, and the PLR was 139.71 ± 26.05. NLR and PLR were significantly higher in the active disease group (p<0.05). Conclusion NLR and PLR are good markers of inflammation in AS patients, and higher values indicate more active disease activity.

Proportion of the CD19-Positive and CD19-Negative Lymphocytes and Monocytes within the Peripheral Blood Mononuclear Cell Set is Characteristic for Rheumatoid Arthritis

Background and objectives: Composition of the peripheral blood (PB) cell populations and their activation state reflect the immune status of a patient. Rheumatoid arthritis (RA) is characterized by abnormal B- and T-cell functions. The objective of this study was to assess the profiles of the PB mononuclear cell (PBMC) populations in patients with rheumatoid and osteoarthritis (OA) in comparison with healthy control (HC) subjects in order to evaluate the PBMC profiles as a potential diagnostic characteristic in RA. The second aim was to assess the CCR1 and CCR2 expression on PB lymphocytes and correlate it with the plasma levels of matrix metallopeptidase 9 (MMP-9), IL-17F, TNF-α, IL-6, and IL-10. Materials and Methods: The frequency and phenotype, including CCR1 and CCR2, of the PBMC populations (monocytes, CD19⁺B cells, and T/NK lymphocytes) in RA (n = 15) and OA (n = 10) patients and HC (n = 12) were analyzed by five-color flow cytometry. DNA of the viruses, HHV-6, HHV-7, and B19, in the whole blood and cell-free plasma, were assessed by nested-polymerase chain reaction (PCR). Results: Active persistent or acute infections, caused by HHV-6, HHV-7, or B19, were not detected in patients of this study. Both CCR1 and CCR2 were determined on the PB B and T/NK lymphocytes in several RA and OA patients and HCs. However, in patients, the frequency of the CCR1-positive T/NK lymphocytes showed a weak negative correlation with the IL-10 level, while the frequency of the CCR2-positive B cells correlated positively with the level of IL-6. Statistically significant differences in the proportions of the CD19-positive and CD19-negative lymphocyte and monocyte subsets within the PBMC set were determined between RA and OA patients and HC adults. Conclusions: We have shown in our pilot study with rather small cohorts of patients that the PBMC-population profiles were very consistent, and statistically significantly differed between RA and OA patients and HC subjects.

TCR repertoire and CDR3 motif analyses depict the role of αβ T cells in Ankylosing spondylitis

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease with worldwide high prevalence. Although AS is strongly associated with HLA-B27 MHC-I antigen presentation, the role played by αβ T cells in AS remains elusive.

Methods

Utilizing TCRβ repertoire sequencing and bioinformatics tools developed in house, we analyzed overall TCR repertoire structures and antigen-recognizing CDR3 motifs in AS patients with different disease activities.

Findings

We found that disease progression is associated with both CD4+ and CD8+ T cell oligo-clonal expansion, which suggests that αβ T cell activation may mediate AS disease progression. By developing a bioinformatics platform to dissect antigen-specific responses, we discovered a cell population consisting of both CD4+ and CD8+ T cells expressing identical TCRs, herein termed CD4/8 T cells. CD4/8 clonotypes were highly enriched in the spondyloarthritic joint fluid of patients, and their expansion correlated with the activity of disease.

Interpretation

These results provide evidence on the T cell clone side to reveal the potential role of CD4/8 T cells in the etiology of AS development.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are associated with disease activity in polymyalgia rheumatica

Background

The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and monocyte‐to‐lymphocyte ratio (MLR) are indicators of systemic inflammation and are useful as markers in systemic rheumatic diseases. In this study, we compared the NLR, PLR, and MLR among patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA), and explored possible associations with clinical features, disease activity, and prognosis in patients with PMR.

Methods

The study enrolled 94 patients with PMR and 242 patients with RA who were initially diagnosed at the rheumatology clinic of a university‐based tertiary hospital. Symptoms, physical examination, and medical histories were collected with the results of laboratory tests.

Results

Neutrophil‐to‐lymphocyte ratio (4.5 ± 3.3 vs 2.8 ± 1.8), PLR (222.7 ± 115.5 vs 159.7 ± 78.1), and MLR (0.4 ± 0.3 vs 0.3 ± 0.2) were higher in patients with PMR compared with patients with RA (all P < .001). NLR, PLR, and MLR were correlated with specific laboratory values, including CRP and albumin, in patients with PMR. After disease activity resolved, NLR (2.95 ± 2.32, P < .001), PLR (137.5 ± 82.3, P < .001), and MLR (0.26 ± 0.16, P < .001) decreased significantly. By comparing patients according to the disease course, swollen joint counts were higher in the chronic course group compared with the remission group (P = .03), while the NLR, PLR, and MLR were similar.

Conclusions

Neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, and monocyte‐to‐lymphocyte ratio levels were associated with disease activity and specific clinical features, although they could not predict prognosis in patients with PMR.

The predictive role of monocyte-to-lymphocyte ratio in osteoporosis patient

Osteoporosis is a chronic, progressive disease in which early diagnosis is very important. The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have been reported as new predictors in inflammatory and immune diseases including osteoporosis. No studies have reported the relationship between monocyte-to-lymphocyte ratio (MLR) and osteoporosis patients.To investigated the ability of MLR to predict osteoporosis.Three hundred sixteen osteoporosis patients and 111 healthy control subjects were enrolled. Patients' laboratory and clinical characteristics were recorded. MLR, NLR, and PLR levels were calculated. The differences were compared and the diagnostic values of MLR were analyzed.There were 76 male and 105 female patients included, with a mean age of 56.57 ± 9.95 years. The levels of MLR, NLR, and PLR in osteoporosis patients were all higher than those in healthy control subjects. The area under the curve of MLR was higher than those of NLR and PLR. Multivariate linear regression analysis showed that T-score was affected by age and MLR. MLR was positively correlated with C-reactive protein, erythrocyte sedimentation rate, red blood cell distribution width, age, sex, and inversely with hemoglobin. MLR and PLR levels were significantly higher in osteoporosis patients than in osteopenia patients (P < .05).The present study shows that MLR had a higher diagnostic value for osteoporosis. MLR may be a reliable, inexpensive, and novel potential predictor of osteoporosis.

Red cell distribution width, platelet-to-lymphocyte ratio, and mean platelet volume in ankylosing spondylitis and their correlations with inflammation: A meta-analysis

Objectives: To evaluate the relationship between red cell distribution width (RDW), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV) and ankylosing spondylitis (AS) and establish a correlation between these haematological indices and AS inflammation.Methods: We searched the Medline, Embase, and Cochrane databases, performed a meta-analysis comparing RDW, PLR, and MPV in patients with AS to controls, and examined correlation coefficients between RDW, PLR, and MPV and C-reactive protein (CRP).Results: Eleven studies were included in this meta-analysis, which revealed that RDW was significantly higher in the AS group than in the control group (standardized mean difference (SMD) = 0.687, 95% confidence interval (CI) = 0.110-1.265, p = .020). However, PLR was not significantly higher in the AS group than in the control group (SMD = 0.197, 95% CI = -0.045-0.439, p = .111). No evidence of elevated MPV in the AS group was found (SMD = -0.005, 95% CI = -0.411-0.400, p = .979). Meta-analysis of correlation coefficients revealed that RDW was positively associated with CRP (correlation coefficient = 0.327, 95% CI = 0.214-0.431, p < .001). PLR was positively associated with CRP (correlation coefficient = 0.444, 95% CI = 0.283-0.581, p < .001). In addition, the meta-analysis showed a correlation between MPV and CRP (correlation coefficient = 0.217, 95% CI = 0.080-0.346, p = .002).Conclusion: This meta-analysis demonstrated that RDW is higher in patients with AS, and a significant positive correlation exists between RDW, PLR, and MPV and CRP.

Diagnostic value of the blood monocyte-lymphocyte ratio in knee osteoarthritis

Objective

Knee osteoarthritis (KOA) is a chronic inflammatory disease. The monocyte–lymphocyte ratio (MLR) was reported to be a non-invasive, cost-effective marker in various systemic diseases, but it has not yet been investigated in KOA. This cross-sectional study evaluated the diagnostic value of MLR in KOA.

Methods

Two hundred and five KOA patients and 120 healthy control subjects were enrolled. Patient data, including age, sex, blood cell counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, red blood cell distribution width, and the Kellgren–Lawrence (KL) score were recorded.

Results

One hundred nineteen patients (55 men, 64 women) were included, with a mean age of 55.47 ± 9.23 years. KOA patients showed a significantly higher MLR, neutrophil–lymphocyte ratio (NLR), and platelet–lymphocyte ratio (PLR) than controls. The MLR area under the curve was 0.81, which was higher than that of NLR and PLR. Multiple logistic regression analysis revealed blood MLR as an independent predictor of KOA. Correlation analysis showed that MLR was positively correlated with ESR and CRP levels. MLR and NLR were significantly higher in KL4 patients than in KL1–3 patients.

Conclusions

MLR has a high diagnostic value for KOA, so could be a reliable disease marker.

Could Neutrophil-to-Lymphocyte Ratio (NLR) Serve as a Potential Marker for Delirium Prediction in Patients with Acute Ischemic Stroke? A Prospective Observational Study

Delirium is an acute brain disorder that commonly occurs in patients with acute ischemic stroke (AIS). Pathomechanism of delirium is related to the neuroinflammatory process and oxidative stress. Search for readily available diagnostic marker that will aid clinicians in early identification of delirium is ongoing. The aim of this study was to investigate whether neutrophil-to-lymphocyte ratio (NLR) could serve as a potential marker for delirium prediction in patients with AIS and to find an easy diagnostic tool using laboratory and clinical parameters to predict delirium. Prospective observational study (NCT03944694) included patients with AIS admitted to the neurology department of a district general hospital. All patients were screened for delirium using CAM-ICU (Confusion Assessment Method for Intensive Care Unit). Demographic and medical history data and admission lab results, including differential white blood cell analysis, were collected from all patients. We included 1001 patients in the final analysis. The mean age of the sample was 71 years, and 52% of patients were males. The incidence of early-onset delirium was 17.2%. The NLR was elevated in delirious patients (6.39 ± 8.60 vs. 4.61 ± 5.61, p < 0.001). The best cut-off value of NLR to predict delirium using the receiver operating characteristics (ROC) was determined at 4.86. Multivariable logistic regression analysis showed that the odds ratio (OR) for developing delirium with NLR > 4.86 (adjusted for age, sex, body mass index (BMI), comorbidities, and baseline neurology) was 1.875 (95% CI 1.314-2.675, p = 0.001). As a result of different combinations of markers and clinical parameters based on logistic regression, a formula-DELirium in Acute Ischemic Stroke (DELIAS score)-was obtained with the area under the ROC curve of 0.801 (p < 0.001). After regression of the cut-off points of the obtained curve, a significant correlation of the DELIAS score was observed with the occurrence of early-onset delirium (OR = 8.976, p < 0.001) and with delirium until the fifth day after AIS (OR = 7.744, p < 0.001). In conclusion, NLR can be regarded as a potential marker for prediction of early-onset delirium after AIS. On the basis of combined laboratory and clinical parameters, the DELIAS score was calculated, which gave the highest predictive value for delirium in the analyzed group of patients after ischemic stroke. However, further studies are needed to validate these findings.

Association of simple hematological parameters with disease manifestations, activity, and severity in patients with systemic sclerosis

INTRODUCTION/OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), mean platelet volume (MPV), and red cell distribution width (RDW) may potentially reflect inflammatory status in systemic autoimmune diseases. The aim of this study is to investigate the association between these proposed markers and disease manifestations, activity, and severity in systemic sclerosis (SSc).

METHOD

We conducted a cross-sectional study of 69 systemic sclerosis (SSc) patients and 50 healthy volunteers in a single center. Adult patients with SSc and healthy controls were compared in terms of NLR, MLR, MPV, RDW, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Venous blood samples were drawn after at least 8 h of fasting in the morning. Extension of skin fibrosis was evaluated by using modified Rodnan skin score (mRSS). Disease severity and activity were assessed by Medsger disease severity and European Scleroderma Trials and Research Group (EUSTAR) disease activity scores, respectively. Associations of disease manifestations, clinical, laboratory, and capillaroscopic findings, mRSS, and the disease activity and severity scores with the proposed hematological markers were evaluated. Multiple regression models were generated for significant associations.

RESULTS

The neutrophil number was higher (p = 0.004) and lymphocyte number was lower (p < 0.001) in SSc group compared to controls. SSc group also had higher NLR, MLR, and RDW. In multiple logistic regression, only the NLR (regression coefficient = 3.49, p = 0.031) and CRP (regression coefficient = 0.17, p = 0.037) remained significantly different between SSc and healthy control groups (Cox and Snell R² = 0.243, Nagelkerke R² = 0.337, p < 0.001). NLR and MLR positively correlated with mRSS, EUSTAR score, and CRP. MLR also positively correlated with Medsger score. Higher monocyte counts independently predicted higher EUSTAR and Medsger scores in multiple linear regressions. Patients with digital ulcers had higher NLR and MLR. We did not find any difference in MPV values between SSc and healthy control groups.

CONCLUSIONS

Globally available and inexpensive hematological tests, particularly the NLR and MLR, may be associated with vascular and cutaneous manifestations as well as disease activity and severity in SSc.Key Points• Monocyte count itself independently predicted higher activity and severity scores in SSc.• Globally available and inexpensive hematological markers, particularly the NLR and MLR, may have an association with vascular and cutaneous manifestations as well as disease activity and severity in patients with SSc.

Neutrophil lymphocyte ratio in patients with ankylosing spondylitis: A systematic review and meta-analysis

Objective: The aim of this meta-analysis was to investigate the association of neutrophil lymphocyte ratio (NLR) with AS (ankylosing spondylitis) patients.Methods: PubMed, Web of Science, Cochrane Library, Elsevier Science Direct and Google Scholar databases (up to 30 September 2018) were searched to collect all pertinent articles. The pooled standard mean difference (SMD) with 95% confidence interval (CI) was calculated by the random effects model.Results: Totally 10 studies contained 765 AS patients and 701 healthy controls were included in our meta-analysis. The results indicated that there were significant statistical differences between AS patients and healthy controls in NLR (SMD = 0.418, 95%CI = 0.239-0.598, p < .001). Meanwhile, the results of subgroup analysis showed, in the subgroup of C-reactive protein (CRP) ≥10 and the two subgroups of BASDAI (the Bath AS Disease Activity Index), NLR levels in AS were significantly higher than in control (all p < .001). The results of subgroup analysis and meta-regression suggested that BASDAI and CRP were likely associated with NLR in AS patients.Conclusion: The current meta-analysis provides evidence that NLR is a reasonable measure to detect systemic inflammation in AS patients. Besides, NLR may be able to indicate disease activity in patients with AS.

Clinical significance of serum calprotectin level for the disease activity in active rheumatoid arthritis with normal C-reactive protein

BACKGROUND

There was limited data concerning predicting ability of calprotectin for disease activity of rheumatoid arthritis (RA) patients with normal C-reactive protein (CRP) level. This study was conducted to evaluate serum calprotectin levels in active RA patients and analyze its predicting value for disease activity evaluation despite normal CRP level.

METHODS

A total of 162 patients with active RA patients with normal CRP levels and 57 healthy subjects were enrolled. Serum calprotectin was measured by using a commercially available enzyme-linked immunosorbent assay (ELISA), and baseline clinical characteristics were collected. The DAS-28 scores were evaluated as indictors of disease activity. The predicting value of calprotectin in disease activity of RA patients with normal CPR was analyzed by using univariate and multivariate analysis and receiver operating characteristic curve.

RESULTS

Serum levels of calprotectin of patients with active RA were significantly higher than that of the healthy controls (3.5±3.2 vs. 2.5±0.8, P<0.01). Univariate analysis showed that serum calprotectin levels were significantly associated with the disease activity of RA. The mean serum calprotectin levels of patients with a high disease activity (DAS-28>5.1) was significantly higher than that of RA patients with low-moderate disease activity (4.3±3.5 vs. 2.6±1.1, P<0.01). Serum calprotectin levels also was evaluated as an independent predictive factor for disease activity of RA in multivariate analysis (OR, 2.31; 95% CI, 1.12-6.84; P<0.01).

CONCLUSIONS

Serum calprotectin levels can be used as a promising indictor for disease activity in active RA patients while CRP fails to do so.

The clinical value of hematological markers in rheumatoid arthritis patients treated with tocilizumab

Background

Emerging evidence indicates that some hematological markers have critical value in evaluating treatment response. This study was performed to determine the clinical value of hemoglobin (Hb), platelet (Plt), neutrophil‐to‐lymphocyte ratio (NLR), and platelet‐to‐lymphocyte ratio (PLR) in rheumatoid arthritis (RA) patients treated with tocilizumab (TCZ).

Methods

Fifty‐two RA patients receiving TCZ were recruited and followed for 6 months. The values of abovementioned hematological markers were collected. Clinical disease activity index (CDAI) and disease activity score based on 28 joints (DAS28)‐ESR were calculated. Correlation analysis was conducted by calculating Pearson's correlation coefficient. The change in disease activity between groups according to the baseline level of hematological markers was compared by t test.

Results

Significant correlation between change in NLR (△NLR), change in PLR (△PLR), and change in CDAI (△CDAI) was found (△NLR: r = 0.30, P = 0.03; △PLR: r = 0.31, P = 0.03). The change in Plt (△Plt) was correlated with change in DAS28‐ESR (△DAS28‐ESR) (r = 0.36, P = 8.24 × 10⁻³). Greater improvement in CDAI was seen in patients categorized into Plt high group (t = 2.06, P = 0.04), NLR high group (t = 2.15, P = 0.04), and PLR high group (t = 2.41, P = 0.02) compared with the contrast group.

Conclusion

Our study demonstrated that △Plt, △NLR, and △PLR could be used to monitor the clinical response to TCZ. RA patients with high baseline levels of Plt, NLR, and PLR achieved more improvement, indicating these hematological markers might be utilized to guide TCZ treatment.

Mechanisms of vascular comorbidity in autoimmune diseases

Purpose of review

Persuasive statistics support the clinical observation that because of cardiovascular comorbidities patients with inflammatory joint disease die significantly earlier despite anti-inflammatory therapy.

Recent findings

The reason for this earlier death is multifactorial and involves a combination of a complex genetic background, environmental influences, classical cardiovascular risk factors and the impact of anti-inflammatory therapy. We will describe the importance of several new mechanisms, especially the diverse intercellular communication routes including extracellular vesicles and microRNAs that support the development of cardiovascular comorbidities.

Summary

The aim of this review is to give an updated overview about the known risk factors in the development of cardiovascular comorbidities with the latest insights about their mechanism of action. Furthermore, the impact of newly identified risk factors and significance will be discussed.

Meta-analysis of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio in rheumatoid arthritis

BACKGROUND

We conducted a meta-analysis to review the available evidence regarding the associations between peripheral blood neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and the presence of rheumatoid arthritis (RA).

METHODS

PubMed, Web of Science and Scopus, from inception to January 2018, were searched for studies reporting on NLR and PLR in RA in comparison with healthy subjects. Standardized mean difference (SMD) was calculated with a confidence interval (CI) of 95%.

RESULTS

Thirteen NLR studies (1550 RA patients and 1128 healthy controls) and 8 PLR studies (380 RA patients and 305 healthy controls) were included in the meta-analysis. NLR and PLR were significantly higher in patients with RA when compared to controls (SMD = 0.79, 95% CI 0.55-1.03; P < 0.001 and SMD = 0.66, 95% CI 0.43-0.88; P < 0.001, respectively).

CONCLUSIONS

The NLR and PLR are significantly associated with the presence of RA. Further studies are required to ascertain the potential clinical use of these simple and relatively inexpensive markers in RA diagnosis.

Understanding the Multifaceted Role of Neutrophils in Cancer and Autoimmune Diseases

Neutrophils are one of the first immune cell types that are recruited to injury and infection site. As a vital component of the immune system, neutrophils are heterogeneous immune cells known to have phagocytic property and function in inflammation. Recent studies revealed that neutrophils play dual roles in tumor initiation, development, and progression. The multifunctional roles of neutrophils in diseases are mainly due to their production of different effector molecules under different conditions. N1 and N2 neutrophils or high density neutrophils (HDNs) and low density neutrophils (LDNs) have been used to distinguish neutrophils subpopulations with pro- vs. anti-tumor activity, respectively. Indeed, N1 and N2 neutrophils also represent immunostimulating and immunosuppressive subsets, respectively, in cancer. The emerging studies support their multifaceted roles in autoimmune diseases. Although such subsets are rarely identified in autoimmune diseases, some unique subsets of neutrophils, including low density granulocytes (LDGs) and CD177⁺ neutrophils, have been reported. Given the heterogeneity and functional plasticity of neutrophils, it is necessary to understand the phenotypical and functional features of neutrophils in disease status. In this article, we review the multifaceted activates of neutrophils in cancer and autoimmune diseases, which may support new classification of neutrophils to help understand their important functions in immune homeostasis and pathologies.

Relationship between neutrophil-lymphocyte, platelet-lymphocyte ratio and disease activity in rheumatoid arthritis treated with rituximab

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may be used as indicators of inflammatory markers and disease activity due to inflammatory changes in neutrophils, platelets and lymphocytes. Our aim is to investigate the relationship between NLR, PLR ratio and disease activity in RA patients treated with rituximab.

METHODS

Thirty-eight patients (8 male, 30 female, mean age 56.8 ± 11.8 years) diagnosed with RA and 30 healthy controls were included in the study. Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS28-ESR), lymphocyte, neutrophil, platelet counts, ESR, C-reactive protein (CRP), PLR, and NLR were evaluated before and after rituximab in RA patients. The relationship between all parameters was assessed by Pearson's correlation, Wilcoxon signed-rank, Mann-Whitney U and paired t tests.

RESULTS

The levels of CRP, ESR, and DAS28-ESR decreased significantly at 6 months of rituximab treatment compared to pre-treatment. NLR and PLR ratios were higher in patients with RA than the control group. The median levels were 33.5 mm/hour, 5.7 mg/dL, and 3.7 respectively after 6 months of rituximab treatment. And, the levels were lower than baseline treatment. There was a significant correlation between the levels of DAS28-ESR and NLR, DAS28-ESR and PLR before and after treatment.

CONCLUSIONS

The NLR and PLR were higher than healthy controls and correlated with DAS28-ESR in patients with RA. These parameters which are indicative of disease activity decrease with rituximab and correlate with disease activity at 6 months. The NLR and PLR may be useful indices to evaluate RA disease activity treated with rituximab.