Predictive value of CRP/albumin ratio in major abdominal surgery

How Immunonutritional Markers Are Associated with Age, Sex, Body Mass Index and the Most Common Chronic Diseases in the Hospitalized Geriatric Population-A Cross Sectional Study

The aim of this study was to assess the relationship of different chronic diseases with immunonutritional markers in the senior population.

METHODS

this study included 1190 hospitalized geriatric patients. The criteria to participate were ability to communicate, given consent and C-reactive protein (CRP) lower than 6 mg/dL.

RESULTS

the mean age of the study population was 81.7 ± 7.6 years. NLR (neutrophil-to-lymphocyte ratio), LMR (lymphocyte-to-monocyte ratio), MWR (monocyte-to-white blood cell ratio), SII (systemic immune-inflammation index), PNI (prognostic nutritional index) and CAR (C-reactive protein-to-albumin ratio) were related to age. NLR and MWR were higher, while LMR, PLR (platelet-to-lymphocyte ratio and SII were lower in men. All markers were related to BMI. NLR, LMR, LCR (lymphocyte-to-CRP ratio), MWR, PNI and CAR were related to several concomitant chronic diseases. In multivariate analyses, age and BMI were selected as independent predictors of all studied immunonutritional markers. Atrial fibrillation, diabetes mellitus and dementia appear most often in the models. PNI presented the most consistent statistical association with age, BMI and concomitant chronic diseases.

CONCLUSIONS

this study reveals the pivotal role of aging and BMI in inflammatory marker levels and the association of immunonutritional markers with different chronic diseases. Atrial fibrillation seems to have the most dominant connection to the immunonutritional markers.

An Exciting Performance of Established and Novel Biomarkers in Diagnosing Periprosthetic Joint Infections: A Single-center Retrospective Cohort Study

OBJECTIVE

Significant progress has been made in recent years in the diagnosis of periprosthetic joint infections (PJI). However, the lack of a gold standard test for the diagnosis of PJI remains a challenge.The aim of this study was to evaluate the diagnostic values of the albumin/fibrinogen ratio (AFR), the C-reactive protein/albumin ratio (CAR), and the levels of fibrinogen (FIB) and albumin (ALB) in the diagnosis of PJI.

METHODS

The medical records of 158 patients who had undergone hip or knee revisions from January 2018 to May 2022 were retrospectively analyzed. Of these patients, 79 were diagnosed with PJI, while 79 were diagnosed with aseptic loosening (AL). PJI was defined using the Musculoskeletal Infection Society criteria. The plasma levels of C-reactive protein (CRP), ALB, and FIB; the erythrocyte sedimentation rate (ESR); and the AFR and CAR in the two groups were recorded and analyzed. The receiver operating characteristic curve was used to calculate the sensitivity and specificity of each indicator; the diagnostic value for each indicator was calculated as the area under the curve (AUC).

RESULTS

The ESR, CRP, FIB, and CAR values in the PJI group were significantly higher than those in the AL group, and the ALB and AFR values were significantly lower than those in the AL group (p < 0.001). The AUC values of AFR and fibrinogen were 0.851 and 0.848, respectively, which were slightly higher than those of CRP (0.826) and ESR (0.846). The AUC of CAR was 0.831 which was slightly lower than that of CRP (0.846). ALB had an AUC of 0.727. The optimal threshold, sensitivity, and specificity, respectively, were 10.05, 84.81%, and 82.28% for AFR; 4.03 μg/mL, 77.22%, and 86.08% for FIB; 0.23, 72.15%, and 82.28% for CAR; and 37.30 g/L, 65.82%, and 73.42% for ALB.

CONCLUSIONS

AFR, CAR, and FIB are good new auxiliary diagnostic indicators of PJI, while ALB is of fair value for the diagnosis of PJI.

C-reactive protein to lymphocyte ratio as a new biomarker in predicting surgical site infection after posterior lumbar interbody fusion and instrumentation

Purpose

This study aims to evaluate the potential of C-reactive protein to lymphocyte count ratio (CLR) for the prediction of surgical site infection (SSI) following posterior lumbar interbody fusion (PLIF) and the instrumentation of lumbar degenerative diseases.

Methods

In this retrospective study, we considered patients with a lumbar degenerative disease diagnosis surgically treated by the instrumented PLIF procedure from 2015 to 2021. Patient data, including postoperative early SSI and other perioperative variables, were collected from their respective hospitalization electronic medical records. The receiver operator characteristic curve was constructed to determine the optimal cut-off value for CLR, and the ability to predict SSI was evaluated by the area under the curve (AUC). According to the cut-off value, patients were dichotomized with high- or low-CLR, and between-group differences were compared using univariate analysis. The independent impact of CLR on predicting SSI was investigated by multivariate logistics regression analysis.

Results

A total of 773 patients were included, with 26 (3.4%) developing an early SSI post-operation. The preoperative CLR was 11.1 ± 26.1 (interquartile range, 0.4–7.5), and the optimal cut-off was 2.1, corresponding to a sensitivity of 0.856, a specificity of 0.643, and an AUC of 0.768 (95% CI, 0.737–0.797). CLR demonstrated a significantly improved prediction ability than did lymphocyte count (P = 0.021) and a similar ability to predict an infection as C-response protein (P = 0.444). Patients with a high CLR had a significantly higher SSI incidence than those with a low CLR (7.6% vs. 0.8%, P < 0.001). After adjustment for numerous confounding factors, CLR ≥ 2.1 was associated with an 11.16-fold increased risk of SSI, along with other significant variables, i.e., diabetes, preoperative waiting time, and surgical duration.

Conclusion

A high CLR exhibited an improved ability to predict incident SSI and was associated with a substantially increased risk of SSI following instrumented PLIF. After better-design studies verified this finding, CLR could potentially be a beneficial tool in surgical management.

C-reactive Protein-to-albumin Ratio in Spinal Epidural Abscess: Association with Post-treatment Complications

INTRODUCTION

Spinal epidural abscess (SEA) is a complex medical condition with high morbidity and healthcare costs. Clinical presentation and laboratory data may have prognostic value in forecasting morbidity and mortality. C-reactive protein-to-albumin ratio (CAR) demonstrates promise for the prediction of adverse events in multiple orthopaedic and nonorthopaedic surgical conditions. We investigated the relationship between CAR and outcomes after treatment of SEA.

METHODS

We retrospectively evaluated adult patients treated within a single healthcare system for a diagnosis of SEA (2005 to 2017). Laboratory and clinical data included age at diagnosis, sex, race, body mass index, smoking status, history of intravenous drug use, Charlson Comorbidity Index, and CAR. The primary outcome was the occurrence of any complication; mortality and readmissions were considered secondarily. We used logistic regression to determine the association between baseline CAR and outcomes, adjusting for confounders.

RESULTS

We included 362 patients with a 90-day mortality rate of 13.3% and a 90-day complication rate of 47.8%. A reduced complication rate was observed in the lowest decile of CAR values compared with the remaining 90% of patients, a threshold value of 2.5 (27.0% versus 50.2%; odds ratio [OR] 2.66, 95% confidence interval [CI] 1.22 to 5.81). CAR values in the highest two deciles experienced significantly increased odds of complications compared with the lowest decile (80th: OR 3.44; 95% CI 1.25 to 9.42; 90th: OR 3.28; 95% CI 1.19 to 9.04).

DISCUSSION

We found elevated CAR to be associated with an increased likelihood of major morbidity in SEA. We suggest using a CAR value of 2.5 as a threshold for enhanced surveillance and recognizing patients with values above 73.7 as being at exceptional risk of morbidity.

LEVEL OF EVIDENCE

Level III observational cohort study.

Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy - a retrospective study

Purpose

Outcomes after emergency laparotomy (EL) are poor. These patients are often admitted to an intensive care unit (ICU). This study explored outcomes in patients who were admitted to an ICU within 48 h after EL.

Materials and Methods

This retrospective single‐center registry study included all patients over 16 years of age that underwent an EL and were admitted to an ICU within 48 h after surgery in Oulu University Hospital, Finland between January 2005 and May 2015. Survival was followed until the end of 2019.

Results

We included 525 patients. Hospital mortality was 13.3%, 30‐day mortality was 17.3%, 90‐day mortality was 24.2%, 1‐year mortality was 33.0%, and 5‐year mortality was 59.4%. Survivors were younger (57 [45–70] years) than the non‐survivors (73 [62–80] years; p < .001). According to the Cox regression model, death during the follow‐up was associated with age, APACHE II‐score, lower postoperative CRP levels and platelet count of the first postoperative day, and the admission from the post‐anesthesia care unit (PACU) to the ICU instead of direct ICU admission.

Conclusion

Age, high APACHE II‐score, low CRP and platelet count, and admission from the PACU to the ICU associated with mortality after EL in patients admitted to an ICU within 48 h after EL.

C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF)

Identification of novel markers would contribute to the individualised risk assessment and development of a risk prediction model. This study aimed to investigate the role of the C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF) of lumbar degenerative diseases. This study enrolled patients who underwent PLIF and instrumentation for treatment of lumbar degenerative diseases between 2015 and 2020. Electronic medical records were inquired for data collection, with follow-up register for identifying SSI cases. The optimal cut-off for CAR was determined by constructing the receiver operator characteristic (ROC) curve. Patients with high- or low-CAR value were compared using the univariate analyses, and the association between CAR and the risk of SSI was investigated using multivariate logistics regression analysis. A total of 905 patients were enrolled, twenty-nine (3.2%) had developed an SSI with 72.4% occurring during index hospitalisation, and 11 (1.2%) had deep and 18 (2.0%) superficial SSIs. An SSI was associated with additional 10.7 days of index total hospital stay (P = .001). The CAR was 0-5.43 (median, 0.05), and the optimal cut-off was 0.09 and area under the curve was 0.720 (P < .001). 336 (37.1%) patients had a CAR ≥0.09 and 22 (6.5%) developed an SSI, with a crude risk of 5.6 relative to those with a low CAR. The multivariate analyses showed CAR ≥0.09 was associated with 8.06-fold increased risk of SSI, together with diabetes (P = .018), while hypertension was identified as a protective factor (OR, 0.34; 95%CI, 0.11-1.00, P = .049). High CAR is found to significantly predict the incident SSI following instrumented PLIF of lumbar degenerative diseases, and can be considered as a useful index in practice only after it is verified by future high-level evidences.

The Prognostic Value of C-Reactive Protein/Albumin Ratio in Acute Mesenteric Ischemia

Background

Diagnosis of acute mesenteric ischemia (AMI) in its early stages is important for reversing ischemic damage. The CRP to albumin (CRP/Alb) ratio has been defined as an inflammatory indicator and is associated with the severity of inflammation and mortality rates. However, the prognostic value of CRP/Alb has not been evaluated in patients with AMI. Here, we aimed to examine the prognostic significance of CRP/Alb and compare it with other inflammatory markers.

Materials and Methods

In this retrospective, case-control study, we included patients diagnosed with AMI at the emergency department between January 1, 2016, and December 31, 2020. In addition to demographic characteristics, lactate, D-dimer, white blood cell (WBC), CRP/Alb, and neutrophil/lymphocyte ratio (NLR) were recorded. Testing characteristics of CRP/Alb in predicting in-hospital mortality were studied.

Results

The mean age of 132 patients was 66.48 ± 15.95 years and 71 (53.8%) of them were male. The cut-off value obtained using the receiver operating characteristic (ROC) curve for in-hospital mortality was a CRP/Alb ratio of >1.32 (sensitivity, 93.65%; specificity, 69.57%; +LR, 3.08; −LR, .091; AUC, .782; 95% CI, .70-.85; P < .0001). The comparison of ROC curves between CRP/Alb and WBC, NLR, and lactate revealed a statistically significant difference ( P < .05), whereas there was not any statistically significant difference between the ROC curves of CRP/Alb and D-dimer ( P = .47).

Conclusion

C-reactive protein/albumin ratio is a powerful predictor of in-hospital mortality for AMI patients. It was superior to WBC, NLR, and lactate. It could be used to determine low-risk patients and help clinicians with treatment options.

Prospective study of surgical site infections post-open esophageal cancer surgery, and the impact of care bundles

SSIs represent common infection-related morbidity following major surgery. Modern care bundles have been established as prophylactic measures aimed at preventing SSI occurring postoperatively. SSI incidence and data on common culprit pathogens post-esophagectomy for cancer have not been previously reported. Patients (2013-2018) treated with curative intent were studied. SSI was defined as per the Center for Disease Control (CDC) definition. A care bundle pathway following the National Institute for Clinical Excellence (NICE) guidelines for prevention of SSIs was introduced in 2013 and was audited quarterly. Risk factors and associations of SSIs were analyzed, as was the prevalence of isolated pathogens. Multivariable logistic regression examined independently predictive factors of SSIs and oncologic outcomes. Of 343 patients, 34 (9.9%) developed a postoperative SSI, with a median (range) of 8 (6-17). Quarterly audit carried out over 6 years showed no significant annual variance or trend. The most prevalent pathogen cultured was Methicillin-sensitive Staphylococcus aureus (MSSA) in nine patients (32%) followed by Candida albicans (29%), Escherichia coli (14%), and Enterococcus faecium (11%). SSI was significantly associated with pneumonia (P = 0.001), respiratory failure (P = 0.014), atrial fibrillation (P = 0.004), anastomotic leak (P < 0.001), and in-hospital blood transfusions (P = 0.031). SSI did not impact the overall survival (P = 0.951). SSI rates can be maintained at less than 10% using strict care bundles and regular audit. The most common culprit pathogen is gram-positive MSSA representing 32% of cases. These data are novel and may represent a modern benchmark for SSI post-open esophagectomy for cancer. This study highlights the incidence and associations of SSI post-esophageal cancer surgery.

CRP/Albumin Has a Promising Prospect as a New Biomarker for the Diagnosis of Periprosthetic Joint Infection

Purpose

In the present study, we aimed to identify more effective biomarkers for the diagnosis of periprosthetic joint infection (PJI) by comparing the diagnostic ability of C-reactive protein (CRP)/albumin, systemic immune-inflammation index (SII), and existing biomarkers.

Methods

In this single-center retrospective analysis, 216 patients who underwent revision knee or hip arthroplasty from June 2013 to June 2021 and met the inclusion and exclusion criteria were analyzed, including 80 patients in the PJI group and 136 patients in the non-PJI group. The following information was collected for analysis, including CRP, fibrinogen, erythrocyte sedimentation rate (ESR), D-dimer, platelet count (PC), neutrophil count (N), lymphocyte count (Lym), and albumin count on the second day of admission. The receiver operating characteristic (ROC) curve was used to compare the diagnostic ability of various biomarkers, and further subgroup analysis was carried out in the PJI group.

Results

Compared with the non-PJI group, CRP, fibrinogen, D-dimer, ESR, CRP/albumin, and SII in the PJI group were significantly increased (P < 0.001), and their area under the curve (AUC) was 0.937, 0.878, 0.777, 0.914, 0.941, and 0.765, respectively. In the three subgroup analyses, there was no significant difference in appeal biomarker (P > 0.05) based on PJI culture results, infection time, and infection site.

Conclusion

CRP/albumin had a promising prospect as a new biomarker for the diagnosis of PJI, while it had insufficient predictive ability in the PJI subgroup analysis. However, SII had insufficient ability to diagnose PJI. Therefore, SII was not suitable to be used as a diagnostic biomarker.

Clinical, microbiological and inflammatory markers of severe diabetic foot infections

AIMS

In addition to systemic inflammatory response syndrome (SIRS), various clinical signs, microbiological findings and inflammatory markers could be associated with severe diabetic foot infections (DFI).

METHODS

This study included a retrospective cohort of 245 patients with DFI treated at San Juan de Dios Hospital in San José de Costa Rica. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), CRP/albumin ratio, peripheral blood leucocyte ratios and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system were evaluated. Univariate analysis was carried out between moderate and severe infections. ROC curves were plotted. Cut-off value of inflammatory markers for diagnosing severe infections was established and then dichotomized to be included in a logistic regression model. A score was designed based on its results.

RESULTS

Skin necrosis (p < 0.01, OR = 8.5, 95% CI = 3.5-20.9), ESR > 94 mm/h (p < 0.01, OR = 2.5, 95% CI = 1.2-5.1), albumin < 2.8 g/dl (p = 0.04, OR = 2.0, 95% CI = 1.0-4.1) and neutrophil-to-lymphocyte ratio (NLR) > 4.52 (p < 0.01, OR = 3.3, 95% CI = 1.6-6.5) were found to be predictive of severe infections. Score >5 had a good diagnosis performance for classifying severe infections. Moderate infections with a score >5 had a worse prognosis than moderate ones.

CONCLUSIONS

We found an association of necrosis, serum albumin, ESR and NLR values with severe DFI. The presence of these predictive factors of severity in cases of moderate infections was significantly associated with a higher rate of amputations and recurrences, longer duration of antibiotic treatment and longer hospital stays. DFI could be classified as mild, moderate, severe without SIRS and severe.

Preoperative risk factors of incisional surgical site infection in severe or intractable ulcerative colitis

PURPOSE

The present study explored preoperative risk factors (predictors) of incisional surgical site infection (I-SSI) in severe or intractable ulcerative colitis (UC).

METHODS

This was a retrospective study of 230 consecutive patients who underwent primary surgery for UC. Patients whose surgical indications were UC with cancer or dysplasia were excluded. SSI was defined as an infection according to the Centers for Disease Control and Prevention Guidelines. Preoperative variables were examined by univariate, receiver operating characteristic curve, and multivariate analyses.

RESULTS

We analyzed 208 patients in this study. In a multivariate logistic analysis, C-reactive protein (CRP) ≥ 1.7 mg/dl [odds ratio (OR) 5.35; 95% confidence interval (CI) 1.50-19.06; p = 0.01), albumin ≤ 2.4 g/dl (OR 5.77; 95% CI 1.41-23.57; p = 0.02), and preoperative blood transfusion (OR 3.21; 95% CI 1.04-9.96; p = 0.04) were predictors of I-SSI. Patients with all predictors had a more than 50% incidence of I-SSI, a higher incidence of all severe complications (13.6% vs. 3.2%; p = 0.02), and a longer postoperative hospital stay (19.5 vs. 17.0 days, p = 0.04) than the other patients.

CONCLUSIONS

CRP ≥ 1.7 mg/dl, albumin ≤ 2.4 g/dl, and transfusion are predictors of I-SSI in severe or intractable UC. Clinician should carefully evaluate the surgical options before these predictors appear.