Acute phase reactants in predicting disease outcome

Utility of the FebriDx point-of-care test for rapid triage and identification of possible coronavirus disease 2019 (COVID-19)

OBJECTIVES

The Coronavirus disease 2019 (COVID-19) pandemic is straining healthcare resources. Molecular testing turnaround time precludes having results at the point-of-care (POC) thereby exposing COVID-19/Non-COVID-19 patients while awaiting diagnosis. We evaluated the utility of a triage strategy including FebriDx, a 10-minute POC finger-stick blood test that differentiates viral from bacterial acute respiratory infection through detection of Myxovirus-resistance protein A (MxA) and C-reactive protein (CRP), to rapidly isolate viral cases requiring confirmatory testing.

METHODS

This observational, prospective, single-center study enrolled patients presenting to/within an acute care hospital in England with suspected COVID-19 between March and April 2020. Immunocompetent patients ≥16 years requiring hospitalisation with pneumonia or acute respiratory distress syndrome or influenza-like illness (fever and ≥1 respiratory symptom within 7 days of enrolment, or inpatients with new respiratory symptoms, fever of unknown cause or pre-existing respiratory condition worsening). The primary endpoint was diagnostic performance of FebriDx to identify COVID-19 as a viral infection; secondary endpoint was SARS-CoV-2 molecular test diagnostic performance compared with the reference standard COVID-19 Case Definition (molecular or antibody detection of SARS-CoV-2).

RESULTS

Valid results were available for 47 patients. By reference standard, 35 had viral infections (34/35 COVID-19; 1/35 non-COVID-19; overall FebriDx viral sensitivity 97.1% (95%CI 83.3-99.9)). Of the COVID-19 cases, 34/34 were FebriDx viral positive (sensitivity 100%; 95%CI 87.4-100); 29/34 had an initial SARS-CoV-2 positive molecular test (sensitivity 85.3%; 95%CI 68.2-94.5). FebriDx was viral negative when the diagnosis was not COVID-19 and SARS-Cov-2 molecular test was negative (negative predictive value (NPV) 100% (13/13; 95%CI 71.7-100)) exceeding initial SARS-CoV-2 molecular test NPV 72.2% (13/19; 95%CI 46.4-89.3). The diagnostic specificity of FebriDx and initial SARS-CoV-2 molecular test was 100% (13/13; 95%CI 70-100 and 13/13; 95%CI 85.4-100, respectively).

CONCLUSIONS

FebriDx could be deployed as part of a reliable triage strategy for identifying symptomatic cases as possible COVID-19 in the pandemic.

Acute phase reactants predict the risk of amputation in diabetic foot infection

BACKGROUND

prediction of amputation would aid clinicians in the management of diabetic foot infections. We aimed to assess the predictive value of baseline and post-treatment levels of acute phase reactants in the outcome of patients with diabetic foot infections.

METHODS

we collected data prospectively during minimum follow-up of 6 months in patients with infected diabetic foot ulcers hospitalized in Dokuz Eylul University Hospital between January 1, 2003, and January 1, 2008. After excluding patients who did not attend the hospital for follow-up visits regularly (n = 36), we analyzed data from 165 foot ulcer episodes.

RESULTS

limb ischemia and osteomyelitis were much more frequent in patients who underwent amputation. Wagner grade, which assesses ulcer depth and the presence of osteomyelitis or gangrene, was higher in patients who needed amputation. Ulcer size was slightly larger in the amputation group. Baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, white blood cell counts, and platelet counts were significantly elevated in patients who underwent amputation. Albumin levels were significantly suppressed in the amputation group. Univariate analysis showed that a 1-SD increase in baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, and white blood cell counts and a 1-SD decrease in post-treatment albumin levels were significantly associated with increased risk of amputation. Post-treatment C-reactive protein level was strongly associated with amputation risk.

CONCLUSIONS

circulating levels of acute phase reactants were associated with amputation risk in diabetic foot infections.

Morin protects acute liver damage by carbon tetrachloride (CCl(4)) in rat

The purpose of this study was to investigate possible beneficial effects of morin on CCl(4)-induced acute hepatotoxicity in rats. Rats received a single dose of CCl(4) (150 microL/100 g 1:1 in corn oil). Morin treatment (20 mg/kg) was given at 48, 24, and 2 h before CCl(4) administration. CCl(4) challenge elevated serum alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP) levels, but these effects were prevented by the pretreatment of rats with morin. To identify the mechanism of protective activity of morin in CCl(4)-induced hepatotoxicity in rats, we investigated expressions of tumor necrosis factor alpha (TNF-alpha), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), and inducible nitric oxide (iNOS). The expressions of TNF-alpha, IL-1beta, IL-6, and iNOS were increased by CCl(4) treatment and increased expressions of those were decreased by morin. These findings suggest that morin prevents acute liver damage by inhibiting the production of TNF-alpha, IL-1beta, IL-6, and iNOS.

Clinical indications for plasma protein assays: transthyretin (prealbumin) in inflammation and malnutrition

A large number of circumstances are associated with reduced serum concentrations of transthyretin (TTR), or prealbumin. The most common of these is the acute phase response, which may be due to inflammation, malignancy, trauma, or many other disorders. Some studies have shown a decrease in hospital stay with nutritional therapy based on TTR concentrations, but many recent studies have shown that concentrations of albumin, transferrin, and transthyretin correlate with severity of the underlying disease rather than with anthropometric indicators of hypo- or malnutrition. There are few if any conditions in which the concentration of this protein by itself is more helpful in diagnosis, prognosis, or follow up than are other clinical findings. In the majority of cases, the serum concentration of C-reactive protein is adequate for detection and monitoring of acute phase responses and for prognosis. Although over diagnosis and treatment of presumed protein energy malnutrition is probably not detrimental to most patients, the failure to detect other causes of decreased concentrations (such as serious bacterial infections or malignancy) of the so-called visceral or hepatic proteins could possibly result in increased morbidity or even mortality. In addition to these caveats, assays for TTR have a relatively high level of uncertainty ("imprecision"). Clinical evaluation--history and physical examination--should remain the mainstay of nutritional assessment.

Models of adjustment to chronic illness: Using the example of rheumatoid arthritis

There are a number of theoretical frameworks that attempt to explain how individuals may adjust to threats to health and serious physical illness. The three major paradigms that attempt to organize key components of health and adaptation to illness include the following: the biomedical model which emphasizes disease; psychological models of adaptation to illness; and biopsychosocial models with the latter two emphasizing health, functioning, and well-being. Each of these three major paradigms, including biomedical, psychosocial, and biopsychosocial frameworks, is discussed and critiqued in turn, and contributions and theoretical issues in terms of adjustment to chronic illness, particularly rheumatoid arthritis (RA), are highlighted. Furthermore, a biopsychosocial framework for conceptualizing adjustment to physical illness is proposed that incorporates elements from key existing biomedical and psychosocial models of adaptation to chronic physical health issues.

Determining minimally important changes in generic and disease-specific health-related quality of life questionnaires in clinical trials of rheumatoid arthritis

OBJECTIVE

To define clinically meaningful changes in 2 widely used health-related quality of life (HQL) instruments in studies of patients with rheumatoid arthritis (RA).

METHODS

Patients with RA (n = 693) who were enrolled in 2 double-blind, placebo-controlled clinical trials completed the Short Form 36 (SF-36) modified health survey and the Health Assessment Questionnaire (HAQ) disability index at baseline and 6-week followup assessments. Data on 5 RA severity measures were also collected at baseline and at 6 weeks (patient and physician global assessments, joint swelling and tenderness counts, and global pain assessment). Comparison of changes in the SF-36 scales and HAQ scores was made between groups of patients known to differ in the level of change on each RA severity measure.

RESULTS

With few exceptions, changes in the SF-36 and HAQ scores were different between patients who differed in the level of change on each RA severity measure. Changes in the SF-36 and HAQ scores were more strongly related to changes in the patient and physician global assessments and patient pain assessment than to changes in the joint swelling and tenderness counts.

CONCLUSION

Based on these results, minimally important changes in the SF-36 scales and HAQ disability scores were determined, which will be useful in interpreting HQL results in clinical trials.