Interpretation of C-reactive protein concentrations in critically ill patients

C-Reactive Protein and Brain Natriuretic Peptides Harmonization

The harmonization of laboratory biomarkers is pivotal in ensuring consistent and reliable diagnostic outcomes across different clinical settings. This systematic review examines the harmonization of C-Reactive Protein (CRP) and N-Terminal Prohormone of Brain Natriuretic Peptide (NT-proBNP) measurements, both of which are jointly utilized in the diagnosis and management of cardiovascular diseases. To identify relevant studies, we searched the PubMed electronic database using specific medical subject headings and keywords such as C-Reactive Protein, CRP, high sensitivity C-Reactive Protein (hs-CRP), N-terminal pro B-type natriuretic peptide, and NT-proBNP, focusing on publications from June 1 to September 26, 2021. The query filtered studies to include only those in English involving human subjects. From our search, 97 articles met the inclusion criteria and were included for in-depth analysis. Despite their widespread use, significant variability remains in the measurements of CRP and NT-proBNP due to a lack of standardized pre-analytical, analytical, and post-analytical practices. This review highlights the consequences of this variability on clinical decision-making and patient outcomes and emphasizes the need for international standards and guidelines to achieve better harmonization. Our findings advocate for the establishment of universal protocols to enhance the reliability of these biomarker measurements across different clinical environments, ensuring improved healthcare delivery.

A Secondary Retrospective Analysis of the Predictive Value of Neutrophil-Reactive Intensity (NEUT-RI) in Septic and Non-Septic Patients in Intensive Care

BACKGROUND

Effective identification and management in the early stages of sepsis are critical for achieving positive outcomes. In this context, neutrophil-reactive intensity (NEUT-RI) emerges as a promising and easily interpretable parameter. This study aimed to assess the predictive value of NEUT-RI in diagnosing sepsis and to evaluate its prognostic significance in distinguishing 28-day mortality outcomes.

MATERIALS

This study is a secondary, retrospective, observational analysis. Clinical data upon ICU admission were collected. We enrolled septic patients and a control group of critically ill patients without sepsis criteria. The patients were divided into subgroups based on renal function for biomarker evaluation with 28-day outcomes reported for septic and non-septic patients.

RESULTS

A total of 200 patients were included in this study. A significant difference between the "septic" and "non-septic" groups was detected in the NEUT-RI plasma concentration (53.80 [49.65-59.05] vs. 48.00 [46.00-49.90] FI, p < 0.001, respectively). NEUT-RI and procalcitonin (PCT) distinguished between not complicated sepsis and septic shock (PCT 1.71 [0.42-12.09] vs. 32.59 [8.83-100.00], <0.001 and NEUT-RI 51.50 [47.80-56.30] vs. 56.20 [52.30-61.92], p = 0.005). NEUT-RI, PCT, and CRP values were significantly different in patients with "renal failure". NEUT-RI and PCT at admission in the ICU in the septic group were higher in patients who died (58.80 [53.85-73.10] vs. 53.05 [48.90-57.22], p = 0.005 and 39.56 [17.39-83.72] vs. 3.22 [0.59-32.32], p = 0.002, respectively). Both NEUT-RI and PCT showed a high negative predictive value and low positive predictive value.

CONCLUSIONS

The inflammatory biomarkers assessed in this study offer valuable support in the early diagnosis of sepsis and could have a possible role in anticipating the outcome. NEUT-RI elevation appears particularly promising for early sepsis detection and severity discrimination upon admission.

The Feasibility of C-Reactive Protein Point-of-Care Testing to Reduce Overuse of Antibiotics in Children with Acute Respiratory Tract Infections in Rural Kyrgyzstan: A Pilot Study

Background

In Kyrgyzstan, the morbidity prevalence of and morbidity from acute respiratory tract infections (ARTI) in children is high. Local healthcare workers (HCW) often prescribe antibiotics that are not indicative due to a mix of professional and societal factors. It is suggested to precede with a decision on antibiotics by a point-of-care test (POCT) on the appropriateness of the treatment, eg, a measurement of C-reactive protein (CRP). CRP-guided antibiotic stewardship in children with ARTI has not previously been studied in Central Asia.

Purpose

This pilot study was conducted to examine the feasibility of the methods and procedures to be used in the upcoming randomised controlled COORDINATE clinical trial (NCT05195866) and in daily clinical practice in primary care.

Patients and methods

HCWs from three selected rural healthcare facilities were trained in the CRP POCT and in interpretation of results. Children aged 6 months to 12 years attending the primary healthcare facilities with respiratory symptoms were randomly assigned to CRP-guided management or standard care, guided by clinical findings only. Children were followed up for 14 days by scheduled telephone calls to caregivers.

Results

Eighty-one children participated in this pilot study. The CRP POCT and the trial procedures were acceptable to the target group as well as to the HCWs. Children from both groups recovered equally well, with an observed significant lower use of antibiotics in the CRP group. HCWs generally adhered to the CRP guidelines, and only once was an antibiotic prescribed despite low CRP results. No safety concerns were observed. Four parents provided wrong phone numbers impeding follow-up. We will collect all mobile phone numbers in the household for the main trial.

Conclusion

The pilot provided satisfactory results, suggesting that the COORDINATE trial of CRP POCT is effective, feasible with minor adjustments and without apparent safety concerns for the participants.

Inflammation and response to nutrition interventions

The complex interplay between nutrition and inflammation has become a major focus of research in recent years across different clinical settings and patient populations. Inflammation has been identified as a key driver for disease-related malnutrition promoting anorexia, reduced food intake, muscle loss, and on a cellular level, insulin resistance, which together stimulate catabolism. However, these effects may well be bidirectional, and there is strong evidence showing that nutrition influences inflammation. Several single nutrients and dietary patterns with either proinflammatory or anti-inflammatory properties have been studied, such as the long-chain ω-3 fatty acids eicosapentaenoic acid or docosahexaenoic acid. The Mediterranean diet combines several such nutrients and has been shown to improve medical outcomes in the outpatient setting. In addition, there is increasing evidence suggesting that inflammation affects the metabolism and modulates the response to nutrition support interventions. In fact, recent studies from the medical inpatient setting suggest that inflammation, mirrored by high levels of C-reactive protein, diminishes the positive effects of nutrition support. This may explain the lack of positive effects of some nutrition trials in severely ill patients, whereas similar approaches to nutritional support have shown positive results in less severely ill patients. The use of biomarkers, such as C-reactive protein, may help to identify patients with a lower response to nutrition, in whom other treatment options need to be used. There is need for additional research to understand how to best address the malnourished patient with inflammation by specifically lowering inflammation through anti-inflammatory medical treatments and/or nutrition interventions.

Pregnancy Outcomes in Patients with Urosepsis and Uncomplicated Urinary Tract Infections-A Retrospective Study

Background and Objectives: Urinary tract infections (UTIs) are an important cause of perinatal and maternal morbidity and mortality. The aim of this study was to describe and compare the main pregnancy outcomes among pregnant patients with complicated and uncomplicated UTIs; Materials and Methods: This retrospective study included 183 pregnant patients who were evaluated for uncomplicated UTIs and urosepsis in the Urology Department of 'C.I. Parhon' University Hospital, and who were followed up at a tertiary maternity hospital-'Cuza-voda' from Romania between January 2014 and October 2023. The control group (183 patients) was randomly selected from the patient's cohort who gave birth in the same time frame at the maternity hospital without urinary pathology. Clinical and paraclinical data were examined. Descriptive statistics and a conditional logistic regression model were used to analyze our data. Results: Our results indicated that patients with urosepsis had increased risk of premature rupture of membranes (aOR: 5.59, 95%CI: 2.02-15.40, p < 0.001) and preterm birth (aOR: 2.47, 95%CI: 1.15-5.33, p = 0.02). We could not demonstrate a statistically significant association between intrauterine growth restriction and pre-eclampsia with the studied urological pathologies. Conclusions: Careful UTI screening during pregnancy is needed for preventing maternal-fetal complications.

Nucleated red blood cells as a novel biomarker in the diagnosis and prediction of sepsis severity in children

Introduction

Sepsis is a vitally serious disease leading to high mortality. Nucleated red blood cells (NRBCs) are present in some noninfectious diseases, but the relationship between NRBCs and sepsis in children remains unknown. The purpose of this study was to compare the clinical characteristics and outcomes of sepsis with positive NRBCs and negative NRBCs in children, and to further explore whether the count of NRBCs has a relationship with the severity of sepsis.

Methods

We enrolled children with sepsis who were admitted to the Children's Hospital of Chongqing Medical University between January 2020 and December 2022. The children's clinical data, laboratory data and outcomes were recorded and analyzed.

Results

One hundred and fifteen children met the inclusion criteria in our study. Compared to negative NRBCs patients, the C-reactive protein, alanine transaminase, urea nitrogen values, mortality rate and length of hospitalization were found to be significantly increased, while platelet counts, and hemoglobin were significantly decreased in sepsis patients with positive NRBC (P < 0.05). Receiver operating characteristic (ROC) curves analysis showed that the optimal cutoff value of the NRBC count in the diagnosis of severe sepsis was 3, with a sensitivity of 87.5% and specificity of 94.9%. The area under the ROC curve was 0.877 (95% CI: 0.798-0.957).

Discussion

These findings demonstrated that NRBC count has the potential to be a biomarker for the diagnosis of sepsis in children, especially an NRBC count greater than 3, which may predict the severity and poor prognosis in children suffering from sepsis.

Predictive Value of PRISM-4, PIM-3, CRP, Albumin, CRP/Albumin Ratio and Lactate in Critically Ill Children

The accurate prediction of the prognosis for critically ill children is crucial, with the Pediatric Index of Mortality (PIM) and Pediatric Risk of Mortality (PRISM) being extensively utilized for this purpose. Albumin, C-reactive protein (CRP), and lactate levels, which are indicative of inflammation and circulatory status in critically ill children, have not been incorporated into existing scoring systems. This retrospective cohort study evaluated the association between biological markers and the clinical outcomes in children with critical illnesses. PRISM-4 and PIM-3 death probability (DP), albumin, lactate, CRP, and CRP/albumin ratio were recorded upon admission. The accuracy of the indexes in predicting mortality were assessed by calculating the area under the curve (AUC). There were 942 patients included and the 28-day mortality rate was 7.9%. The AUC for PRISM-4, PIM-3, CRP, CRP/albumin ratio, albumin, and lactate were 0.923, 0.896, 0.798, 0.795, 0.751, 0.728, respectively. The findings in the subgroup analysis of septic patients were similar to those found in the overall population. Although CRP, CRP/albumin ratio, albumin, and lactate levels are all linked to mortality in children, CRP and the CRP/albumin ratio have lower predictive values than albumin and lactate. Incorporation of albumin and lactate into scoring systems will improve predictability.

Model-informed precision dosing in vancomycin treatment

Introduction: While vancomycin remains a widely prescribed antibiotic, it can cause ototoxicity and nephrotoxicity, both of which are concentration-associated. Overtreatment can occur when the treatment lasts for an unnecessarily long time. Using a model-informed precision dosing scheme, this study aims to develop a population pharmacokinetic (PK) and pharmacodynamic (PD) model for vancomycin to determine the optimal dosage regimen and treatment duration in order to avoid drug-induced toxicity. Methods: The data were obtained from electronic medical records of 542 patients, including 40 children, and were analyzed using NONMEM software. For PK, vancomycin concentrations were described with a two-compartment model incorporating allometry scaling. Results and discussion: This revealed that systemic clearance decreased with creatinine and blood urea nitrogen levels, history of diabetes and renal diseases, and further decreased in women. On the other hand, the central volume of distribution increased with age. For PD, C-reactive protein (CRP) plasma concentrations were described by transit compartments and were found to decrease with the presence of pneumonia. Simulations demonstrated that, given the model informed optimal doses, peak and trough concentrations as well as the area under the concentration-time curve remained within the therapeutic range, even at doses smaller than routine doses, for most patients. Additionally, CRP levels decreased more rapidly with the higher dose starting from 10 days after treatment initiation. The developed R Shiny application efficiently visualized the time courses of vancomycin and CRP concentrations, indicating its applicability in designing optimal treatment schemes simply based on visual inspection.

Establishment of growth stimulating gene 2 protein time-resolved fluorescence immunoassay and its application in sepsis

AIM

This study aimed to establish a highly sensitive time-resolved fluorescence immunoassay of growth stimulating express gene 2 protein (ST2-TRFIA) and evaluate its application value for sepsis.

METHODS

Two types of ST2 monoclonal specific antibodies against different epitopes of antigen molecule were used as coating and Eu3+-labeled antibodies. The double-antibody sandwich method was used in establishing ST2-TRFIA, and the methodology was evaluated. The established ST2-TRFIA was used in detecting ST2 concentration in the plasma samples of healthy controls and sepsis.

RESULTS

The linear range of ST2-TRFIA was 1.446-500 ng/mL. Plasma ST2 concentrations detected through ST2-TRFIA were consistent with the results of fluorescence quantitative immunochromatography (ρ = 0.946). The plasma ST2 concentrations of patients with sepsis were significantly higher than those of healthy controls (P < 0.01).

CONCLUSION

This study successfully established a highly sensitive ST2-TRFIA, which was highly comparable to commercially available fluorescent quantitative immunochromatographic kits and can facilitate the timely diagnosis of sepsis.

Development and validation of prediction scores for the outcome associated with persistent inflammation, immunosuppression, and catabolism syndrome among patients with trauma

Background

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has impacted on long-term prognosis of patients with trauma. We aimed to identify patients with trauma at risk of PICS-related complications early in the intensive care unit (ICU) course.

Methods

A single-center retrospective cohort study was conducted. All consecutive patients with trauma who had stayed in the ICU for >7 days were included in the study. We developed the prediction score for the incidence of PICS-related outcomes in the derivation cohort for the initial period and then evaluated in the validation cohort for the subsequent period. Other outcomes were also assessed using the score.

Results

In total, 170 and 133 patients were included in the derivation and validation cohorts, respectively. The prediction score comprised the variables indicating PICS presence, including a maximum value of C-reactive protein >15 mg/dL, minimum value of albumin <2.5 g/dL, and an episode of nosocomial infection for the first 7 days after admission. A score of 1 was assigned to each variable. The area under the receiver operating characteristic curve of the score to predict PICS incidence was 0.74 (95% CI 0.66 to 0.81) and 0.72 (95% CI 0.64 to 0.81) in the derivation and validation cohorts, respectively. The higher score was also significantly associated with a higher Sequential Organ Failure Assessment score at day 14, a longer duration of mechanical ventilation, a longer length of stay in ICU, and experienced multiple episodes of infection. Similar results were obtained in the validation cohort.

Conclusions

Our scoring system could predict the outcomes associated with PICS among patients with trauma. Because the score comprised the parameters measured for the first 7 days during the ICU course, it could contribute to identifying patients at a high risk of unfavorable outcome earlier.

Level of evidence

Multivariate prediction models; level IV.

Decreased level of serum NT-proCNP associates with disease severity in COVID-19

BACKGROUND

C-type natriuretic peptide (CNP) is an endothelium-derived paracrine molecule with an important role in vascular homeostasis. In septic patients, the serum level of the amino-terminal propeptide of CNP (NT-proCNP) shows a strong positive correlation with inflammatory biomarkers and, if elevated, correlates with disease severity and indicates a poor outcome. It is not yet known whether NT-proCNP also correlates with the clinical outcome of patients suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In the current study, we aimed to determine possible changes in the NT-proCNP levels of patients with coronavirus disease 2019 (COVID-19), with special regard to disease severity and outcome.

METHODS

In this retrospective analysis, we determined the serum level of NT-proCNP in hospitalized patients with symptoms of upper respiratory tract infection, using their blood samples taken on admission, stored in a biobank. The NT-proCNP levels of 32 SARS-CoV-2 positive and 35 SARS-CoV-2 negative patients were measured to investigate possible correlation with disease outcome. SARS-CoV-2 positive patients were then divided into two groups based on their need for intensive care unit treatment (severe and mild COVID-19).

RESULTS

The NT-proCNP was significantly different in the study groups (e.g. severe and mild COVID-19 and non-COVID-19 patients), but showed inverse changes compared to previous observations in septic patients: lowest levels were detected in critically ill COVID-19 patients, while highest levels in the non-COVID-19 group. A low level of NT-proCNP on admission was significantly associated with severe disease outcome.

CONCLUSIONS

Low-level NT-proCNP on hospital admission is associated with a severe COVID-19 disease course. The pathomechanism underlying this observation remains to be elucidated, while future studies in larger patient cohorts are necessary to confirm these observations and reveal therapeutic importance. Trial registration DRKS00026655 Registered 26. November 2021.

[Early predictor of bronchial suture failure after pneumonectomy]

OBJECTIVE

To identify the relationship between serum CRP/albumin and bronchial suture failure after pneumonectomy.

MATERIAL AND METHODS

A retrospective analysis included 100 patients who underwent pneumonectomy with extended lymph node dissection for lung cancer. Patients were divided into 2 groups depending on postoperative complications: group 1 - bronchial stump failure, group 2 - no similar complications. In all patients, we analyzed markers of inflammation (C-reactive protein and albumin) in preoperative period and after 24 postoperative hours. Bronchial stump failure was found in 20 patients (10 patients (14.7%) after left-sided pneumonectomy and 10 (31%) patients after right-sided pneumonectomy). We found a significant relationship between serum CRP/albumin and bronchial stump failure after pneumonectomy (p<0.05). A prognostic formula was based on the ratio of serum C-reactive protein and albumin: PC = CRP/Alb, where PC - prognostic coefficient, CRP - serum C-reactive protein (mg/l) 24 hours after surgery, Alb - serum albumin (g/l) 24 hours after surgery. PC >2.6 determines high risk of bronchial stump failure after pneumonectomy, PC <2.6 - low risk. Sensitivity of this method is 90%, specificity - 97.5%.

Monitoring of the Forgotten Immune System during Critical Illness-A Narrative Review

Immune organ failure is frequent in critical illness independent of its cause and has been acknowledged for a long time. Most patients admitted to the ICU, whether featuring infection, trauma, or other tissue injury, have high levels of alarmins expression in tissues or systemically which then activate innate and adaptive responses. Although necessary, this response is frequently maladaptive and leads to organ dysfunction. In addition, the counter-response aiming to restore homeostasis and repair injury can also be detrimental and contribute to persistent chronic illness. Despite intensive research on this topic in the last 40 years, the immune system is not routinely monitored in critical care units. In this narrative review we will first discuss the inflammatory response after acute illness and the players of maladaptive response, focusing on neutrophils, monocytes, and T cells. We will then go through commonly used biomarkers, like C-reactive protein, procalcitonin and pancreatic stone protein (PSP) and what they monitor. Next, we will discuss the strengths and limitations of flow cytometry and related techniques as an essential tool for more in-depth immune monitoring and end with a presentation of the most promising cell associated markers, namely HLA-DR expression on monocytes, neutrophil expression of CD64 and PD-1 expression on T cells. In sum, immune monitoring critically ill patients is a forgotten and missing piece in the monitoring capacity of intensive care units. New technology, including bed-side equipment and in deep cell phenotyping using emerging multiplexing techniques will likely allow the definition of endotypes and a more personalized care in the future.

Differentiating between bacterial and viral infections by estimated CRP velocity

PURPOSE

Differentiating between acute viral and bacterial infection is challenging due to the similarity in symptom presentation. Blood tests can assist in the diagnosis, but they reflect the immediate status and fail to consider the dynamics of an inflammatory response with time since symptom onset. We applied estimated C-reactive protein (CRP) velocity (eCRPv), as derived from the admission CRP level divided by time from symptom onset, in order to better distinguish between viral and bacterial infections.

METHODS

This cross-sectional study included patients admitted to the emergency department with a confirmed viral (n = 83) or bacterial (n = 181) infection. eCRPv was defined as the ratio between the absolute CRP level upon admission to time from symptom onset (in hours). Absolute CRP and eCRPv values were compared between the 3 groups.

RESULTS

Bacterial patients presented with higher CRP levels (133 mg/L) upon admission compared to viral patients (23.31 mg/L) (P < 0.001). Their median value of eCRPv velocity was 4 times higher compared to the viral patients (1.1 mg/L/h compared 0.25 mg/L/h, P < 0.001). Moreover, in intermediate values of CRP (100-150 mg/L) upon admission, in which the differential diagnosis is controversial, high eCRPv is indicative of bacterial infection, eCRPv >4 mg/L/h represents only bacterial patients.

CONCLUSIONS

During an acute febrile illness, the eCRPv value can be used for rapid differentiation between bacterial and viral infection, especially in patients with high CRP values. This capability can potentially expedite the provision of appropriate therapeutic management. Further research and validation may open new applications of the kinetics of inflammation for rapid diagnosis of an infectious vs. a viral source of fever.

Increased progranulin as an independent predictive biomarker for poor prognosis in sepsis

BACKGROUND

Recently, many diagnostic biomarkers were reported, but each had its own limitation. However, there is a need for an effective sensitivity and specificity of biomarker in diagnosis and prognosis of sepsis. In this context, progranulin (PGRN), at elevated levels, has been associated with poor prognosis in infectious diseases. Moreover, increased PGRN levels were seen in septic mice. As the prognostic value of PGRN in humans is unclear, we aimed to identify the predictive value of serum PGRN for the prognosis of sepsis.

METHODS

A total of 128 participants with sepsis and 58 healthy controls were recruited in this study. The levels of serum PGRN were detected by enzyme-linked immunosorbent assay. According to the outcomes, patients were divided into survival and non-survival groups.

RESULTS

Serum PGRN levels had upregulated in patients with sepsis compared with those in healthy controls (P < 0.001) as well as in non‑survivors compared with those in survivors (P < 0.001). Furthermore, serum PGRN levels exhibited positive correlation with hypersensitive C-reactive protein, procalcitonin, sepsis‑related organ failure assessment (SOFA) scores, and acute physiology and chronic health evaluation II (APACHE II) scores. PGRN had a higher predictive effect, especially the 28-day in-hospital mortality (p < 0.001), when using it with SOFA or APACHE II scores. Cox proportional regression analysis showed that PGRN was an independent predictor for 28-day mortality risk in sepsis.

CONCLUSIONS

PGRN, as a biomarker of sepsis, could improve the prognostic power of traditional parameters. This study is the first to report the clinical significance of PGRN levels in terms of the severity and prognosis of sepsis.

Peri-Operative Fall in Serum Albumin Levels Correlate Well With Outcomes in Children Undergoing Emergency Abdominal Surgery: A Prospective Study From a Resource-Limited Setting

Background

Albumin is a negative acute-phase protein as its levels fall after injury, sepsis, and surgical stress. A review of the literature suggests that serum albumin level drops rapidly after surgery in adults and correlates well with the outcomes. However, there is limited data on the use of peri-operative fall in serum albumin levels as an outcome predictor in children undergoing emergency abdominal surgeries. We aim to investigate the correlation between the degree of peri-operative fall in serum albumin levels and the outcomes in children undergoing emergent abdominal surgeries.

Materials and methods

This prospective study included all children aged 2-15 years undergoing emergent abdominal surgeries between January 2019 to June 2020 at our center. Preoperative serum albumin level (A1) was recorded for all children. Postoperative day 0 serum albumin level (A2) was sent 4-6 hours following the surgery. The degree of peri-operative fall in serum albumin level (∆A) was calculated by subtracting A2 from A1. Patients were then grouped on the basis of ∆ A, i.e. groups 1 and 2 with ∆ A < 0.5 and ≥ 0.5 gm/dl respectively. Additional data like diagnosis, surgical procedure, duration of surgery, complications, and length of hospital stay were also recorded. Recorded parameters in group 1 were then compared to group 2 statistically.

Results

Fifty-six children (male to female ratio {M:F} = 1.5:1), who met the inclusion criteria during the study period, were included in the study. Groups 1 and 2 comprised 38 and 18 children respectively. The postoperative serum albumin levels were significantly lower in group 2 (p = 0.0005). Duration of surgery was significantly higher in group 2 (p = 0.0474). Complications and length of hospital stay were significantly higher in group 2 (p = 0.0107 and p = 0.0375 respectively).

Conclusion

The present study evaluated the fall in peri-operative serum albumin level (∆A) in children undergoing emergent abdominal surgery as a marker of stress. Higher values of ∆A (≥ 0.5 gm/dl) depicted a significant correlation with complications requiring re-laparotomy and a longer length of hospital stay. 

C-reactive protein as a potential biomarker in psychiatric practice: Are we there yet?

OBJECTIVES

Serum or plasma levels of C-reactive protein (CRP) and high-sensitivity CRP (hsCRP) are widely used clinical markers of inflammation in other branches of medicine, whereas its clinical use in psychiatry has been limited to research studies. We aimed to assess the possibility of using CRP/hsCRP in psychiatric practice. This is a review and evaluation of various lines of evidence supporting the concept of CRP as a biomarker for psychiatric disorders in certain conditions.

METHODS

We searched the literature for studies which assessed CRP/hsCRP levels in various psychiatric disorders.

RESULTS

The accumulating evidence from large studies and meta-analyses allows us to understand the role of CRP in major psychiatric disorders and increase our understanding of specific symptoms and subtypes of disorders. CRP may be considered a 'psychiatric biomarker' which can alert clinicians about neuroinflammation, adverse effects of medications, cardiometabolic status, co-morbidities, and may also predict clinical outcomes and guide optimal treatment.selection.

CONCLUSION

Although the underlying pathophysiological role of CRP and hsCRP is still elusive and the association between CRP and psychiatric disorders is inconsistent, CRP holds promise to become a psychiatric biomarker.

Predictors of COVID-19 Hospital Treatment Outcome

Background

There are more than 228,394,572 confirmed cases and 4,690,186 confirmed deaths caused by COVID-19 worldwide. The magnitude of the COOVID-19 pandemic has stimulated research on the treatment and diagnosis of COVID-19 patients.

Objective

In this report, a battery of specific parameters was used to develop a model that allows prediction of the outcome of the COVID-19 treatment. These parameters are C-reactive protein, procalcitonin, fibrinogen, D-dimers, immature granulocytes, and interleukin-6.

Methods

The study was carried out on a sample of N = 49 survivors (22 men, 27 women) and 83 deceased patients (62 men, 21 women). The distribution of means and differences in means of the parameters studied between survivors and deceased patients were evaluated using the bootstrap method.

Results

A mathematical model that allows for the prediction of hospitalization outcome was obtained using the Naive Bayes model. The results demonstrated a statistically significant difference between survivors and deceased patients in all parameters studied. A mathematical model employing a battery of parameters provided a 97% precision in predicting the outcome of hospitalization.

Conclusion

This study showed that the cross-correlation of survivability with absolute levels of C-reactive protein, procalcitonin, fibrinogen, D-dimers, immature granulocytes, and interleukin-6 could be used successfully in the hospital setting as a diagnostic tool.

Relationship between adiponectin multimer levels and subtypes of cerebral infarction

Aim

Serum adiponectin levels are decreased in patients with cerebral infarction. Adiponectin in circulation exists in three isoforms: high molecular weight (HMW), medium molecular weight (MMW), and low molecular weight (LMW) adiponectin. We measured serum levels of total adiponectin and adiponectin multimers (HMW, MMW, and LMW) in patients with cerebral infarction and compared the serum levels of the three adiponectin multimers in stroke subtypes. We also evaluated the clinical value of adiponectin multimer levels as a biomarker for cerebral infarction.

Methods

We assessed a total of 132 patients with cerebral infarctions. The serum levels of total and adiponectin multimers were measured using enzyme-linked immunosorbent assay (ELISA).

Results

The total and HMW adiponectin levels were significantly lower in atherothrombotic infarction (AI) than in cerebral embolism (CE) (total, p < 0.05; HMW, p < 0.05). In male patients, the MMW adiponectin level was significantly lower in the lacunar infarction (LI) group than in the AI group (p < 0.05). The LMW adiponectin level was significantly lower in the AI group than in the LI and CE groups (LI, p < 0.001; CE, p = 0.001). However, there were no significant differences in adiponectin multimer levels among the stroke subtypes in female subjects. Additionally, in female patients with AI and LI, the LMW adiponectin levels were negatively associated with C-reactive protein (CRP; AI, p < 0.05; LI, p < 0.05).

Conclusion

These findings suggest that a decrease in adiponectin is associated with AI and that serum LMW adiponectin level represents a potential biomarker for AI.

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.

Identification of factors affecting meropenem pharmacokinetics in critically ill patients: Impact of inflammation on clearance

INTRODUCTION

The purpose of this study was to explore factors influencing meropenem pharmacokinetics (PKs) in critically ill patients by developing a population PK model and to determine the optimal dosing strategy.

METHODS

This prospective observational study involved 12 critically ill patients admitted to the intensive care unit and treated with meropenem 1 g infused over 1 h every 8 h. Blood samples were collected on days 1, 2, and 5 immediately prior to dosing, and at 1, 2, 4, and 6 h after the start of infusion. Population PK parameters were estimated using nonlinear mixed-effects model software.

RESULTS

Meropenem PK was adequately described using a two-compartment model. Typical values of total and inter-compartmental clearance were 9.30 L/h and 9.70 L/h, respectively, and the central and peripheral compartment volumes of distribution were 12.61 L and 7.80 L, respectively. C-reactive protein (CRP) was identified as significant covariate affecting total meropenem clearance. The probability of target attainment (PTA) predicted by Monte Carlo simulations varied according to the patients' CRP. The PTA of 100% time above the minimum inhibitory concentration ≤2 mg/L for bacteria was achieved after a dose of 1 and 2 g infused over 4 h every 8 h in patients with CRP of 30 and 5 mg/dL, respectively.

CONCLUSION

The findings of this study suggest that CRP might be helpful in managing meropenem dosing in critically ill patients. Higher doses and extended infusion may be required to achieve optimal pharmacodynamic targets.

Recombinant Fasciola hepatica Fatty Acid Binding Protein as a Novel Anti-Inflammatory Biotherapeutic Drug in an Acute Gram-Negative Nonhuman Primate Sepsis Model

Due to their phylogenetic proximity to humans, nonhuman primates (NHPs) are considered an adequate choice for a basic and preclinical model of sepsis. Gram-negative bacteria are the primary causative of sepsis. During infection, bacteria continuously release the potent toxin lipopolysaccharide (LPS) into the bloodstream, which triggers an uncontrolled systemic inflammatory response leading to death. Our previous research has demonstrated in vitro and in vivo using a mouse model of septic shock that Fh15, a recombinant variant of the Fasciola hepatica fatty acid binding protein, acts as an antagonist of Toll-like receptor 4 (TLR4) suppressing the LPS-induced proinflammatory cytokine storm. The present communication is a proof-of concept study aimed to demonstrate that a low-dose of Fh15 suppresses the cytokine storm and other inflammatory markers during the early phase of sepsis induced in rhesus macaques by intravenous (i.v.) infusion with lethal doses of live Escherichia coli. Fh15 was administered as an isotonic infusion 30 min prior to the bacterial infusion. Among the novel findings reported in this communication, Fh15 (i) significantly prevented bacteremia, suppressed LPS levels in plasma, and the production of C-reactive protein and procalcitonin, which are key signatures of inflammation and bacterial infection, respectively; (ii) reduced the production of proinflammatory cytokines; and (iii) increased innate immune cell populations in blood, which suggests a role in promoting a prolonged steady state in rhesus macaques even in the presence of inflammatory stimuli. This report is the first to demonstrate that a F. hepatica-derived molecule possesses potential as an anti-inflammatory drug against sepsis in an NHP model.

IMPORTANCE Sepsis caused by Gram-negative bacteria affects 1.7 million adults annually in the United States and is one of the most important causes of death at intensive care units. Although the effective use of antibiotics has resulted in improved prognosis of sepsis, the pathological and deathly effects have been attributed to the persistent inflammatory cascade. There is a present need to develop anti-inflammatory agents that can suppress or neutralize the inflammatory responses and prevent the lethal consequences of sepsis. We demonstrated here that a small molecule of 14.5 kDa can suppress the bacteremia, endotoxemia, and many other inflammatory markers in an acute Gram-negative sepsis rhesus macaque model. These results reinforce the notion that Fh15 constitutes an excellent candidate for drug development against sepsis.

Effect of Recombinant Human Soluble Thrombomodulin on Coagulation-Related Variables in Patients With Sepsis-Induced Disseminated Intravascular Coagulation: A Retrospective Observational Study

To evaluate associations among coagulation-related variables, resolution of disseminated intravascular coagulation (DIC) and mortality, we retrospectively investigated 123 patients with sepsis-induced DIC treated with recombinant human soluble thrombomodulin (rTM). Changes in coagulation-related variables before and after treatment with rTM were examined. Further, associations between coagulation-related variables and DIC resolution were evaluated. The platelet count, prothrombin international normalized ratio (PT-INR), and fibrin/fibrinogen degradation products (FDP) significantly (p < .001) improved after rTM administration in survivors (n = 98), but not in nonsurvivors (n = 25). However, the DIC score significantly (p < .001) reduced in survivors and in nonsurvivors. Among coagulation-related variables examined before rTM, only PT-INR was significantly (p = .0395) lower in survivors than in nonsurvivors, and PT-INR before rTM was significantly (p = .0029) lower in patients attaining than not attaining DIC resolution (n = 87 and 36, respectively). The 28-day mortality was significantly lower in patients attaining than not attaining DIC resolution (11.5% vs 41.7%, p = .0001). In conclusion, the initiation of rTM administration before marked PT-INR elevation may be important to induce DIC resolution and thus to decrease mortality in patients with sepsis-induced DIC. Conversely, the treatment with rTM in patients with marked PT-INR elevation may be not so effective in achieving such goals.

C-reactive protein velocity discriminates between acute viral and bacterial infections in patients who present with relatively low CRP concentrations

Background

To assess the utility of C-reactive protein (CRP) velocity to discriminate between patients with acute viral and bacterial infections who presented with relatively low CRP concentrations and were suspected of having a bacterial infection.

Methods

We analyzed a retrospective cohort of patients with acute infections who presented to the emergency department (ED) with a relatively low first CRP measurement (CRP1) ≤ 31.9 mg/L and received antibiotics shortly after. We then calculated C-reactive protein velocity (CRPv), milligram per liter per hour, for each patient based on CRP1 and the second CRP value (CRP2) measured within the first 24 h since admission. Finally, we compared CRPv between patients with bacterial and viral infections.

Results

We have presently analyzed 74 patients with acute bacterial infections and 62 patients with acute viral infections at the mean age of 80 and 66 years respectively, 68 male and 68 female. CRP1 did not differ between both groups of patients (16.2 ± 8.6 and 14.8 ± 8.5 for patients with viral and bacterial infections respectively, p value = 0.336). However, the CRP2 was significantly different between the groups (30.2 ± 21.9 and 75.6 ± 51.3 for patients with viral and bacterial infections respectively, p-value < 0.001) and especially the CRPv was much higher in patients with acute bacterial infections compared to patients with acute viral infections (0.9 ± 1.2 and 4.4 ± 2.7 respectively, p-value < 0.001).

Conclusion

CRPv and CRP2 are useful biomarkers that can discriminate significantly between patients who present with acute bacterial and viral infections, and relatively low CRP concentration upon admission who were suspected of having a bacterial infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06878-y.

High concentration of serum FGF19 at ICU admission is associated with 28-day mortality in sepsis patients

BACKGROUND

Sepsis remains associated with a high mortality rate despite recent advances in treatment. Traditional biomarkers are inadequate for stratification of patients by sepsis severity. We examined use of the baseline concentration of fibroblast growth factor 19 (FGF19) in predicting 28-day mortality from sepsis.

METHODS

A total of 220 consecutive adult patients with sepsis who were admitted to our intensive care unit (ICU) during 2020 were prospectively recruited. Patients were categorized as survivors or non-survivors according to status at 28 days. Baseline concentrations of FGF19 and other parameters were measured. Receiver operating characteristic (ROC) analysis was used to determine the sensitivity, specificity, predictive value, and optimal cutoff of FGF19 in prediction of survival. Prognostic factors were identified using Cox regression analysis.

RESULTS

The serum FGF19 concentration was much higher in non-survivors than in survivors (355.0 pg/ml [range: 37.2, 2315.6] vs. 127.3 pg/ml [5.7, 944.1]; P < 0.05]. ROC analysis indicated an FGF19 concentration of 180 pg/ml was the optimal cutoff value. Multivariable Cox regression analysis showed that FGF19 concentration and the change in sequential organ failure assessment (ΔSOFA) score at baseline were independently and significantly associated with 28-day mortality. ROC analysis indicated that FGF19 had a better predictive value than PCT or CRP. Although ΔSOFA had a better predictive value than FGF19, ΔSOFA and FGF19 together had a significantly better predictive value than ΔSOFA alone.

CONCLUSION

Sepsis patients with high serum concentrations of FGF19 at ICU admission were associated with an increased risk of 28-day mortality in our ICU.

Presepsin as a predictor of septic shock in patients with urinary tract infection

Background

Recently, presepsin has been reported to be a useful biomarker for early diagnosis of sepsis and evaluation of prognosis in septic patients. However, few reports have evaluated its usefulness in patients with urinary tract infections (UTI). This study aimed to evaluate whether presepsin could be a valuable marker for detecting severe sepsis, and whether it could predict the therapeutic course in patients with UTI compared with markers already used: procalcitonin (PCT) and C-reactive protein (CRP).

Methods

From April 2014 to December 2016, a total of 50 patients with urinary tract infections admitted to Gunma university hospital were enrolled in this study. Vital signs, presepsin, PCT, CRP, white blood cell (WBC) count, causative agents of urinary-tract infections, and other data were evaluated on the enrollment, third, and fifth days. The patients were divided into two groups: with (n = 11) or without (n = 39) septic shock on the enrollment day, and with (n = 7) or without (n = 43) sepsis on the fifth day, respectively. Presepsin was evaluated as a biomarker for systemic inflammatory response syndrome (SIRS) or septic shock.

Results

Regarding the enrollment day, there was no significant difference of presepsin between the SIRS and non-SIRS groups (p = 0.276). The median value of presepsin (pg/mL) was significantly higher in the septic shock group (p < 0.001). Multivariate logistic regression analysis showed that presepsin (≥ 500 pg/ml) was an independent risk factor for septic shock (p = 0.007). ROC curve for diagnosing septic shock indicated an area under the curve (AUC) of 0.881 for presepsin (vs. 0.690, 0.583, and 0.527 for PCT, CRP and WBC, respectively). Regarding the 5th day after admission, the median presepsin value on the enrollment day was significantly higher in the SIRS groups than in the non-SIRS groups (p = 0.006). On the other hand, PCT (≥ 2 ng/ml) on the enrollment day was an independent risk factor for SIRS. ROC curve for diagnosing sepsis on the fifth day indicated an AUC of 0.837 for PCT (vs. 0.817, 0.811, and 0.802 for presepsin, CRP, and WBC, respectively).

Conclusions

This study showed that presepsin may be a good marker for diagnosing septic shock based on admission data in patients with UTI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00906-4.

Involvement of G-CSF, IL-6, and cortisol in transient neutrophilia after marathon races

OBJECTIVES

The aim of this study was to clarify the mechanisms of the transient increase in neutrophils after running standard marathon races by measurement of cytokines involved in the production and survival of neutrophils, and cortisol.

METHODS

Fourteen male runners who participated in the Hokkaido Marathon, which is the sole marathon race held in summer in Japan, and finished the standard marathon were analyzed sequentially from the start until a maximum of 8 days after the finish.

RESULTS

Neutrophilia was observed in all runners just after they reached the goal (mean neutrophils: 13 226/μL). IL-6, G-CSF, and cortisol, but not GM-CSF, increased at the same time. Time-course studies with complete blood counts, biochemical markers, cytokines, and cortisol showed transient increases in neutrophils, monocytes, myoglobin, high-sensitivity C-reactive protein (hsCRP), G-CSF, IL-6, and cortisol. The increase in hsCRP was delayed 6 hours from the first increase in neutrophils. Correlations were observed between the neutrophil count and G-CSF, IL-6, and cortisol (G-CSF; r = .667, IL-6; r = .667, cortisol; r = .623).

CONCLUSION

These results suggest that G-CSF is directly involved, and IL-6 is involved via cortisol in the transient neutrophilia that occurs after marathon races.

Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery

BACKGROUND

The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology.

METHODS

The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology.

RESULTS

A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction.

CONCLUSIONS

In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.

Proteomic Signature of Urosepsis: From Discovery in a Rabbit Model to Validation in Humans

Urosepsis after upper urinary tract endoscopic lithotripsy (UUTEL) may cause uroseptic shock with high mortality, which can be prevented if early diagnosis and timely intervention are implemented with help of a diagnostic protein panel. The plasma of five rabbits of uroseptic shock and five controls was subjected to exploratory proteomics to search biomarker candidates from proteomic profiles related to uroseptic shock. Then, plasma from 21 nonsepsis and 20 urosepsis patients according to European diagnostic criteria of sepsis was enrolled in the validation study via targeted proteomics. Changes in a massive number of plasma proteins, mainly enriched in immune regulation, coagulation, structural repair, and transport activity, were observed in the rabbit model of septic shock. Fifteen proteins were identified as differential expression proteins between sepsis and nonsepsis patients. A diagnostic model composed of three proteins lipopolysaccharide-binding protein (LBP), clusterin (CLU), and vascular cell adhesion protein 1 (VCAM1) was developed for the early detection (2 hours postoperatively) of urosepsis after UUTEL, with a high area under the receiver operating characteristic (ROC) curve of 0.921. In conclusion, changes in the proteomic profile may reflect the underlying biological mechanisms during the development of urosepsis and produce diagnostic biomarkers for the early detection of urosepsis after UUTEL.

Prognostic value of the C-reactive protein to albumin ratio in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Background/aim

This study investigated whether baseline serum level of C-reactive protein (CRP)/albumin ratio is associated with infarct localization, number of vascular lesions, and in-hospital mortality in patients undergoing primary percutaneous coronary intervention (PCI) for acute ST elevation myocardial infarction (STEMI).

Methods

The study population consisted of 116 patients diagnosed with STEMI. The CRP/albumin ratio at first admission, cardiac troponin-I (cTnI), PCI results, and clinical outcomes were recorded.

Results

The mean CRP/albumin ratio, cTnI level, and mean number of vascular lesions were significantly higher in non-survivors than in survivors (p = 0.006, p = 0.004, and p = 0.007, respectively). Multivariate logistic regression analysis demonstrated that the CRP/ albumin ratio and number of coronary artery lesions were independent predictors of mortality in STEMI patients. According to these analyses, the presence of ≥ 2 vessel lesions was the most important predictor of mortality, with an odds ratio of 2.009 (95% confidence interval: 1.191–3.387, p = 0.009).

Conclusion

This study demonstrates the potential utility of the CRP/albumin ratio for predicting the clinical outcome of patients with STEMI. In addition, the presence of ≥ 2 vascular lesions contributed to a 2-fold increase in mortality rate in STEMI patients.

Influence of Prednisone on Inflammatory Biomarkers in Community-Acquired Pneumonia: Secondary Analysis of a Randomized Trial

Glucocorticoids are frequently prescribed in inflammatory diseases and have recently experienced a boom in the treatment of COVID-19. Small studies have shown an effect of glucocorticoids on inflammatory marker levels, but definitive proof is lacking. We investigated the influence of prednisone on inflammatory biomarkers in a previous multicenter, randomized, placebo-controlled trial that compared a 7-day treatment course of 50-mg prednisone to placebo in patients hospitalized with community-acquired pneumonia. We compared levels of C-reactive protein (CRP), procalcitonin (PCT), leukocyte and neutrophil count between patients with and without glucocorticoid treatment at baseline and on days 3, 5, and 7 and at discharge by Wilcoxon tests and analysis of variance. A total of 356 patient data sets in the prednisone group and 355 in the placebo group were available for analysis. Compared to placebo, use of prednisone was associated with reductions in levels of CRP on days 3, 5, and 7 (mean difference of 46%, P < .001 for each time point). For PCT, no such difference was observed. Leukocyte and neutrophil count were higher in the prednisone group at all time points (mean difference of 27% for leukocytes and 33% for neutrophils, P <.001 for all time points). We conclude that after administration of glucocorticoids in community-acquired pneumonia, patients had lower CRP levels and increased leukocyte and neutrophil count as compared to the placebo group. PCT levels were not different between treatment groups. PCT levels thus may more appropriately mirror the resolution of infection compared to more traditional inflammatory markers.

Prediction of 72-hour mortality in patients with extremely high serum C-reactive protein levels using a novel weighted average of risk scores

The risk factors associated with mortality in patients with extremely high serum C-reactive protein (CRP) levels are controversial. In this retrospective single-center cross-sectional study, the clinical and laboratory data of patients with CRP levels ≥40 mg/dL treated in Saitama Medical Center, Japan from 2004 to 2017 were retrieved from medical records. The primary outcome was defined as 72-hour mortality after the final CRP test. Forty-four mortal cases were identified from the 275 enrolled cases. Multivariate logistic regression analysis (MLRA) was performed to explore the parameters relevant for predicting mortality. As an alternative method of prediction, we devised a novel risk predictor, “weighted average of risk scores” (WARS). WARS features the following: (1) selection of candidate risk variables for 72-hour mortality by univariate analyses, (2) determination of C-statistics and cutoff value for each variable in predicting mortality, (3) 0–1 scoring of each risk variable at the cutoff value, and (4) calculation of WARS by weighted addition of the scores with weights assigned according to the C-statistic of each variable. MLRA revealed four risk variables associated with 72-hour mortality—age, albumin, inorganic phosphate, and cardiovascular disease—with a predictability of 0.829 in C-statistics. However, validation by repeated resampling of the 275 records showed that a set of predictive variables selected by MLRA fluctuated occasionally because of the presence of closely associated risk variables and missing data regarding some variables. WARS attained a comparable level of predictability (0.837) by combining the scores for 10 risk variables, including age, albumin, electrolytes, urea, lactate dehydrogenase, and fibrinogen. Several mutually related risk variables are relevant in predicting 72-hour mortality in patients with extremely high CRP levels. Compared to conventional MLRA, WARS exhibited a favorable performance with flexible coverage of many risk variables while allowing for missing data.

Retinal and Choroidal Thickness in relation to C-Reactive Protein on Swept-Source Optical Coherence Tomography

Purpose

To evaluate the relationships between C-reactive protein (CRP) and retinal and choroidal thickness by swept-source optical coherence tomography (SS-OCT).

Methods

The participants included in the prospective cross-sectional study underwent a comprehensive ophthalmic examination. Based on the CRP values, the subjects were divided into the CRP (+) group (CRP ≥ 8.2 mg/L) and the CRP (−) group (CRP < 8.2 mg/L). The retinal and choroidal thickness was compared between the two groups.

Results

This study enrolled 43 right eyes of 43 subjects from the CRP (+) group and 86 right eyes of 86 gender- and age-match subjects from the CRP (−) group. The choroidal thickness in the CRP (+) group was thinner than that in the CRP (−) group except for the outer nasal sector of the Early Treatment Diabetic Retinopathy Study (ETDRS) grid. However, the retinal thickness only in the inner temporal sector showed a significant difference. According to Pearson's correlation analysis, the CRP was significantly negatively correlated with the choroidal thickness in all sectors and the retinal thickness only in the inner temporal and outer nasal sectors of the ETDRS grid.

Conclusion

CRP levels are associated with retinal and choroidal thickness. The data related to the retinal and choroidal thickness changes may help understand the pathogenesis of specific ocular abnormalities in patients with systemic inflammation.

Non-specific blood tests as proxies for COVID-19 hospitalisation: are there plausible associations after excluding noisy predictors?

This study applied causal criteria in directed acyclic graphs for handling covariates in associations for prognosis of severe coronavirus disease 2019 (COVID-19) cases. To identify non-specific blood tests and risk factors as predictors of hospitalisation due to COVID-19, one has to exclude noisy predictors by comparing the concordance statistics (area under the curve - AUC) for positive and negative cases of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Predictors with significant AUC at negative stratum should be either controlled for their confounders or eliminated (when confounders are unavailable). Models were classified according to the difference of AUC between strata. The framework was applied to an open database with 5644 patients from Hospital Israelita Albert Einstein in Brazil with SARS-CoV-2 reverse transcription - polymerase chain reaction (RT-PCR) exam. C-reactive protein (CRP) was a noisy predictor: hospitalisation could have happened due to causes other than COVID-19 even when SARS-CoV-2 RT-PCR is positive and CRP is reactive, as most cases are asymptomatic to mild. Candidates of characteristic response from moderate-to-severe inflammation of COVID-19 were: combinations of eosinophils, monocytes and neutrophils, with age as risk factor; and creatinine, as risk factor, sharpens the odds ratio of the model with monocytes, neutrophils and age.

Prognostic value of the creatinine-albumin ratio in acute pancreatitis debridement

Background

Increases in the levels of serum C-reactive protein (CRP) and creatinine (Cr) and decreases in those of albumin (Alb) are commonly observed in acute pancreatitis (AP). We aimed to evaluate the efficacy of the Cr/Alb and CRP/Alb ratios in the prediction of surgical treatment effect in AP patients.

Methods

This study retrospectively analyzed clinical data obtained from 140 AP patients who underwent debridement from January 2008 to November 2018 in Shanghai Ruijin Hospital. The Cr/Alb and CRP/Alb ratios at admission and before surgery were assessed in the analysis of clinical statistics, prediction of prognoses, and logistic regression analysis.

Results

The admission Cr/Alb had the best predictive value of the four ratios. This value was significantly higher in patients with re-operation and those who died (P < 0.05) and was correlated with the Acute Physiology and Chronic Health Evaluation (APACHE II) score, admission CRP/Alb, preoperative Cr/Alb, and post-operative complications. The admission Cr/Alb could predict the risk of AP-related re-operation and mortality with sensitivities, specificities and areas under the curve of 86.3%, 61.7% and 0.824, and 73.4%, 81.3% and 0.794, respectively. At a cut-off value of 3.43, admission Cr/Alb values were indicative of a worse clinical state, including impaired laboratory test values, APACHE II scores, rates of post-operative complications and re-operation, and mortality (P < 0.05). In the logistic regression analysis, admission Cr/Alb values were independently related to the APACHE II score, post-operative renal failure, and mortality.

Conclusion

Cr/Alb is a novel but promising, easy-to-measure, reproducible, non-invasive prognostic score for the prediction of the effect of debridement in AP patients.

Clinical value of C-reactive protein/albumin ratio in Guillain-Barré syndrome

BACKGROUND

Respiratory failure in patients with Guillain-Barré syndrome (GBS) can lead to serious complications and dysfunctions, emphasizing the importance of early detection. The C-reactive protein-to-albumin ratio (CAR) is emerging as a novel inflammatory marker for predicting neurological outcome. We aimed to identify the association of CAR with respiratory failure and short-term outcome in GBS patients.

METHODS

A total of 200 patients diagnosed with GBS were retrospectively analyzed. Data were collected from an electronic database. The associations of C-reactive protein (CRP), albumin, and CAR at admission with outcomes were evaluated by logistic regression analysis. Using receiver operating characteristic curves, we calculated the cutoff value for the CAR and compared its discriminatory power with that of C-reactive protein alone.

RESULTS

Fifty-two (26%) patients showed poor short-term outcome, and 50 (25%) developed respiratory failure. CAR > 0.21 was an independent predictor of respiratory failure, and CAR > 0.19 was an independent predictor of poor short-term outcome. CAR showed a better predictive value than CRP alone. In addition, the c-index of the predictive nomogram for respiratory failure was higher when it included CAR (0.962) than when it did not (0.958). A similar result was observed for the predictive nomogram for poor short-term outcome (0.953 vs 0.947).

CONCLUSION

CAR > 0.21, a novel inflammatory biomarker, is independently associated with the occurrence of respiratory failure in GBS patients, while CAR > 0.19 is independently associated with poor short-term outcome. CAR may help identify GBS patients at high risk of poor prognosis.

Clinical Value of Serum Amyloid-A Protein, High-density Lipoprotein Cholesterol and Apolipoprotein-A1 in the Diagnosis and Follow-up of Neonatal Sepsis

BACKGROUND

To evaluate the performance of serum amyloid-A (SAA), high-density lipoprotein cholesterol (HDL-C) and apolipoprotein-A1 (Apo-A1) levels in the identification and monitoring of neonatal sepsis.

METHODS

This prospective study included 113 full-term septic neonates (postnatal age 4-28 days) admitted to the Special Care Neonatal Unit of a University Hospital from January 1, 2016, to April 30, 2019, and 68 healthy neonates (controls). Blood samples were drawn serially in septic neonates at enrollment and on days 1, 3 and 7, and once in controls, for SAA, HDL-C and Apo-A1 determination.

RESULTS

At enrollment, SAA levels were significantly higher in septic neonates in comparison with controls (median 50.7 vs. 3.5 mg/L; P < 0.0001); HDL-C and Apo-A1 levels were significantly lower in patients than in controls (P < 0.001 and P < 0.006, respectively). SAA levels were higher in culture-positive compared with culture-negative sepsis (median 202.0 vs. 14.2 mg/L; P < 0.0001). HDL-C and Apo-A1 levels did not differ significantly between culture-positive and culture-negative sepsis. Receiver operating characteristic curve analysis of SAA levels at enrollment resulted in significant areas under the curve (AUC) for detecting sepsis {AUC = 0.929 [95% confidence interval: 0.885-0.973]; P < 0.0001} and also for discriminating between culture-positive and culture-negative sepsis [AUC = 0.933 (95% confidence interval: 0.882-0.984); P < 0.0001]. The combination of HDL-C and Apo-A1 with SAA increased its diagnostic performance. Furthermore, serial SAA levels following enrollment could indicate clinical response in septic neonates.

CONCLUSIONS

SAA seems to be a useful biomarker for identification and monitoring of neonatal sepsis, and also for discriminating between culture-positive and culture-negative sepsis. HDL-C and Apo-A1 could be used as complementary markers.

Predicting Bacterial Versus Viral Infection, or None of the Above: Current and Future Prospects of Biomarkers

Sepsis and pneumonia cause significant morbidity and mortality worldwide. Despite improvements in diagnostic methodologies for organism identification, the early recognition and further risk stratification of these infections can be challenging. Although traditional clinical scoring systems are beneficial for the management of sepsis and pneumonia, biomarkers supporting the diagnosis and management of these infectious diseases are needed. Many biomarkers have been identified and there is no lack of studies and meta-analyses assessing the utility of biomarkers. Focusing primarily on sepsis and pneumonia, this article discusses the most commonly used biomarkers for which clinical laboratory testing methods are available.

Early sepsis markers in patients admitted to intensive care unit with moderate-to-severe diabetic ketoacidosis

Background

Bacterial infections are frequent triggers for diabetic ketoacidosis. In this context, delayed antibiotic treatment is associated with increased morbidity and mortality. Unnecessary administration of antimicrobial therapy might however, also negatively impact the prognosis. The usefulness of sepsis markers in diabetic ketoacidosis has not been assessed. Thus, we sought to investigate diagnostic performances of clinical and biological sepsis markers during diabetic ketoacidosis.

Methods

In this monocentric retrospective cohort study, all consecutive episodes of diabetic ketoacidosis (defined as pH ≤ 7.25, glycaemia > 300 mg/dL and presence of ketones) admitted in intensive care unit were included. A proven bacterial infection was defined as bacteriological documentation on any bacterial sample. Clinical (presence of fever: temperature > 38 °C and presence of hypothermia: temperature < 36 °C) and biological markers (whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and procalcitonin), recorded at admission, were compared according to the presence or absence of a proven bacterial infection.

Results

Between 2011 and 2018, among 134 episodes of diabetic ketoacidosis, 102 were included (91 patients). Twenty out of 102 were infected. At admission, procalcitonin (median: 3.58 ng/mL vs 0.52 ng/mL, p < 0.001) and presence of fever (25% vs 4%, p = 0.007) were different between episodes with and without proven bacterial infection in both univariate and multivariate analysis. Whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and presence of hypothermia were not different between both groups. The diagnostic performance analysis for procalcitonin revealed an area under the curve of 0.87 with an optimal cutoff of 1.44 ng/mL leading to a sensitivity of 0.90 and a specificity of 0.76. Combining procalcitonin and presence of fever allowed to distinguish proven bacterial infection episodes from those without proven bacterial infection. Indeed, all patients with procalcitonin level of more than 1.44 ng/mL and fever had proven bacterial infection episodes. The presence of one of these 2 markers was associated with 46% of proven bacterial infection episodes. No afebrile patient with procalcitonin level less than 1.44 ng/mL had a proven bacterial infection.

Conclusion

At admission, combining procalcitonin and presence of fever may be of value to distinguish ketoacidosis patients with and without proven bacterial infection, admitted in intensive care unit.

Presepsin and procalcitonin as predictors of sepsis based on the new Sepsis-3 definitions in obstructive acute pyelonephritis

Background

Acute pyelonephritis (APN) with obstructive uropathy often causes sepsis. Recently, sepsis was redefined using the sequential organ failure assessment (SOFA) score, based on the new Sepsis-3 criteria. We investigated predictors for sepsis using this new definition in patients with obstructive APN associated with upper urinary tract calculi.

Methods

We retrospectively evaluated patients who were admitted to our hospital for treatment of obstructive APN associated with upper urinary tract calculi. Blood and urine samples were collected before treatment of obstructive APN. Treatment included adequate antimicrobial therapy and emergency drainage to decompress the renal collecting system. We diagnosed sepsis using the new Sepsis-3 definition. We assessed predictors for sepsis by multivariate logistic regression analysis.

Results

Sixty-one patients were included in this study. Overall, all patients underwent emergency drainage, and 11 (18.0%) patients showed sepsis. There were no significant differences in performance status or comorbidities between sepsis and non-sepsis groups. Platelet count and serum albumin level were significantly lower in the sepsis group than in the non-sepsis group (p = 0.001 and p = 0.016, respectively). Procalcitonin (PCT) and presepsin (PSEP) levels were significantly higher in the sepsis group than in the non-sepsis group (p < 0.001 and p < 0.001, respectively). Multivariate analysis showed that PCT elevation (OR = 13.12, p = 0.024) and PSEP elevation (OR = 13.13, p = 0.044) were independent predictors for sepsis.

Conclusions

Elevation of PCT and PSEP levels before treatment might predict the development of sepsis in patients with obstructive APN.