Significance of measurement of high-sensitivity C-reactive protein in acute pancreatitis

The role of predictive and prognostic values of inflammatory markers in acute pancreatitis: a narrative review

Pancreatitis is an inflammatory condition affecting the pancreas and is classified into 2 types, acute and chronic, which can manifest in various forms. This review article summarizes the role of predictive and prognostic values of inflammatory markers in the pathogenesis of acute pancreatitis, mainly focused on preclinical and clinical studies. It includes serum amyloid A (SAA), monocyte chemotactic protein-1 (MCP-1), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), C-reactive protein (CRP), IL-10, myeloperoxidase, pentraxin 3, and plasminogen activator inhibitor 1. SAA3 plays a crucial role in developing acute pancreatitis by triggering a receptor-interacting protein 3–dependent necroptosis pathway in acinar cells. Targeting SAA3 could be a potential strategy for treating acute pancreatitis. The recruitment of monocytes/macrophages and the activation of the systemic MCP-1 signaling pathway play a role in the progression of pancreatitis, and blocking MCP-1 may have a suppressive effect on the development of pancreatic fibrosis. The ESR can predict severe acute pancreatitis with slightly lower accuracy than CRP. When ESR and CRP levels are combined at 24 hours, they predict severe acute pancreatitis accurately. IL-6 plays a crucial role in activating the Janus kinase/signal transducers and activators of the transcription pathway, exacerbating pancreatitis and contributing to the initiation and progression of pancreatic cancer. Endogenous IL-10 plays a crucial role in controlling the regenerative phase and limiting the severity of fibrosis and glandular atrophy induced by repeated episodes of acute pancreatitis in mice. The predictive and diagnostic roles of these inflammatory factors in pancreatitis were introduced in detail in this review.

Anti-obesity Effects of Some Plant Extracts in Rats Fed with High-Fat Diet

Background and Aim:

Obesity has reached epidemic proportions around the world, resulting in severe health effects and financial costs, which have led to prompt actions and the advancement of phytochemistry technologies as new treatment techniques. This study aimed to assess and compare the anti-obesity, antioxidant, and anti-inflammatory effects of some common and safe doses of natural products like bitter orange, flax seeds, and ginger in adult male albino rats fed a high-fat diet.

Methods:

Fifty adult male albino rats were divided into five groups (n=10): a negative control group that received a balanced normal diet, a positive control group that received a high-fat diet (HFD) for eight weeks, and other 3 groups were fed HFD for eight weeks receiving daily 20 mg/kg/day of bitter orange fruit aqueous extract (standardized at 10% p- synephrine) or 250 mg/kg/- day of flax seeds ethanol extract or 200 mg/kg/day of ginger rhizomes ethanol extract for the last 4 weeks. All rats were sacrificed at the end of the study to obtain blood, liver, and kidney samples for biochemical and histopathological analyses.

Results:

The herbal extracts reduced body weight, lipid profile, inflammatory markers alpha-fetoprotein (AFP) and C reactive protein (CRP), malondialdehyde (MDA), and liver enzymes, all of which had been increased by the HFD. Furthermore, treatment with herbal extracts resulted in a significant reduction and improvement of the proliferated inflammatory infiltration, congested veins, and fatty vacuolated vesicles induced by HFD in liver and kidney tissues. Bitter orange exhibited the strongest anti-obesity effects, while flaxseed and ginger showed the strongest antioxidant and anti-inflammatory effects in response to the HFD.

Conclusion:

In obese rats, the use of these herbal extracts displayed a variety of possible protective and therapeutic effects. As a result, they are recommended for obese people, and further research is needed to determine the effects of a combination of various biochemical components found in these plant extracts on obesity and related disorders.

The Prognostic Value of Different Levels of Cortisol and High-sensitivity C-reactive Protein in Early Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) ranges in severity from mild to severe with high mortality. Severe AP, similar to other critical illnesses, is associated with changes in cortisol level. Early increase of high-sensitivity C-reactive protein (hs-CRP) as an inflammatory marker could be an indicator of AP progression. We aimed to assess the level of cortisol and hs-CRP on initial diagnosis of AP and identify their prognostic value.

METHODS

This case-control study included patients with AP and a control group of healthy subjects. Laboratory tests such as liver profile, kidney functions, blood picture, lactate dehydrogenase, blood glucose, and lipogram were evaluated, the severity of AP was determined, the duration of hospitalization, complications, and outcomes were identified, and the serum levels of cortisol and hs-CRP were assessed.

RESULTS

There were 90 patients with AP and 60 controls with a higher percent of females in both groups. Serum cortisol and hs-CRP were significantly higher in AP relative to controls and were higher in severe AP relative to mild AP. Significant positive correlation was present between high cortisol and severity of AP (r=0.520 and p<0.001) and negatively with pancreatic necrosis (r= - 0.303 and p= 0.007) and morality (r= - 0.432, p= 0.005) while hs-CRP did not show significant correlation.

CONCLUSIONS

Different levels of serum cortisol in early AP should be considered on initial diagnosis. High cortisol level was a good prognostic indicator for AP with low mortality. This could have further implications on the appropriate initiation of steroid therapy to prevent necrotizing pancreatitis and lower the mortality. Meanwhile, hs-CRP has a low prognostic value in early AP.

Mitochondrial DNA Copy-Number Variation and Pancreatic Cancer Risk in the Prospective EPIC Cohort

BACKGROUND

Mitochondrial DNA (mtDNA) copy number in peripheral blood has been found to be associated with risk of developing several cancers. However, data on pancreatic ductal adenocarcinoma (PDAC) are very limited.

METHODS

To further our knowledge on this topic, we measured relative mtDNA copy number by a quantitative real-time PCR assay in peripheral leukocyte samples of 476 PDAC cases and 357 controls nested within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

RESULTS

We observed lower mtDNA copy number with advancing age (P = 6.54 × 10-5) and with a high body mass index (BMI) level (P = 0.004) and no association with sex, smoking behavior, and alcohol consumption. We found an association between increased mtDNA copy number and decreased risk of developing PDAC with an odds ratios (OR) of 0.35 [95% confidence interval (CI), 0.16-0.79; P = 0.01] when comparing the fifth quintile with the first using an unconditional logistic regression and an OR of 0.19 (95% CI, 0.07-0.52; P = 0.001) with a conditional analysis. Analyses stratified by BMI showed an association between high mtDNA copy number and decreased risk in the stratum of normal weight, consistent with the main analyses.

CONCLUSIONS

Our results suggest a protective effect of a higher number of mitochondria, measured in peripheral blood leukocytes, on PDAC risk.

IMPACT

Our findings highlight the importance of understanding the mitochondrial biology in pancreatic cancer.

Change in serum levels of inflammatory markers reflects response of percutaneous catheter drainage in symptomatic fluid collections in patients with acute pancreatitis

BACKGROUND

Percutaneous catheter drainage (PCD) is used as the first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). There are limited data on the effect of PCD on inflammatory markers.

AIM

To study the effects of PCD on serum levels of C-reactive protein (CRP), IL-6, and IL-10 and its correlation with the outcome.

METHODS

Consecutive patients of AP with symptomatic fluid collections undergoing PCD were evaluated for serum levels of CRP, IL-6, and IL-10 before PCD and at 3 and 7 days after PCD. Resolution of organ failure (OF), sepsis, and pressure symptoms was considered to demonstrate the success of PCD. Changes in levels following PCD were correlated with outcome.

RESULTS

Indications of PCD in 59 patients (age 38.9 ± 13.17 years, 49 male) were suspected/documented infected pancreatic necrosis (n = 45), persistent OF (n = 40), and pressure symptoms (n = 7). A total of 49 (83.1%) patients improved with PCD, five patients required surgery, and six died. A significant difference was noted between baseline levels of CRP (P = 0.026) and IL-6 (P = 0.013) among patients who improved compared to those who worsened following PCD. Significant decrease (P < 0.01) of all three markers on day 3 of PCD insertion, with further decrease (P < 0.01) on day 7, was noted. The percentage of the decrease of IL-6 levels on day 3 and of CRP on day 7 correlated with the outcome.

CONCLUSION

PCD is associated with a significant decrease in CRP, IL-6, and IL-10 levels. Percentage decrease in IL-6 on day 3 and CRP on day 7 correlated with the outcome of patients managed with PCD.

Thrombin activatable fibrinolysis inhibitor as an indicator of the severity of acute pancreatitis

BACKGROUND/AIMS

Thrombin Activatable Fibrinolysis Inhibitor (TAFI), in addition to suppressing fibrinolysis, can be involved as a natural anti-inflammatory molecule in the inflammatory process in acute pancreatitis (AP). The goal of this study was to discover the significance of early determination of the values of TAFI in the assessment of the severity of AP.

MATERIALS AND METHODS

The prospective study included 92 patients with AP. In accordance with the revised Atlanta classification, we divided all patients into 3 groups (I-mild AP, II- moderate AP and III-severe AP). All patients were further classified into group A (mild AP) and group B (moderate and severe AP) with the aim of separating the patients with complicated and potentially bad prognosis. Biochemical markers, inflammatory biomarkers, coagulation parameters and TAFI were analyzed in all patients.

RESULTS

The level of TAFI were significantly higher among the patients with the complicated form (group B) of AP (p=0.002). The analysis of the ROC curve in regard to the inflammatory biomarkers (fibronectin and CRP) has shown that TAFI possesses the best discriminatory ability for complicated forms of AP (AUC=0.724, p=0.013), with the sensitivity of 83.30% and the specificity of 56.00%.

CONCLUSION

The level of TAFI in plasma is higher in patients with moderate or severe AP. Determining the level of TAFI as a single parameter has a greater significance in the early estimation of the severity of AP than inflammatory biomarkers that we have analyzed.

Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis

BACKGROUND

The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels.

MAIN RESULTS

A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice.

AUTHORS' CONCLUSIONS

The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.

Association of Asymmetric Dimethylarginine With Acute Pancreatitis-Induced Hyperglycemia

OBJECTIVE

The objective of this study was to investigate the relationship between asymmetric dimethylarginine (ADMA), an endogenous nitric oxide synthase inhibitor, oxidative-nitrosative damage, and glucoregulation in acute pancreatitis (AP).

METHODS

The study evaluated serum levels of ADMA, nitrotyrosine, and urinary 8-hydroxydeoxyguanosine in 40 male patients hospitalized for AP at baseline and at 2 and 10 days of treatment, respectively. The patients were classified into a mild and a moderately severe AP group (MAP and MSAP, respectively) according to Atlanta classification criteria. Glycemic status was evaluated by a 75-g oral glucose tolerance test 1 month after AP onset. Forty age-matched healthy subjects served as control subjects.

RESULTS

Significant decrease of ADMA and increased levels of nitrotyrosine and urinary 8-hydroxydeoxyguanosine were found in MSAP, but not in MAP at baseline, with ADMA correction toward control levels at the 10th day of treatment. Fructosamine was found to significantly influence ADMA levels (r = -0.362, P = 0.002). After AP recovery, either impaired glucose tolerance or diabetes was identified with the oral glucose tolerance test in 10.5% and 92.8% of patients with MAP and MSAP, respectively.

CONCLUSIONS

Insufficient inhibition of nitric oxide synthesis, through reduced bioavailability of ADMA, might be a novel significant contributory factor to the severity of AP and subsequent development of hyperglycemia.

Relationship between the degree of severe acute pancreatitis and patient immunity

PURPOSE

To investigate the relationship between the APACHE II score and the immunity of patients with severe acute pancreatitis.

METHODS

Clinical data were collected from 88 patients with acute pancreatitis, divided into four groups according to the severity of the disease. C-reactive protein (CRP), tumor necrosis factor-α, interleukin-6, interleukin-10, interleukin-4 and endotoxin (ET) in serum were measured on admission and then on days 3, 5, and 7.

RESULTS

The incidence of local complications and multiple organ dysfunction syndrome increased with a higher APACHE II score. The CRP levels were increased significantly on day 3 in all four groups, but remained high only in the extremely severe group. In the mild and moderate groups, the pro-/anti-inflammatory cytokines peaked on day 3 and then decreased slowly. In the severe and extremely severe groups, the proinflammatory cytokines levels peaked on days 3 and 5, and then decreased rapidly. The antiinflammatory cytokines increased progressively on days 3, 5 and 7. The ET levels peaked significantly and then decreased slowly in the mild, moderate and severe groups, but remained high in the extremely severe group.

CONCLUSIONS

An APACHE II score of 16 or higher is predictive of more local and systemic complications, excessive immune response, and premature immunosuppression.

Postoperative atrial fibrillation: role of inflammatory biomarkers and use of colchicine for its prevention

Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery, occurring in up to 65% of cardiac surgical patients. It is a condition associated with increased morbidity, increased length of hospital stay, and increased health care costs. One of the many potential causes of POAF is postsurgical inflammation, as demonstrated by increased levels of inflammatory biomarkers such as C-reactive protein and interleukin-6. Although still a subject of debate, the role of these inflammatory markers in the pathogenesis of POAF remains under vigorous investigation. Several antiinflammatory drugs have demonstrated promising results in prevention of POAF, including nonsteroidal antiinflammatory drugs, glucocorticoids, and statins. Colchicine is one of the oldest medications used in modern medicine, typically for the treatment and prevention of gout. New evidence has recently surfaced that colchicine may also be useful in the prevention of POAF. In recent studies, colchicine has demonstrated both safety and efficacy in the prevention of POAF. Several new studies are currently being initiated that may further elucidate colchicine's role in the prevention of POAF.

In utero exposure to the endocrine disruptor di-(2-ethylhexyl) phthalate promotes local adipose and systemic inflammation in adult male offspring

Background:

Di-(2-ethylhexyl) phthalate (DEHP) is a plasticizer used to increase the flexibility of polyvinyl chloride. DEHP and its active metabolite mono-(2-ethylhexyl) phthalate are detected in many biological fluids during fetal and postnatal life. In rodent models, in utero DEHP exposure has been shown to alter sexual organ development, decrease testosterone and aldosterone production, increase body and epididymal adipose tissue weight, and raise serum lipids and glucose levels in male offspring.

Objectives:

The objective of this study is to characterize the effects of in utero DEHP exposure on adipose tissue development and function in male offspring.

Methods:

Sprague–Dawley pregnant dams were gavaged 1, 20, 50 or 300 mg DEHP per kg per day from gestational day 14 until birth.

Results:

Global gene expression analyses of postnatal day 60 male offspring that were exposed in utero to 300 mg DEHP per kg per day revealed increased expression of immune response and inflammation markers, and increased expression of differentiation pathway genes in the epididymal whole-adipose tissue and isolated stromal vascular fraction. C-reactive protein and tumor necrosis factor (TNF) serum levels were increased in the 300 mg DEHP in utero-exposed offspring. TNF levels in adipose tissue homogenates were increased in the 50 and 300 mg DEHP in utero-exposed offspring. Immunofluorescence studies revealed focal macrophage infiltration in whole-adipose tissue confirmed by increased CD163 tissue content.

Conclusions:

In utero DEHP exposure promotes local adipose tissue inflammation and chronic low-grade systemic inflammation. Moreover, evidence is presented, suggesting that DEHP increases the differentiation capacity of the pre-adipocytes of male offspring without affecting total body weight.

Protective effects of the combination of sodium ferulate and oxymatrine on cecal ligation and puncture-induced sepsis in mice

The aim of this study was to investigate the effects of the combination of sodium ferulate (SF) and oxymatrine (OMT) on mice with cecal ligation and puncture (CLP)-induced sepsis. Swiss male mice were randomly divided into a control group, CLP group, three SF + OMT groups (3.1+6.9; 6.2+13.8 and 12.3+27.7 mg/kg), SF (6.2 mg/kg) group and OMT (13.8 mg/kg) group. Eight hours after the administration of the drugs, the survival rates and survival times of the animals were monitored. In addition, the lung wet/dry weight (W/D) ratio; alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) levels in the serum; the C-reactive protein (CRP), interleukin-6 (IL-6) and interferon-γ (IFN-γ) levels in the serum and lung and liver homogenates; and the malondialdehyde (MDA) and superoxidase dismutase (SOD) levels in the lung and liver homogenates were measured. The bacterial load in the serum was also studied. Following treatment with the combination of SF and OMT, the survival rate increased and the survival time was prolonged; CLP-induced increases in the lung W/D ratio and the levels of ALT, AST, LDH, CRP, IL-6, IFN-γ and MDA were significantly reduced; and the SOD activity levels were increased, compared with those of the untreated animals with CLP-induced sepsis. These results indicated that the combination of SF and OMT induced protective effects against CLP-induced lethal sepsis of mice. The possible mechanism of these effects may be associated with the alleviation of systemic inflammation and diminishment of oxidative injury.

The Role of IL-6, 8, and 10, sTNFr, CRP, and Pancreatic Elastase in the Prediction of Systemic Complications in Patients with Acute Pancreatitis

Background and Aim. Early assessment of severity in acute pancreatitis (AP) is a key measure to provide rational and effective management. The aim of our study is to determine the prognostic value of interleukins (IL) 6, 8, and 10, soluble receptor for tumor necrosis factor (sTNFr), pancreatic elastase (E1), and C-reactive protein (CRP) as predictors of systemic complications in AP. Patients and Methods. A hundred and fifty patients with confirmed AP were enrolled in the study. The severity of AP was defined according to Atlanta criteria. Measurements of interleukins and sTNFr were performed on the first day of admission. CRP and E1 levels were assessed on admission and after 48 hours. ROC analysis was performed for all parameters. Results. Interleukins and sTNFr significantly differentiated patients with systemic complications from those without. Elevation of IL-6 showed the highest significance as a predictor (P = 0.001). CRP and elastase levels did not differ between mild and severe cases on admission, but reached statistical significance when measured on the third day (P = 0.002 and P = 0.001, resp.). Conclusion. Our study confirmed that IL-6, IL-8, IL-10, and sTNFr measured on admission, and CRP and pancreatic elastase measured on third day of admission represent valuable prognostic factors of severity and systemic complications of AP.

Plasma thrombin-activatable fibrinolysis inhibitor as an indicator of inflammation and disease severity in acute pancreatitis

AIM

In addition to suppressing fibrinolysis, thrombin activatable fibrinolysis inhibitor (TAFI) was suggested to be involved in inflammation. To date, no study has been published that reports the role of TAFI in acute pancreatitis (AP). Therefore, the objective of the present study was to investigate the role of plasma TAFI as an indicator of inflammation in AP, and its association with disease severity.

METHODS

Plasma TAFI antigen levels quantitatively determined by using ELISA kits in 21 AP patients at onset and remission and 17 healthy controls. Associations of TAFI with inflammatory markers to determine AP and disease severity were assessed. To predict the severity of AP, modified Glasgow prognostic score (mGPS) and computerized tomography severity index (CTSI) were used for each subject.

RESULTS

Plasma TAFI levels was higher in AP patients at onset of the disease compared with healthy controls. The disease severity according to mGPS was significantly correlated with TAFI levels. Overall, accuracy of TAFI in determining AP was 83.3% with a sensitivity, specificity, NPV and PPV of 80.9%, 85.7%, 81.8%, and 85% respectively (AUC: 0.915).

CONCLUSIONS

The present study for the first time demonstrated that TAFI is elevated in AP. The appraisal of TAFI levels in patients with AP in conjunction with other markers of inflammation may provide additional information in estimating AP severity.

Mean platelet volume as an indicator of disease severity in patients with acute pancreatitis

AIM

Acute pancreatitis (AP) constitutes a systemic inflammatory process which is often accompanied by thrombosis and bleeding disorders. The role of platelets in the pathophysiology of the disease has not been elucidated yet. Mean platelet volume (MPV) is an index of platelet activation and reported to be influenced by inflammation. The objective of the present study is to assess whether platelet volume would be useful in predicting disease severity in AP. Additionally possible relationship of MPV with clinical and radiologic parameters in conjunction with other inflammatory markers during AP was also investigated.

PATIENTS AND METHODS

A total of 144 AP patients (male/female: 87/57), and 40 healthy subjects (male/female: 23/17) were enrolled in this study. Mean platelet volume and inflammatory parameters were measured for all study participants. Modified Glasgow Prognostic Score (mGPS) and the computerized tomography severity index (CTSI) were used as to predict the disease severity in AP patients.

RESULTS

A statistically significant decrease in MPV levels was observed in AP patients (8.06 ± 0.71 fL) compared with healthy controls (8.63 ± 0.62 fL) (P<0.001). According to the mGPS, overall accuracy of MPV in determining severe AP was 72.7% with a sensitivity, specificity, NPV and PPV of 70.6%, 73.9%, 81.9%, and 60 respectively (AUC: 0.762). Overall accuracy of MPV in predicting disease severity according to CTSI was not superior compared with other inflammation markers.

CONCLUSION

The present study demonstrated that MPV is decreased in AP. Assessment of MPV with other inflammatory markers may provide additional information about disease severity in AP.

The synergistic anti-inflammatory effect of the combination of sodium ferulate and oxymatrine and its modulation on inflammation-associated mediators in RAW 264.7 cells

ETHNOPHARMACOLOGICAL RELEVANCE

The combination of Radix Angelicae sinensis (Oliv.) Diels and Radix Sophora flavescens Ait. was extensively used in traditional Chinese medicine to treat inflammatory diseases, such as acne, heart disease, and hepatitis. Sodium ferulate (SF) and oxymatrine (OMT) were effective component of Radix Angelicae sinensis (Oliv.) Diels and Radix Sophora flavescens Ait., respectively.

AIM OF THE STUDY

In this study, we investigated the synergistic anti-inflammatory effect of the combination of SF and OMT, and its modulation on inflammation-associated mediators in RAW 264.7 cells.

MATERIALS AND METHODS

In vivo, the anti-inflammatory effects of the combination of SF and OMT were evaluated with the xylene-induced mouse ear edema model and the carrageenan-induced rat paw edema model. In vitro, chemokines and cytokines mRNA expressions in lipopolysaccharide (LPS)-activated RAW 264.7 cells were determined by real-time PCR (RT-PCR) microarray analysis. The levels of interleukin-11 (IL-11), C-reactive protein (CRP) and interferon-γ (INF-γ) in the supernatant of LPS-stimulated RAW 264.7 cells were measured by enzyme-linked immune-sorbent assay (ELISA).

RESULTS

The combination of SF and OMT could significantly inhibit the edema in the xylene-induced mouse ear edema and carrageenan-induced rat paw edema, but no effect was found when each drug was used alone according to above doses. The combination exhibited a better effect in down-regulating mRNA expressions of inflammation-associated mediators in LPS-stimulated RAW 264.7 cells than SF or OMT alone. The ELISA results showed that the combination synergistically inhibited LPS-induced IL-11, CRP and INF-γ production in a dose-dependent manner.

CONCLUSION

The combination of SF and OMT showed synergistic anti-inflammatory effect, and the activity was probably related to its modulation on inflammation-associated mediators, especially IL-11, CRP and INF-γ.

Assessment of the prognostic value of certain acute-phase proteins and procalcitonin in the prognosis of acute pancreatitis

OBJECTIVES

Of patients with acute pancreatitis (AP), 20% develop severe attacks that need early and intensive therapy. Yet, to administer such treatment, it is important to classify early on the patients with mild and severe pancreatitis. The aim of this study was to evaluate the role of serum amyloid A, C-reactive protein, procalcitonin, and routinely measured parameters in the early prediction of the course of AP.

METHODS

A total of 40 consecutive patients with AP confirmed by computed tomography were prospectively enrolled in the study-29 were graded as mild and 11 were graded as severe. Blood samples were obtained on admission and 24 hours thereafter.

RESULTS

Procalcitonin concentration in both measurements was significantly higher in patients with severe pancreatitis, and the cutoff level was estimated at 0.5 ng/mL. Although serum amyloid A and C-reactive protein levels rose significantly during the period of observation, these were not differentiated between both groups. Among the routinely measured parameters, a prognostic value was found for total calcium concentration, lactic dehydrogenase activity, and glucose concentration.

CONCLUSIONS

The best efficiency in the early prediction of severe AP would be achieved with the measurement of procalcitonin, total calcium level, and lactic acid dehydrogenase activity immediately after admission to the ward.

The role of C-reactive protein as an inflammatory marker in gastrointestinal diseases

C-reactive protein (CRP) is an acute-phase protein that is produced in large amounts by hepatocytes, upon stimulation by the cytokines interleukin-6, tumor-necrosis-factor-alpha and interleukin-1beta, during an acute-phase response. CRP is an objective marker of inflammation and, in gastrointestinal diseases such as Crohn's disease and acute pancreatitis, its levels correlate well with clinical disease activity. In contrast to its use as a marker in Crohn's disease, however, CRP is a less reliable marker of inflammation and disease activity in patients with ulcerative colitis, except perhaps for severe, extensive colitis. The increased production of CRP after an acute-phase stimulus, such as active gut inflammation, might explain why strong anti-inflammatory agents, such as anti-tumor-necrosis-factor-alpha antibodies and other biologic agents, work particularly well in patients with increased levels of CRP. CRP is also useful as a laboratory marker to predict prognosis and relapse in patients with Crohn's disease and acute pancreatitis. Elevated CRP levels have been associated with an increased risk of colorectal cancer and are a marker of poor prognosis, indicating more advanced disease and, possibly, reduced survival. An important question that remains is how often CRP levels should be measured. Until there are more data, the use of CRP and of other biomarkers should be seen as an additional tool that aids clinical observation and physical examination, but that cannot replace it.

Applicability of disseminated intravascular coagulation parameters in the assessment of the severity of acute pancreatitis

OBJECTIVES

To evaluate the clinical applicability of the determination of disseminated intravascular coagulation (DIC) parameters in acute pancreatitis.

METHODS

The subjects for this study were 139 consecutive patients with acute pancreatitis. DIC parameters were assessed at the initial observation of these patients.

RESULTS

The levels of the DIC parameters at admission were significantly associated with the severity and the prognosis of acute pancreatitis. Antithrombin III (AT-III), fibrin/fibrinogen degradation products-E, platelet count, D-dimer, and thrombin-AT-III complex at admission showed better area under the receiver operating characteristics curve values compared with C-reactive protein. An AT-III value of 69% at admission was the best cut-off value to predict fatal outcome (sensitivity, 81%; specificity, 86%).

CONCLUSIONS

The aggravated coagulation parameters predict a fatal outcome in patients with acute pancreatitis. AT-III level (<69%) was the most accurate marker for poor outcome of acute pancreatitis at admission.

Comparison of sensitivity and specificity of serum poly-C avid ribonuclease activity and C-reactive protein concentration in detection of mild and severe acute pancreatitis

The aim of this study was to compare diagnostic performance of C-reactive protein (CRP) and poly-C avid ribonuclease (P-RNase) levels in the prediction of a severe clinical course of acute pancreatitis (AP). The study included 36 patients with mild and 20 with severe AP. CRP concentration was measured by an immunonephelometric method and P-RNase activity by the rate of polycytidylate hydrolysis at pH 7.8. At the time of admission, both P-RNase and CRP levels were significantly increased in all patients when compared to healthy subjects (29.2 vs. 18.7 U/l and 91.1 vs. 2.89 mg/l; p < 0.001). Up to days 3 and 4 a further increase in P-RNase was observed. On the other hand, the increase in CRP continued only through days 2 and 3 (p < 0.001). Severe acute pancreatitis (SAP) and mild acute pancreatitis (MAP) differed significantly with respect to P-RNase levels on all days studied; whereas CRP levels differed significantly on days 2-5 but did not differ at admission. Receiver operating characteristic (ROC) curve function analysis yielded the best sensitivity of SAP detection for P-RNase, equaling 72.2%, at the cut-off point value 65.3 U/l on day 3 after admission. The sensitivity of CRP for detection of SAP was 85.0% at 125.7 mg/l on the 2nd day after admission. Both parameters studied were significantly associated with the severity of the AP clinical course; however, on days 1 and 2 post-admission, P-RNase was more specific for detection of SAP than CRP (94.4% vs. 77.1% on the 1st day and 94.4% vs. 55.5% on the 2nd day). In conclusion, P-RNase has shown an excellent performance for early differentiation of acute necrotizing pancreatitis.