The value of acute phase protein measurements in clinical practice

Effect of Alpha-1 Antitrypsin and Irisin on Post-Exercise Inflammatory Response: A Narrative Review

Physical activity has a positive effect on human health and emotional well-being. However, in both amateur and professional athletes, training poses a risk of acute or chronic injury through repetitive overloading of bones, joints, and muscles. Inflammation can be an adverse effect of intense exercise caused by several factors including oxidative stress. The present narrative review summarizes current knowledge on inflammatory markers induced by physical exercise. Post-exercise recovery may reduce inflammatory responses and is key to effective training and adaptation of muscle tissues to sustained physical exertion.

Faecal microbiota in two-week-old female dairy calves during acute cryptosporidiosis outbreak - Association with systemic inflammatory response

In the present study, relationships between the intestinal microbiota and innate immunity response, acute cryptosporidiosis, and weight gain in female dairy calves were investigated. A total of 112 calves born during a natural outbreak of cryptosporidiosis on one dairy farm was included in the study. Microbiota composition was analysed by means of 16S ribosomal RNA gene amplicon sequencing from faecal samples collected during the second week of life, while the status of Cryptosporidium spp. infection was determined using immunofluorescence. Serum samples from the second week of life were colourimetrically analysed for the following markers of acute inflammation: acute-phase proteins (serum amyloid A and haptoglobin) and pro-inflammatory cytokines (interleukin-1 beta, interleukin-6, and tumour necrosis factor-alpha). Statistical analyses were performed using random forest analysis, variance-partitioning, and negative binomial regression. The faecal microbiota of the two-week old calves was composed of the phyla Firmicutes, Bacteroidetes, Proteobacteria, Fusobacteria, and Actinobacteria (in order of decreasing abundance). Microbial diversity, measured in terms of the Shannon index, increased with the age of the calves and decreased if a high count of Cryptosporidium spp. oocysts was found in the faeces. Fusobacterium was positively associated with Cryptosporidium spp. oocyst count and serum amyloid A concentration. Peptostreptococcus was positively associated with haptoglobin and serum amyloid A concentrations, and negatively associated with average daily weight gain at 9 months of age. The markers of innate immunity, in combination with age, explained 6% of the microbial variation. These results suggest that some components of the intestinal microbiota may have a long-lasting negative effect on animal growth through the stimulation of the systemic innate immune response.

Serum Amyloid A as a Promising Biomarker in Domestic Animals’ Reproduction: Current Knowledge and Future Perspective

Simple Summary

Acute phase proteins (APPs) are useful markers which can be evaluated in animals to assess health status and characterize inflammation, infection, and trauma. Among APPs, serum amyloid A (SAA) has been widely investigated in pets and food-producing species as a possible biomarker of inflammatory and infective conditions, especially in the field of animal reproduction. The aims of this paper are to review the literature available on the use of SAA for the diagnosis and monitoring of inflammatory reproductive disease in animals, critically appraising the usefulness of such marker and summarizing the current state of knowledge.

Abstract

The investigation of acute phase proteins in veterinary medicine has opened the doors towards the identification and use of new markers for a timely assessment of health status in both companion and food-producing animals. The aim of this paper is to review the literature available on the use of serum amyloid A (SAA), an acute phase protein, for the diagnosis and monitoring of reproductive disorders in animals. This review critically appraises the usefulness of such marker in clinical practice and summarizes the current state of knowledge. Recent advances in the diagnosis and monitoring of reproductive diseases are presented, highlighting where SAA evaluation may enhance early diagnostic tools for dogs, cats, cattle, and equines.

Chronic inflammation was a major predictor and determinant factor of anemia in lactating women in Sidama zone southern Ethiopia: A cross-sectional study

Anemia in women of reproductive age is highly prevalent globally and remains a public health problem. In Ethiopia, despite efforts to minimize the burden of anemia, it is still a moderate public health problem. Anemia has various etiologies including nutritional deficiency, parasitic infection, and inflammation. The aim of this study was to examine contributing factors to anemia in lactating women. Following ethical approval, and six months after delivery, all lactating women (n = 150) were recruited to participate in this study from eight randomly selected rural villages. Anthropometric and socio-economic factors were assessed. From each, a blood sample was collected for measuring hemoglobin, iron biomarkers, zinc, selenium, and inflammation markers. The median (IQR) hemoglobin (Hb) was 132 (123, 139) g/L. Of the women, 19% were anemic and 7% had iron deficiency anemia; 31% were iron deficient and 2% had iron overload. Also, 8% had functional iron deficit, 6% had acute inflammation, 13% had chronic inflammation, and 16% had tissue iron deficiency. The majority (78%) of the women had low plasma zinc out of which more than 16% were anemic. Hb was positively associated with plasma iron and plasma zinc and negatively associated with transferrin receptor (TfR) and α-1-acid glycoprotein (AGP). Plasma iron, AGP, TfR, hepcidin and plasma zinc were significant predictors of maternal anemia. Additionally MUAC and level of education were associated positively with maternal hemoglobin. This study showed that maternal anemia was associated with multiple factors including nutritional deficiencies, inflammation and limited education.

Review of clinical aspects, epidemiology and diagnosis of haemotropic Mycoplasma ovis in small ruminants: current status and future perspectives in tropics focusing on Malaysia

Mycoplasma ovis (formerly Eperythrozoon ovis) is an epierythrocytic parasitic bacterium of small ruminants known as haemotropic mycoplasma, which is transmitted mechanically by biting flies and contaminated instruments. Acute mycoplasmosis causes severe haemolytic anaemia and mortality in young animals. At the same time, chronic disease may produce mild anaemia and varying degrees of morbidity depending on several factors, including age, reproductive status, the plane of nutrition, immunological status and the presence of concurrent infection. Haemotropic Mycoplasma ovis is currently recognised as an emerging zoonotic pathogen which is widely distributed in the sheep and goat producing areas of tropics and subtropics, where the disease is nearly endemic. Human infection has been reported in pregnant women, immunocompromised patients and people exposed to animals and arthropods. The current diagnosis of haemoplasma relies on microscopic evaluation of Giemsa-stained blood smear and PCR. Although there are few published reports on the incidence of haemotropic Mycoplasma ovis infection of small ruminants in Malaysia, information on its prevalence, risk factors, severity and economic impacts is grossly inadequate. Therefore, a large-scale survey of small ruminant flocks is necessary to elucidate the current seroprevalence status and molecular characteristics of haemotropic M. ovis infection in Malaysia using ELISA and PCR sequencing technologies. In the future, surveillance programs, including vector forecast, quarantine, monitoring by periodic surveys and public enlightenment, will limit the internal and transboundary spread of M. ovis, enhance control efforts and mitigate production losses in Malaysia.

Precision multiparameter tracking of inflammation on timescales of hours to years using serial dried blood spots

Aim: High-frequency longitudinal tracking of inflammation using dried blood microsamples provides a new window for personalized monitoring of infections, chronic inflammatory disease and clinical trials of anti-inflammatory drugs. Results/methodology: Using 1662 dried blood spot samples collected by 16 subjects over periods of weeks to years, we studied the behavior of 12 acute phase response and related proteins in inflammation events correlated with infection, vaccination, surgery, intense exercise and Crohn's disease. Proteins were measured using SISCAPA mass spectrometry and normalized to constant plasma volume using low-variance proteins, generating high precision within-person biomarker trajectories with well-characterized personal baselines. Discussion/conclusion: The results shed new light on the dynamic regulation of APR responses, offering a new approach to visualization of multidimensional inflammation trajectories.

Factors associated with anaemia and iron deficiency among women of reproductive age in Northeast Thailand: a cross-sectional study

Background

Anaemia and iron deficiency (ID) affect women of reproductive age globally and considered to be a major public health problem in developing countries. This study determines the prevalence of anaemia and ID among women of reproductive age in urban northeast Thailand and examined the relative contribution of various risk factors to anaemia and ID in this population.

Methods

Three hundred ninety-nine non-pregnant women, aged 18–45 years, from three universities in northeast Thailand participated in this cross-sectional study. Selected socio-demographic, history of blood loss, usual consumption of red meat and tea/coffee, and anthropometric data were collected. Complete blood count including haemoglobin (Hb) concentration, serum ferritin (SF), C-reactive protein (CRP), and thalassemia were determined. Multiple logistic regressions were applied to identify the risk factors of anaemia and ID.

Results

Overall, 370 participants were included for data analyses after excluding women with severe/intermedia thalassemia diseases and/or those with positive serum CRP. The prevalence of anaemia, ID, and iron deficiency anaemia (IDA) were 28.4, 28.4, and 13.2%, respectively. Women with thalassemia had a higher prevalence of anaemia but a lower prevalence of ID than the women without thalassemia. By multiple regression analysis, ID [adjusted OR (AOR) = 4.9, 95% CI = 2.8–8.3], two α-gene defects (AOR = 8.0, 95% CI = 3.0–21.3) and homozygous Hb E (AOR = 8.5, 95% CI = 3.0–24.3) were identified as the potential risk factors of anaemia. Further, the odds of ID were significantly higher among women who donated blood within the past 3 months (AOR = 6.7, 95% CI = 2.8–16.3), and had moderate to a high amount of blood loss during menstruation (AOR = 2.2, 95% CI = 1.3–3.9).

Conclusion

This study found a relatively high but differential prevalence of anaemia and ID among women of reproductive age with or without thalassemia. Only homozygous Hb E and two α-gene defects of thalassemia types and ID were the main factors contributing to anaemia. Recent blood donation, and moderate to a high amount of blood loss during menstruation were potential risk factors of ID in this population.

Development and Validation of the Mucosal Inflammation Noninvasive Index For Pediatric Crohn's Disease

BACKGROUND & AIMS

Mucosal healing (MH) has become a goal of therapy for Crohn's disease (CD), but frequent endoscopies are not feasible. We aimed to develop and validate a non-invasive index to assess mucosal inflammation in children with CD.

METHODS

We collected data from the multi-center prospective ImageKids study, in which children with CD underwent ileocolonoscopy with magnetic resonance enterography. We investigated the association of pediatric CD activity index (PCDAI) items and laboratory test results with the simple endoscopic score for CD (SESCD). We used these data in a blended mathematical judgmental clinimetric approach to develop a weighted categorized index to identify children with CD who have MH, which we called the MINI index. We validated the index using data from 3 independent patient cohorts. The derivation and validation cohorts included 154 and 168 children, respectively (age 14.1 ± 2.5 years and 14.2 ± 3.9 years), of whom 16% and 36% had MH (defined as SESCD<3).

RESULTS

In multivariable models, the stooling item of the PCDAI, erythrocyte sedimentation rate, and level of fecal calprotectin were associated with SESCD (all P < .05). We added data on level of C-reactive protein to develop the MINI index. MINI scores below 8 identified children with MH with 88% sensitivity and 85% specificity in the derivation cohort and with 84% sensitivity and 87% specificity in the validation cohorts. Ninety percent of the patients in the validation cohort with scores of 8 or more had active mucosal inflammation, yet 78% of patients with scores below 8 had MH. Scores below 6 increase the positive predictive value to 86%.

CONCLUSIONS

We developed an index to non-invasively assess mucosal inflammation in children with CD. This index, identifies children with MH with high sensitivity and specificity. The added benefit of MINI over measurement of fecal calprotectin was small but significant, especially for patients with concentrations of fecal calprotectin from 100 to 599 μg/g. ClinicalTrials.gov no: NCT01881490.

Chronic inflammation markers are associated with risk of pancreatic cancer in the Swedish AMORIS cohort study

BACKGROUND

Nested case-control studies examining the association between serum markers of chronic inflammation, focused on three specific biomarkers (CRP, IL-8 and TNF-α), and risk of pancreatic cancer have reported no associations. In this study, we evaluated associations between standard pre-diagnostic serum markers of chronic inflammation (CRP, albumin, haptoglobin and leukocytes) and pancreatic cancer risk in the Swedish Apolipoprotein-related MORtality RISk (AMORIS) prospective cohort study.

METHODS

We selected all participants (≥20 years old) with baseline measurements of CRP, albumin, haptoglobin and leukocytes between 1985 and 1996 (n = 61,597). Participants were excluded if they had a history of chronic pancreatitis and all individuals were free from pancreatic cancer at baseline. Cox proportional multivariable hazards regression analysis was carried out for medical cut-offs of CRP, albumin, haptoglobin and leukocytes.

RESULTS

We observed an increased risk of pancreatic cancer for those individuals with higher levels of serum haptoglobin (≥1.4 g/L), CRP (≥10 mg/L) and leukocytes (≥10 × 109 cells/L) compared to those with haptoglobin levels < 1.4 g/L, CRP levels < 10 mg/L and Leukocyte levels < 10 × 109 cells/L [haptoglobin HR: 2.23 (95% CI 1.72-2.88), CRP HR: 1.32 (95% CI 1.00-1.74), leukocytes HR: 2.20 (95% CI 1.52-3.18)]. No associations were noted for serum albumin.

CONCLUSIONS

We found an increased risk of pancreatic cancer associated with pre-diagnostic serum levels of haptoglobin, CRP and leukocytes. Our finding suggests a possible role of chronic inflammation in the aetiology of pancreatic cancer and highlight the need to further investigate this association.

Reducing inappropriate antibiotic prescribing for children in primary care: a cluster randomised controlled trial of two interventions

BACKGROUND

Antibiotics are overprescribed for non-severe acute infections in children in primary care.

AIM

To explore two different interventions that may reduce inappropriate antibiotic prescribing for non-severe acute infections.

DESIGN AND SETTING

A cluster randomised, factorial controlled trial in primary care, in Flanders, Belgium.

METHOD

Family physicians (FPs) enrolled children with non-severe acute infections into this study. The participants were allocated to one of four intervention groups according to whether the FPs performed: (1) a point-of-care C-reactive protein test (POC CRP); (2) a brief intervention to elicit parental concern combined with safety net advice (BISNA); (3) both POC CRP and BISNA; or (4) usual care (UC). Guidance on the interpretation of CRP was not provided. The main outcome was the immediate antibiotic prescribing rate. A mixed logistic regression was performed to analyse the data.

RESULTS

In this study 2227 non-severe acute infections in children were registered by 131 FPs. In comparison with UC, POC CRP did not influence antibiotic prescribing, (adjusted odds ratio [AOR] 1.01, 95% confidence interval [CI] = 0.57 to 1.79). BISNA increased antibiotic prescribing (AOR 2.04, 95% CI = 1.19 to 3.50). In combination with POC CRP, this increase disappeared.

CONCLUSION

Systematic POC CRP testing without guidance is not an effective strategy to reduce antibiotic prescribing for non-severe acute infections in children in primary care. Eliciting parental concern and providing a safety net without POC CRP testing conversely increased antibiotic prescribing. FPs possibly need more training in handling parental concern without inappropriately prescribing antibiotics.

Hepatic, renal and inflammatory biomarkers are positively associated with blood pressure changes in healthy pregnant women: a prospective cohort

This article evaluates the association of hepatic, renal, and inflammatory biomarkers with changes in systolic (SBP) and diastolic (DBP) blood pressure (BP) during healthy pregnancies.A prospective cohort study with 225 healthy pregnant women was conducted in Rio de Janeiro, Brazil. SBP and DBP were evaluated throughout pregnancy (5th-13th, 20th-26th, and 30th-36th gestational weeks) and were the outcomes. The following biomarkers were measured at the first trimester and analyzed according to tertiles of the sample distribution and were considered the main independent predictors: alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), uric acid (UA), creatinine (Cr), and C-reactive protein (CRP) concentrations. The statistical analysis included 3 stages of modeling with the longitudinal linear mixed-effects procedures: Model 1 was adjusted for gestational age and quadratic gestational age; Model 2 included interactions between the biomarkers and gestational age; and Model 3 was adjusted for self-reported skin color, education, parity, early-pregnancy body mass index (BMI) (under/normal <25; overweight/obese ≥25 kg/m), smoking habit, and leisure-time physical activity. Additional models were performed for CRP and UA with the inclusion of interaction terms between the biomarkers and BMI.Women classified in the third tertile of the ALP (≥61.1 U/L; βSBP = 3.474; 95% confidence interval [CI]: 0.955-5.992; βDBP = 3.291; 95% CI: 1.098-5.485), ALT (≥14.3 U/L; βSBP = 2.232; 95% CI: 0.221-4.242; βDBP = 2.355; 95% CI: 0.721-3.989), and Cr values (≥48.6 μmol/L; βDBP = 1.927; 95% CI: 0.347-3.508) presented higher BP levels during pregnancy compared to those in the first and second tertiles. Women in the highest tertile of the ALP concentration distribution presented a lower rate of change in SBP and DBP during pregnancy (interaction term with gestational age βSBP = -0.004; 95% CI: -0.007 to -0.001; P = 0.02; βDBP = -0.003; 95% CI: -0.006 to -0.001; P = 0.01). Higher UA concentrations were associated with higher SBP levels only in overweight/obese women (β = 3.878; 95% CI: 0.687-7.068), whereas higher CRP concentrations (≥2.6 mg/L) were associated with higher DBP in under/normal weight women (β =2.252; 95% CI: 0.267-4.236).ALP, ALT, and Cr concentrations were positively associated with BP levels, whereas ALP was associated with a lower rate of change in BP. The associations of UA and CRP with BP differ according to the early-pregnancy BMI.

The use of adjustment factors to address the impact of inflammation on vitamin A and iron status in humans

Many nutrient biomarkers are altered by inflammation. We calculated adjustment factors for retinol and ferritin by using meta-analyses of studies containing the respective biomarker and 2 acute phase proteins in serum, C-reactive protein (CRP), and α1-acid glycoprotein (AGP). With the use of CRP and AGP we identified 4 groups in each study: reference (CRP ≤5 mg/L, AGP ≤1 g/L), incubation (CRP >5 mg/L, AGP ≤1 g/L), early convalescence (CRP >5 mg/L, AGP >1 g/L), and late convalescence (CRP ≤5 mg/L, AGP >1 g/L). For each biomarker, ratios of the geometric means of the reference to each inflammation group concentration were used to calculate adjustment factors for retinol (1.13, 1.24, and 1.11) and ferritin (0.77, 0.53, and 0.75) for the incubation, early, and late convalescent groups, respectively. The application of the meta-analysis factors in more recent studies compares well with study-specific factors. The same method was used to calculate adjustment factors for soluble transferrin receptor (sTfR) and body iron stores (BISs) in Lao children. We found no advantage in adjusting sTfR for inflammation; in fact, adjustment decreased iron deficiency. Neither adjusted (10% <0 mg/kg) nor nonadjusted (12% <0 mg/kg) BISs detected as much iron deficiency as did ferritin (18% <12 μg/L) and adjusted ferritin (21% <12 μg/L) unless the cutoff for BISs was increased from 0 to <3 mg/kg. However, we could find no evidence that the larger number of children identified as having BISs <3 mg/kg had risks of anemia comparable to those identified by using ferritin <12 μg/L. In conclusion, both corrected and uncorrected ferritin concentrations <12 μg/L are associated with more iron deficiency and anemia than either sTfR >8.3 mg/L or BISs <0 mg/kg in Lao children.

Relationships between Causes of Fever of Unknown Origin and Inflammatory Markers: A Multicenter Collaborative Retrospective Study

OBJECTIVE

Although inflammatory markers, such as the white blood cell (WBC) count, erythrocyte sedimentation rate (ESR) and levels of C-reactive protein (CRP) and procalcitonin, are widely used to differentiate causes of fever of unknown origin (FUO), little is known about the usefulness of this approach. We evaluated relationships between the causes of classical FUO and the levels of inflammatory markers.

METHODS

A nationwide retrospective study including 17 hospitals affiliated with the Japanese Society of Hospital General Medicine was conducted.

PATIENTS

This study included 121 patients ≥18 years old diagnosed with "classical FUO" (axillary temperature ≥38.0°C at least twice over a ≥3-week period without elucidation of the cause on three outpatient visits or during three days of hospitalization) between January and December 2011.

RESULTS

The causative disease was infectious diseases in 28 patients (23.1%), non-infectious inflammatory disease (NIID) in 37 patients (30.6%), malignancy in 13 patients (10.7%), other in 15 patients (12.4%) and unknown in 28 patients (23.1%). The rate of malignancy was significantly higher for a WBC count of <4,000/μL than for a WBC count of 4,000-8,000/μL (p=0.015). Among the patients with a higher WBC count, the rate of FUO due to NIID tended to be higher and the number of unknown cases tended to be lower. All FUO patients with malignancy showed an ESR of >40 mm/h. A normal ESR appeared to constitute powerful evidence for excluding a diagnosis of malignancy. In contrast, the concentrations of both serum CRP and procalcitonin appeared to be unrelated to the causative disease.

CONCLUSION

The present study identified inflammatory markers that should be considered in the differential diagnosis of classical FUO, providing useful information for future diagnosis.

Undernutrition, the acute phase response to infection, and its effects on micronutrient status indicators

Infection and undernutrition are prevalent in developing countries and demonstrate a synergistic relation. Undernutrition increases infection-related morbidity and mortality. The acute phase response (APR) is an innate, systemic inflammatory reaction to a wide array of disruptions in a host's homeostasis, including infection. Released from immune cells in response to deleterious stimuli, proinflammatory cytokines act on distant tissues to induce behavioral (e.g., anorexia, weakness, and fatigue) and systemic effects of the APR. Cytokines act to increase energy and protein requirements to manifest fever and support hepatic acute phase protein (APP) production. Blood concentrations of glucose and lipid are augmented to provide energy to immune cells in response to cytokines. Additionally, infection decreases intestinal absorption of nutrients and can cause direct loss of micronutrients. Traditional indicators of iron, zinc, and vitamin A status are altered during the APR, leading to inaccurate estimations of deficiency in populations with a high or unknown prevalence of infection. Blood concentrations of APPs can be measured in nutrition interventions to assess the time stage and severity of infection and correct for the APR; however, standardized cutoffs for nutrition applications are needed. Protein-energy malnutrition leads to increased gut permeability to pathogens, abnormal immune cell populations, and impaired APP response. Micronutrient deficiencies cause specific immune impairments that affect both innate and adaptive responses. This review describes the antagonistic interaction between the APR and nutritional status and emphasizes the need for integrated interventions to address undernutrition and to reduce disease burden in developing countries.

To study the levels of C - reactive protein and total leucocyte count in patients operated of open and laparoscopic cholecystectomy

BACKGROUND

The recovery from laparoscopic cholecystectomy (LC) is rapid and most of the patients are discharged on the 1st post-operative day. There is an increased concentration of certain serum proteins, known as acute-phase reactive proteins (APRP) during the post-operative period depends on the degree of tissue damage and the inflammatory reaction. There is a direct positive correlation between the concentrations of APRP, especially C-reactive protein (CRP), and the severity of inflammation. This study was done to study the levels of C - reactive protein and Total Leucocyte Count in patients operated either by Open Cholecystectomy (OC) and Laparoscopic Cholecystectomy (LC).

MATERIALS AND METHODS

This prospective study was conducted on 50 patients after approval from the Institutional Ethics Committee. Twenty five patients underwent open cholecystectomy and the other 25 had laparoscopic cholecystectomy. The pre and post operative concentrations of serum C-reactive protein (CRP) and total leukocyte count (TLC) were compared in both the groups.

RESULTS

There were no differences in the preoperative serum CRP and TLC concentrations - in both the groups. Serum CRP rose significantly following OC compared to that of patients who underwent LC (10.52 ± 1.96 mg% vs. 8.88 ± 1.23 mg %). There were also significant differences in the post-operative TLC ( 9.49 ± 1.05 m/mm3 for the OC group vs. 8.57 ± 1.31 m/mm3 for the LC group), and the post-operative hospital stay (5.5 ±1.5 days vs. 1.9 ± 0.9 days). There was no correlation between serum CRP concentrations and the other post-operative parameters.

CONCLUSION

The study provided the biochemical evidence supporting the clinical observation that LC is far less traumatic to the patient than OC.

The acute phase response affected traditional measures of micronutrient status in rural Zambian children during a randomized, controlled feeding trial

The acute phase response (APR) to infection can alter blood-based indicators of micronutrient status. Data from a 3-mo randomized, controlled feeding trial in rural Zambian children (n = 181, aged 3-5 y) were used to determine the impact of the APR on indicators of vitamin A and iron status using baseline and final blood samples. Concentrations of acute phase proteins were categorized as raised C-reactive protein (CRP; >5 and >10 mg/L) only, both raised CRP and α1-acid glycoprotein (AGP; >1.2 g/L), raised AGP only, and neither CRP nor AGP raised to identify the respective stages of infection: incubation, early convalescence, convalescence, and healthy state. Data were insufficient to examine the incubation stage of infection. A CRP concentration of >5 mg/L was an effective elevation cutoff point in this population to show impact on micronutrient markers. Time did not affect hemoglobin, serum ferritin, or serum retinol concentrations (P > 0.05). During early convalescence, hemoglobin decreased (14-16%; P ≤ 0.05), serum ferritin increased (279-356%; P ≤ 0.05), and serum retinol decreased (20-30%; P ≤ 0.05). Serum retinol concentrations did not change during convalescence; however, hemoglobin remained depressed (4-9%) and serum ferritin was elevated (67-132%) (both P ≤ 0.05). Modified relative dose response values were unaffected by the APR (P > 0.05) but increased between time points (16%; P ≤ 0.05), indicating a decrease in liver vitamin A reserves on the background of a semiannual vitamin A supplementation program. The observed prevalence of anemia and vitamin A deficiency assessed by serum retinol concentration was higher during the APR (P ≤ 0.05). It is important to consider the impact of infection on dietary interventions and to adjust for acute phase proteins when assessing iron status or vitamin A status by serum retinol concentration alone in children.

Significant sex difference in the association between C-reactive protein concentration and anthropometry among 13- to 19-year olds, but not 6- to 12-year olds in Nepal

Life history theory predicts a trade-off between immunostimulation and growth. Using a cross-sectional study design, this study aims to test the hypothesis that C-reactive protein (CRP) is negatively associated with height-for-age z-scores (HAZ scores) and BMI-for-age z-scores (BAZ scores) among 6- to 19-year olds (N = 426) residing in five Nepalese communities. Dried blood spot (DBS) samples were collected and assayed for CRP using an in-house enzyme immunoassay (EIA). Sex- and age-group-specific CRP quartiles were used to examine its association with growth in linear mixed-effects (LME) models. A significant difference was found in the proportion of elevated CRP (>2 mg/L, equivalent to ∼3.2 mg/L serum CRP) between 13- and 19-year-old boys (12%) and girls (4%). Concentrations of CRP were positively associated with HAZ score among adolescent (13-19 years) boys, which may indicate that individuals with greater energy resources have better growth and a better response to infections, thus eliminating the expected trade-off between body maintenance (immunostimulation) and growth. Adolescent boys with low BAZ and HAZ scores had low CRP values, suggesting that those who do not have enough energy for growth cannot increase their CRP level even when infected with pathogens. Among adolescent girls a positive association was observed between CRP and BAZ scores suggesting the possible effects of chronic low-grade inflammation due to body fat rather than infection. The association between CRP and growth was less evident among children (6-12 years) compared with adolescents, indicating that the elevated energy requirement needed for the adolescent growth spurt and puberty may play some role.

Early prediction of adverse events in enhanced recovery based upon the host systemic inflammatory response

AIM

Early identification of patients experiencing postoperative complications is imperative for successful management. C-reactive protein (CRP) is a nonspecific marker of inflammation used in many specialties to monitor patient condition. The role of CRP measurement early in the elective postoperative colorectal patient is unclear, particularly in the context of enhanced recovery (ERAS).

METHODS

Five hundred and thirty-three consecutive patients who underwent elective colorectal surgery between October 2008 and October 2010 within an established ERAS programme were studied. Patients were separated into a development group of 265 patients and a validation group of 268 patients by chronological order. CRP and white cell count were added to a prospectively maintained ERAS database. The primary outcome of the study was all adverse events (including infective complications, postoperative organ dysfunction and prolonged length of stay) during the initial hospital admission. Significant predictors for adverse events on univariate analysis were submitted to multivariate regression analysis and the resulting model applied to the validation group. The validity and predictive accuracy of the regression model was assessed using receiver operating characteristic curve/area under the curve (AUC) analysis.

RESULTS

CRP levels >150 mg/l on postoperative day 2 and a rising CRP on day 3 were independently associated with all adverse events during the hospital admission. A weighted model was applied to the validation group yielding an AUC of 0.65 (95% CI 0.58-0.73) indicating, at best, modest discrimination and predictive accuracy for adverse events.

CONCLUSION

Measurement of CRP in patients after elective colorectal surgery in the first few days after surgery within ERAS can assist in identifying those at risk of adverse events and a prolonged hospital stay. A CRP value of >150 mg/l on day 2 and a rising CRP on day 3 should alert the surgeon to an increased likelihood of such events.

Significant role of serum CRP in differentiating inflammatory from non-inflammatory causes of thyrotoxicosis

BACKGROUND

C-reactive protein (CRP), which is a marker of inflammation, has not been widely studied in inflammatory thyroid disorders particularly in sub-acute thyroiditis (SAT).

AIM

This study was aimed to find the significance of CRP level rise in patients with SAT and compare that to the rise in erythrocyte sedimentation rate (ESR), a gold standard laboratory parameter in establishing the diagnosis of SAT.

MATERIALS AND METHODS

Serum CRP levels were measured at initial presentation in 28 subjects with SAT(12 male, 16 female, age (Mean +SD) 37.96 ±8.5 years),and 19 patients with Graves' disease (2 male, 17 female, age [Mean +SD] 36.8 ±16.5 years) as controls. Erythrocyte sedimentation rate (ESR) was measured in all 28 patients with SAT by Westergrens' method. Either Tc(99) nucleotide thyroid scan or high resolution ultrasonography (HR-USG) was performed to differentiate SAT from Graves' disease.Fine needle aspiration cytology (FNAC) of thyroid was performed selected patients.

RESULTS

Serum CRP level was high in 61% of SAT patients but in none of the Graves'patients. Mean (SEM) (90%CI) serum CRP level (mg/L) was also significantly higher (P <0.0004) in the SAT group [27.55 (5.76) (15.72-39.38)], than in the Graves' group [4.09 (0.12) (3.81-4.36)]. The sensitivity of serum CRP was 73.33%, specificity 53.85%, positive predictive value (PPV) 64.71%, and negative predictive value (NPV) 63.64% as compared to the sensitivity (53.57%), specificity (15.38%), PPV (57.69 %), and NPV (13.33%) of ESR.

CONCLUSION

There is significantly higher rise in serum CRP level in patients with SAT is compared to patients with Graves' disease. It correlates well with the rise in ESR. Such findings of this pilot study highlight the scope of using serum CRP as a diagnostic marker of SAT specially in situations when it may be confused with Graves' disease, another common cause of thyrotoxicosis. It is logical to carry out studies to find a particular cut-off for serum CRP which can serve as an objective parameter for grading the inflammation in patients with SAT.

Whole cowpea meal fortified with NaFeEDTA reduces iron deficiency among Ghanaian school children in a malaria endemic area

Cowpeas, like other legumes, contain high amounts of native iron but are rich in phytic acid (PA) and polyphenols (PP) that inhibit iron absorption. NaFeEDTA may overcome the combined inhibitory effect of PA and PP. Our objective was to test the efficacy of NaFeEDTA-fortified cowpea meal in improving iron status of school children in a malaria endemic area. We conducted a double-blind, controlled trial with 5- to 12-y-old school children from 2 rural communities in northern Ghana (n = 241). Eligible children were randomly assigned to 2 treatment groups to receive either cowpea meal fortified with 10 mg Fe/meal as NaFeEDTA, or an identical but nonfortified cowpea meal. Meals were provided 3 d/wk for a period of ~7 mo under strict supervision. Mass deworming and malaria antigenemia screening and treatment were carried out at baseline and 3.5 mo into the trial. Consumption of cowpea flour fortified with NaFeEDTA resulted in improvement of hemoglobin (P < 0.05), serum ferritin (P < 0.001), and body iron stores (P < 0.001) and reduction of transferrin receptor (P < 0.001) compared with nonfortified flour. Fortification resulted in a 30 and 47% reduction in the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) (P < 0.05), respectively. The results indicate that fortification of cowpea flour with NaFeEDTA overcomes the combined inhibitory effect of PA and PP and, when used for targeted school-based fortification of cowpea flour, is effective in reducing the prevalence of ID and IDA among school children in malaria endemic rural northern Ghana.

Effect of long-term intermittent supplementation with multiple micronutrients compared with iron-and-folic acid supplementation on Hb and micronutrient status of non-anaemic adolescent schoolgirls in rural Bangladesh

The present study examined whether long-term supplementation with once- and twice-weekly multiple micronutrients (MMN-1 and MMN-2) can improve Hb and micronutrient status more than twice-weekly Fe–folic acid (IFA-2) supplementation in non-anaemic adolescent girls in Bangladesh. An equal number of 324 rural schoolgirls aged 11–17 years were given MMN-1 or MMN-2 or IFA-2 supplements for 52 weeks in a randomised, double-blind trial. Blood samples were collected at baseline, and at 26 and 52 weeks of supplementation. The girls receiving IFA-2 supplements were more likely to be anaemic than the girls receiving MMN-2 supplements for 26 weeks (OR 5·1, 95 % CI 1·3, 19·5; P = 0·018). All three supplements reduced Fe deficiency effectively. Both the MMN-1 and MMN-2 groups showed significantly greater improvements in vitamins A, B2 and C status than the girls in the IFA-2 group, as might be expected. Receiving a MMN-1 supplement was found to be less effective than MMN-2 supplement in improving Fe, vitamins A, B2 and folic acid status. Receiving micronutrient supplements beyond 26 weeks showed little additional benefit in improving micronutrient status. In conclusion, given twice-weekly for 26 weeks, MMN supplements can improve micronutrient status effectively with no significant increase in Hb concentration compared with IFA supplements in non-anaemic Bangladeshi adolescent girls. However, it significantly reduces the risk of anaemia. Before any recommendations can be made, further research, including into cost-effectiveness, is needed to see whether MMN supplementation has any additional longer-term health benefits over that of IFA supplementation in this population.

Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron + folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Monitoring the response of canine hyperadrenocorticism to trilostane treatment by assessment of acute phase protein concentrations

BACKGROUND

Acute phase proteins (APPS) include haptoglobin (Hp), C-reactive protein (CRP) and serum amyloid A (SAA). Increased Hp concentrations may be induced by endogenous or exogenous glucocorticoids in dogs.

OBJECTIVES

To assess whether control of hyperadrenocorticism (HAC) affects the concentrations of Hp, CRP, SAA, alkaline phosphatase (ALKP) and cholesterol, to determine whether these analytes can be used to assess control of HAC following trilostane treatment, and whether a combination of these tests offers a valid method of assessing disease control.

METHODS

Hp, CRP, SAA, ALKP and cholesterol were assessed in 11 dogs with spontaneous HAC before and after treatment with trilostane. Adequate control of HAC was defined as post-ACTH cortisol less than 150 nmol/l.

RESULTS

Significant reductions in Hp, ALKP, cholesterol and SAA (P<0.05) but not of CRP were found after control of HAC. Only Hp, cholesterol and ALKP were moderately informative (Se & Sp>0.7) of disease control when compared to adrenocorticotropin or corticotropin (ACTH) stimulation test. SAA and CRP were unhelpful (Se & Sp<0.7). The analysis of the combination of the analytes did not improve the correlation with ACTH stimulation test.

CLINICAL RELEVANCE

Relying on these analytes does not provide additional information over ACTH stimulation test results when assessing control of HAC treated with trilostane.

The influence of inflammation on plasma zinc concentration in apparently healthy, HIV+ Kenyan adults and zinc responses after a multi-micronutrient supplement

BACKGROUND/OBJECTIVES

Plasma zinc is an important biomarker of zinc status, but the concentration is depressed by inflammation.

SUBJECTS/METHODS

Apparently healthy adults, who tested positive twice for human immunodeficiency virus (HIV) but who had not reached stage IV or clinical AIDS, were randomly allocated to receive a food supplement (n=17 and 21) or the food plus a micronutrient capsule (MN; n=10 men and n=33 women) containing 15 mg zinc/day. We used the inflammation biomarkers, C-reactive protein (CRP) and alpha1-acid glycoprotein (AGP), to identify subjects with and without inflammation and determine the effect of inflammation on the response of plasma zinc concentrations to the MN and food supplements.

RESULTS

There were no differences between men and women either in plasma zinc or in the responses to the supplements and their data were combined. Plasma zinc was lower in those with inflammation than without. Repeated measures analysis of variance (ANOVA) showed that inflammation blocked increases in plasma zinc, and there was an approximate 10% increase in plasma zinc concentration in response to the MN supplement (P=0.023) in those without inflammation. Subgroup analysis showed mean changes in plasma zinc of 0.95 and -0.83 micromol/l (P=0.031) in response to the MN and food treatments, respectively, in those without inflammation at both time points.

CONCLUSIONS

Inflammation seems to block any increase in plasma zinc after MN supplement and it is important to identify those without inflammation to determine the effectiveness of a zinc supplementation program.

Adjusting for the acute phase response is essential to interpret iron status indicators among young Zanzibari children prone to chronic malaria and helminth infections

The extent to which the acute phase response (APR) influences iron status indicators in chronic infections is not well documented. We investigated this relationship using reported recent fever and 2 acute phase proteins (APP), C-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP). In a sample of 690 children matched on age and helminth infection status at baseline, we measured plasma for AGP, CRP, ferritin, transferrin receptor (TfR), and erythropoietin (EPO) and whole blood for hemoglobin (Hb) concentration, zinc protoporphyrin (ZPP), and malaria parasite density, and we obtained maternal reports of recent fever. We then examined the influence of the APR on each iron status indicator using regression analysis with Hb as the outcome variable. Ferritin was inversely related to Hb in the APR-unadjusted model. Adjusting for the APR using reported recent fever alone was not sufficient to reverse the inverse Hb-ferritin relationship. However, using CRP and/or AGP resulted in the expected positive relationship. The best fit model included reported recent fever, AGP and CRP (R(2) = 0.241; P < 0.001). The best fit Hb-ZPP, Hb-TfR, and Hb-EPO models included reported recent fever and AGP but not CRP (R(2) = 0.253, 0.310, and 0.292, respectively; P < 0.001). ZPP, TfR, and EPO were minimally influenced by the APR, whereas ferritin was immensely affected. Reported recent fever alone cannot be used as a marker for the APR. Either AGP or CRP is useful for adjusting if only 1 APP can be measured. However, AGP best predicted the APR in this population.

Activation of plasminogen activator inhibitor implicates protease InhA in the acute-phase response to Bacillus anthracis infection

Anthrax is a zoonotic disease caused by Bacillus anthracis. The infection is associated with inflammation and sepsis, but little is known about the acute-phase response during disease and the nature of the bacterial factors causing it. In this study, we examined the levels of the acute-phase proteins (APPs) in comparative experiments using mice challenged with spores and a purified B. anthracis protease InhA as a possible factor mediating the response. A strong increase in the plasma levels of APPs such as haptoglobin and serum amyloid A was observed during infection. Protein and mRNA levels of plasminogen activator inhibitor (PAI)-1 in the liver were also increased concurrently with bacterial dissemination at 72 h post-infection. Similar effects were observed at 6 h post injection with InhA. Induction of hepatic transforming growth factor-beta1, a PAI-1 inducer, was also found in the liver of InhA-injected mice. PAI-1 elevation by InhA resulted in an increased level of urokinase-type plasminogen activator complex with PAI-1 and a decreased level of D-dimers indicating inhibition of blood fibrinolysis. These results reveal an acute liver response to anthrax infection and provide a plausible pathophysiological link between the host inflammatory response and the pro-thrombotic haemostatic imbalance in the course of disease through PAI-1 induction in the liver.

Using plasma acute-phase protein concentrations to interpret nutritional biomarkers in apparently healthy HIV-1-seropositive Kenyan adults

Inflammation influences the assessment of nutritional status. For example, inflammation reduces plasma retinol concentrations and vitamin A deficiency is overestimated. Conversely inflammation increases plasma ferritin concentrations and Fe deficiency is underestimated. Blood samples were obtained from 163 free-living HIV-1-infected adults, not on continuous medication, anti-retroviral drugs or micronutrients, not unwell and who had not reached WHO stage IV of HIV/AIDS. We used four markers of inflammation, C-reactive protein (CRP), α1-acid glycoprotein (AGP), α1-antichymotrypsin and erythrocyte sedimentation rate but mainly CRP and AGP were used to separate the subjects into four groups: ‘healthy’ where both CRP and AGP were normal; ‘incubation phase’ where CRP was elevated; ‘early convalescence’ where AGP and CRP were elevated and ‘late convalescence’ where only AGP was elevated. Correction factors were calculated to remove the influence of inflammation from each biomarker and group where inflammation was present and the data are shown before and after recalculation. The correction increased median plasma retinol concentrations of the whole group from 1·16 to 1·33 μmol/l, comparable with values (mean 1·29 μmol/l) in HIV-negative Kenyan women. Median ferritin concentrations fell by about 50 % in both sexes and the number of women with plasma ferritin concentrations ≤ 12 μg/l increased from eleven to twenty. The correction also increased plasma carotenoids and Hb but not α-tocopherol concentrations. We suggest that the method described to remove the influence of inflammation from nutritional biomarkers should be generally applicable in apparently healthy people and prevents discarding valuable data because of mild inflammation. The method does now need to be tested in other populations.

Homeless street children in Nepal: use of allostatic load to assess the burden of childhood adversity

As challenges to child well-being through economic disadvantage, family disruption, and migration or displacement escalate world wide, the need for cross-culturally robust understanding of childhood adversity proportionately increases. Toward this end, developmental risk was assessed in four contrasting groups of 107 Nepali children ages 10-14 years that represent distinctive, common conditions in which contemporary children grow up. Relative cumulative burden (allostatic load) indexed by multiple dimensions of physical and psychosocial stress was ascertained among homeless street boys and three family-based groups, from poor urban squatter settlements, urban middle class, and a remote rural village. Biomarkers of stress and vulnerability to stress included growth status, salivary cortisol, antibodies to Epstein-Barr virus, acute phase inflammatory responses (alpha1-antichymotrypsin), and cardiovascular fitness and reactivity (flex heart rate and pressor response). Individual biomarkers of risk and allostatic load differed markedly among groups, were highest in villagers, and varied by components of allostatic load. Such data suggest a need for critical appraisal of homelessness and migration as a risk factor to youth, given prevailing local conditions such as rural poverty, and represents the only multidimensional study of childhood allostatic load and developmental risk in non-Western settings.

The influence and benefits of controlling for inflammation on plasma ferritin and hemoglobin responses following a multi-micronutrient supplement in apparently healthy, HIV+ Kenyan adults

Hemoglobin and ferritin are important biomarkers of iron status but are both altered by inflammation. We used the inflammation biomarkers C-reactive protein (CRP) and alpha1-acid glycoprotein (AGP) to adjust hemoglobin and ferritin concentrations to clarify interpretation of iron status. Apparently healthy adults who tested positive twice for HIV but who had not reached stage IV or clinical AIDS were randomly allocated to receive a food supplement (n = 17 and 21) or the food plus a micronutrient capsule (MN; 10 men and 34 women, respectively) containing 30 mg iron/d. Hemoglobin, ferritin, CRP, and AGP concentrations were measured at baseline and 3 mo and subjects were divided into 4 groups (reference, no inflammation; incubating, raised CRP; early convalescence, raised AGP and CRP; and late convalescence, raised AGP). Correction factors (the ratios of the median for the reference group over each inflammatory group) improved the consistency of the ferritin but not the hemoglobin results. After correction, ferritin (but not hemoglobin) increased in both men (48 microg/L; P = 0.02) and women (12 microg/L; P = 0.04) who received MN but not in the food-only group. However, hemoglobin did improve in subjects who showed no inflammation both at baseline and mo 3 (P = 0.019), but ferritin did not increase in this group. In conclusion, ferritin concentrations were more closely linked to current inflammation than hemoglobin; hence, correction by inflammation biomarkers improved data consistency. However, low hemoglobin concentrations were the consequence of long-term chronic inflammation and improvements in response to MN supplements were only detected in subjects with no inflammation.

An overview of interactions between micronutrients and of micronutrients with drugs, genes and immune mechanisms

The objective of the present review is to examine critically the consequences of interactions that micronutrients undergo with nutrients and non-nutrients (mainly prescribed medicines) in diets and lifestyle factors (smoking, tea and alcohol consumption). In addition, the review describes recent work on interactions between nutrients and genes, the influence of gene polymorphisms on micronutrients, the impact of immune responses on micronutrients and specific interactions of antioxidant micronutrients in disease processes to minimise potential pro-oxidant damage.

Maternal reports of child illness and the biochemical status of the child: the use of morbidity interviews in rural Bangladesh

In a longitudinal study of child growth and nutritional status in Bangladesh, child morbidity was recorded using health interviews with the mother. The aim of the present study was to establish whether maternal reports of child illness were associated with the biochemical health status of the child. Children aged 2–5 years (n 117) took part in the study and their mothers were interviewed every fortnight by Bangladeshi fieldworkers. Maternal reports of diarrhoea were associated with significantly lower plasma albumin concentrations (P < 0·001), poorer intestinal permeability (P < 0·001), higher plasma immunoglobulin A levels (P < 0·005) and higher α-1-antichymotrypsin (ACT) levels (P < 0·05) compared with children reported to be healthy. Children with fever had significantly higher ACT (P < 0·001) and lower albumin (P < 0·05) levels compared with their healthy counterparts. Respiratory infections (RI) were not associated with any significant changes; however, reports of RI with fever were associated with significantly higher levels of ACT than either illness individually (interaction P < 0·05). These highly significant associations between maternal reports of illness and biochemical profiles of child health support the use of health interviews in developing countries.

Best practice in primary care pathology: review 6

This sixth best practice review examines four series of common primary care questions in laboratory medicine: (1) laboratory monitoring in hypertension and heart failure abnormalities; (2) markers of inflammatory joint disease; (3) laboratory investigation of chronic diarrhoea; and (4) mumps and chickenpox. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus based rather than evidence based. They will be updated periodically to take account of new information.

The coexistence of other micronutrient deficiencies in anaemic adolescent schoolgirls in rural Bangladesh

OBJECTIVE

To investigate the prevalence of selected micronutrient deficiencies amongst anaemic adolescent schoolgirls in rural Bangladesh and to examine their relationship with haemoglobin (Hb) levels.

DESIGN

A cross-sectional study.

SETTING

Girls' high schools in rural areas of Dhaka District in Bangladesh.

SUBJECTS AND METHODS

Three hundred and ten anaemic adolescent girls aged 14-18 years from eight schools participated in the study. Information on personal characteristics and food habits were collected by interview. Parents were asked about their socio-economic conditions. Anthropometric data and blood samples were collected following the interview.

RESULTS

Twenty-eight per cent of the girls had depleted iron stores (serum ferritin <12.0 microg/l), 25% had folic acid deficiency (red blood cell folic acid <317 nmol/l), 89% had vitamin B(2) (erythrocyte glutathione reductase activity coefficient > or =1.4) and 7% had vitamin B(12) deficiencies (serum vitamin B(12) <150 pmol/l). Although the prevalence of vitamins A and C deficiency was very low, a significant proportion had low vitamin A (serum retinol between 0.70 and <1.05 micromol/l) and vitamin C status (plasma ascorbic acid between 11.4-23.0 micromol/l). Frequency of consumption of meat, serum ferritin and vitamin B(2) status were found to be strongly related to Hb by multiple regression analysis. For 1 microg/l change in serum ferritin, there was a 0.13 g/l change in Hb when adjusted for other factors.

CONCLUSIONS

There is coexistence of micronutrient deficiencies among anaemic adolescent girls in rural Bangladesh, although they do not suffer from energy deficiency. Of all micronutrients, only iron and vitamin B(2) concentrations were found to be related to the Hb concentration.

Is secondary haemorrhage after tonsillectomy in adults an infective condition? Objective measures of infection in a prospective cohort

OBJECTIVES

Traditionally secondary post-tonsillectomy haemorrhage has been thought to be due to post-operative infection and as such is treated with broad-spectrum antibiotics. The aim of this study was to identify clinical evidence of infection in patients with secondary post-tonsillectomy haemorrhage that might justify the use of antibiotics in these patients.

DESIGN

Prospective data collection.

SETTING

Tertiary University Teaching Hospital.

PARTICIPANTS

Adult patients admitted with post-tonsillectomy haemorrhage over a 2-year period.

MAIN OUTCOME MEASURES

Temperature, white cell count, Neutrophil count and C-reactive protein.

RESULTS

47 patients were admitted with secondary post-tonsillectomy haemorrhage. Fifteen out of 47 patients (32%) had an elevated white cell count but in them the other indicators of temperature and C-reactive protein were extremely variable: none of these 15 patients was pyrexial (> 37.6 C). An elevated C-reactive protein was found in 55% of patients but none had an elevated white cell count. The elevated C-reactive protein may have been influenced by the recent surgery rather than infection. Overall there was no clear interrelation between the indicators of infection in the patients and none had the three main indicators of infection (pyrexia, increased white cell count and elevated C-reactive protein).

CONCLUSIONS

Our results suggest that clinical signs of infection are lacking in patients with secondary tonsillectomy bleeding. Correspondingly the routine use of antibiotics should be questioned for secondary tonsillectomy haemorrhage.

Relationships between biochemical bone turnover markers, season, and inflammatory status indices in prepubertal Gambian boys

Seasonal and interindividual differences in food availability and illnesses cause variations in growth, including bone growth, in children in developing countries. We investigated seasonal differences in biochemical (serum) markers of bone metabolism and relationships between these markers (procollagen type I N propeptide [P1NP], serum C-terminal telopeptide of type 1 collagen [S-CTX]) and serum markers of inflammation (alpha(1)- antichymotrypsin [ACT], C-reactive protein [CRP], sialic acid) in prepubertal Gambian boys. Three seasonal time points were chosen: August, mid-rainy season; October, late rainy season (both are associated with decreased food supply, increased prevalence of infection, reduced weight gain, and stunting); and April, late dry season, when environmental conditions are better and rates of weight gain are higher. The prevalence of raised inflammatory markers was high: 29% of ACT values >0.40 g/L in August, 42% >0.40 g/L in October, and 18% >0.40 g/L in April. Of CRP values, 92-96% were >0.47 mg/L and 30%, 46%, and 18% were >3.95 mg/L in August, October, and April, respectively. Also, 42-52% of sialic acid values were >648 mg/L. Of the bone markers, S-CTX exhibited the highest values in August; P1NP did not vary with season. Inverse relationships between each bone marker and the acute phase markers occurred, with the strongest relationships between P1NP and ACT or sialic acid. We conclude that bone collagen synthesis and turnover are reduced during inflammation in rural Gambian boys. Biochemical indices can provide powerful, single-time point evidence of infection and growth-faltering episodes.

Comparative effectiveness of zinc protoporphyrin and hemoglobin concentrations in identifying iron deficiency in a group of low-income, preschool-aged children: practical implications of recent illness

OBJECTIVE

The goal was to assess the influence of recent infection on screening tests for iron depletion (zinc protoporphyrin and hemoglobin) among low-income, preschool-aged children.

METHODS

This cross-sectional study was conducted at community sites and ambulatory care clinics in Hartford, Connecticut, and included 180 preschool-aged children. Iron depletion was defined as serum ferritin levels of < or = 15 microg/L. Recent illness was defined by parent or guardian (caretaker) report or evidence of elevated C-reactive protein concentrations. History of anemia was determined through medical records review. Sensitivity, specificity and positive predictive values of hemoglobin and zinc protoporphyrin were calculated overall and for children with and without recent illness.

RESULTS

At enrollment, more than one half of the children had a recent illness, and 57.5% had a history of anemia. More than one third had iron depletion. Serum ferritin levels were significantly higher among recently ill children. Secondary to recent illness, the positive predictive value of elevated zinc protoporphyrin, but not low hemoglobin, was reduced significantly. Zinc protoporphyrin levels of >69 micromol/mol heme identified significantly more iron-deficient children.

CONCLUSIONS

Compared with anemia, elevated zinc protoporphyrin levels identified significantly more iron-deficient children. Recently ill children were one half as likely to have low serum ferritin levels, compared with children without recent illness. The negative effect of recent illness on the positive predictive value of zinc protoporphyrin when ferritin is used to determine iron status has many practical implications.

Characterization of proteins in human pancreatic cancer serum using differential gel electrophoresis and tandem mass spectrometry

The purpose of this study was to develop techniques for identifying cancer biomarkers in human serum using differential in-gel electrophoresis (DIGE), and characterizing the protein biomarkers using tandem mass spectrometry (MS/MS). A major problem in profiling protein expression by DIGE comes from the presence of high concentrations of a small number of proteins. Therefore, serum samples were first chromatographed using an immunoaffinity HPLC column (Agilent Technologies), to selectively remove albumin, immunoglobulins, transferrin, haptoglobin, and antitrypsin. Serum samples from three individuals with pancreatic cancer and three individuals without cancer were compared. Serum samples were processed using the immunoaffinity column. Differential protein analysis was performed using DIGE. A total of 56 protein spot-features were found to be significantly increased and 43 significantly decreased in cancer serum samples. These spot features were excised, trypsin digested, and analyzed by MALDI/TOF/TOF (4700 Proteomics Analyzer, Applied Biosystems). We identified 24 unique proteins that were increased and 17 unique proteins that were decreased in cancer serum samples. Western blot analysis confirmed increased levels of several of these proteins in the pancreatic cancer serum samples. In an independent series of serum samples from 20 patients with pancreatic cancer and 14 controls, increased levels of apolipoprotein E, alpha-1-antichymotrypsin, and inter-alpha-trypsin inhibitor were found to be associated with pancreatic cancer. These results suggest that affinity column enrichment and 2-D DIGE can be used to identify numerous proteins differentially expressed in serum from individuals with pancreatic cancer.

Plasma 25-hydroxyvitamin D does not vary over the course of a malarial infection

Assessment of the status of some micronutrients is complicated by the acute phase response to infection. We investigated whether 25-hydroxyvitamin D (25OHD) is an acute phase reactant by measuring the effect of a malarial infection on plasma 25OHD level. Blood samples were taken from patients with Plasmodium falciparum malaria daily during the course of their stay in hospital and at a follow-up session 2-6 weeks after discharge. 25OHD was measured by radioimmunoassay. Time course data for the 14 subjects who provided samples for at least the first 2 d in hospital showed no change in 25OHD level during the acute infection. For the 14 subjects with follow-up results, there was no difference between median 25OHD level at admission (25.6 ng/ml, interquartile range (IQR) 23.0, 40.2) and at follow-up (25.2 ng/ml, IQR 19.2, 32.1; P=0.084). 25OHD level appears to be unaffected during the course of a severe malarial infection and thus can be used as a measure of vitamin D status even in subjects who are currently ill.

Efficacy of twice-weekly multiple micronutrient supplementation for improving the hemoglobin and micronutrient status of anemic adolescent schoolgirls in Bangladesh

BACKGROUND

Although iron deficiency is a major cause of anemia, other micronutrient deficiencies may also play a role.

OBJECTIVE

We examined whether multiple micronutrient supplementation is more efficacious than is supplementation with iron and folic acid alone for improving the hemoglobin and iron status of anemic adolescent girls in Bangladesh.

DESIGN

Anemic (hemoglobin < 12.0 g/dL) girls (n = 197) aged 14-18 y from rural schools in Dhaka District were entered into a randomized double-blind trial and received twice-weekly supplements of iron and folic acid (IFA group) or multiple micronutrients (15 micronutrients, including iron and folic acid; MMN group) for 12 wk.

RESULTS

At recruitment, the characteristics of the girls in the 2 groups were not significantly different, except for family size and body mass index. At the end of the study, although both groups benefited significantly from supplementation, mean changes in hemoglobin and serum ferritin concentrations were not significantly different between groups. Compared with the IFA group, girls in the MMN group had significantly greater increases in mean serum vitamin A, plasma vitamin C, red blood cell folic acid, and riboflavin concentrations (assessed as erythrocyte glutathione reductase activation coefficient). After 12 wk of supplementation, only the prevalence of vitamins A and C and riboflavin deficiencies decreased more significantly in the MMN group than in the IFA group.

CONCLUSIONS

Twice-weekly MMN supplementation for 12 wk significantly improved the status of the micronutrients assessed but was not more efficacious than was supplementation with iron and folic acid alone in improving the hematologic status of anemic adolescent girls. More frequent doses may be needed to achieve full benefit.

Pathophysiology and diagnostic value of urinary trypsin inhibitors

Inflammation is an important indicator of tissue injury. In the acute form, there is usually accumulation of fluids and plasma components in the affected tissues. Platelet activation and the appearance in blood of abnormally increased numbers of polymorphonucleocytes, lymphocytes, plasma cells and macrophages usually occur. Infectious disorders such as sepsis, meningitis, respiratory infection, urinary tract infection, viral infection, and bacterial infection usually induce an inflammatory response. Chronic inflammation is often associated with diabetes mellitus, acute myocardial infarction, coronary artery disease, kidney diseases, and certain auto-immune disorders, such as rheumatoid arthritis, organ failures and other disorders with an inflammatory component or etiology. The disorder may occur before inflammation is apparent. Markers of inflammation such as C-reactive protein (CRP) and urinary trypsin inhibitors have changed our appraisal of acute events such as myocardial infarction; the infarct may be a response to acute infection and (or) inflammation. We describe here the pathophysiology of an anti-inflammatory agent termed urinary trypsin inhibitor (uTi). It is an important anti-inflammatory substance that is present in urine, blood and all organs. We also describe the anti-inflammatory agent bikunin, a selective inhibitor of serine proteases. The latter are important in modulating inflammatory events and even shutting them down.

Factors affecting the duration of exclusive breastfeeding among HIV-infected and -uninfected women in Lusaka, Zambia

Exclusive breastfeeding (EBF) is optimal for infant health and is associated with decreased risk of mother-to-child HIV transmission compared with mixed feeding of breast milk and other foods. To investigate why many women stop EBF before the recommended 6 months, maternal and infant health and infant-feeding data were collected from 177 HIV-infected and 177-uninfected Zambian women regularly from 34 weeks gestation to 16 weeks postpartum. Despite strong support for good breastfeeding practice, only 37% of women were still EBF at week 16. Factors significantly associated with shorter duration of EBF were primiparity, maternal systemic illness, and infant length at 6 weeks. The results suggest that the association of EBF with lower rates of mother-to-child HIV transmission may not be causal but may be secondary to the reduced duration of EBF associated with poor maternal or infant health. Programs supporting EBF should include support for maternal health.

Effects of volumetric vs. pressure-guided fluid therapy on postoperative inflammatory response: a prospective, randomized clinical trial

OBJECTIVE

To compare intrathoracic blood volume (ITBV) guided fluid management and central venous pressure (CVP) guided therapy in ameliorating the progression of early systemic inflammatory response in patients undergoing major surgery.

DESIGN

Prospective, randomized clinical trial.

PATIENTS

Forty patients undergoing major abdominal surgery were randomized into CVP and ITBV groups.

INTERVENTIONS

In the CVP group the target CVP was 8-12 mmHg while in the ITBV group the goal was to keep the ITBV between 850 and 950 ml/m2 during the operation.

MEASUREMENTS AND RESULTS

Hemodynamic parameters were determined by single arterial thermodilution. Measurements were repeated every 30 min intraoperatively. Serum procalcitonin (PCT) and C-reactive protein (CRP) was monitored preoperatively, on ICU admission, and then daily for 3 days. Serum TNF-alpha levels were measured intraoperatively hourly and then daily for 3 days. There was no significant difference between the two groups regarding hemodynamic parameters at any assessment point. In the overall population changes in the stroke volume index showed a significant correlation with changes in CVP and ITBV. TNF-alpha levels remained in the normal range intraoperatively and during the three postoperative days in both groups. Preoperatively normal PCT and CRP levels increased significantly postoperatively, without significant differences between the groups.

CONCLUSIONS

ITBV guided fluid therapy did not alter the magnitude of inflammatory response as monitored by serum PCT, CRP, and TNF-alpha in the early postoperative period.