A comparison of the predictive validity of the combination of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and other risk scoring systems for intravenous immunoglobulin (ivig)-resistance in Kawasaki disease

Novel predictors of intravenous immunoglobulin resistance in patients with Kawasaki disease: a retrospective study

Objective

The aim of this study was to investigate the predictive value of systemic immune inflammation index (SII), systemic inflammatory response index (SIRI), and pan-immune inflammation value (PIV) in predicting intravenous immunoglobulin (IVIG) resistance in children diagnosed with Kawasaki disease (KD).

Methods

The clinical data of pediatric patients diagnosed with Kawasaki disease and admitted to our hospital between January 2006 and December 2022 were retrospectively analyzed.

Results

In total, 771 children diagnosed with KD were included in this study, 86 (11.2%) of whom were diagnosed with IVIG resistance. The correlation between SII, SIRI, PIV and IVIG resistance was evaluated using univariate testing, binary logistic regression analysis, and receiver operating characteristic (ROC) curve analysis. Our study found that the SII, SIRI, and PIV were independent risk factors (p=0.001, p<0.001, and p=0.02, respectively). The area under the ROC curve (AUC) values of the SII, SIRI, and PIV were 0.626 (95% confidence interval (CI): 0.553-0.698, p<0.001), 0.571 (95% CI: 0.500-0.642, p=0.032), and 0.568 (95% CI: 0.495-0.641, p=0.040), respectively, and the cutoff values were 2209.66, 3.77, and 1387.825, respectively.

Conclusion

The SII, SIRI, and PIV have potential value in predicting IVIG resistance in patients with KD.

C-reactive protein to albumin ratio as a prognostic tool for predicting intravenous immunoglobulin resistance in children with kawasaki disease: a systematic review of cohort studies

BACKGROUND

Intravenous immunoglobulin (IVIG) is the primary treatment for Kawasaki disease (KD). However, 10-20% of KD patients show no response to IVIG treatment, making the early prediction of IVIG resistance a key focus of KD research. Our aim is to explore the application of the C-reactive protein to albumin ratio (CAR) for predicting IVIG resistance in children with KD through meta-analysis.

METHODS

Cochrane Library, PubMed, MEDLINE, EMbase, CNKI, WanFang, the Chinese Biomedical Database, and CQVIP were searched up to November 2023 for cohort studies on predicting IVIG-resistant KD using the CAR. Articles were selected based on pre-established inclusion and exclusion criteria after extracting literature data and assessing them using the QUADAS-2.0 tool for evaluating the accuracy of diagnostic tests. Stata 15.0 software was used for meta-analysis.

RESULTS

Four Chinese and English literature reports were included in this meta-analysis. The results revealed the presence of a threshold effect and high heterogeneity among the included studies. The combined sensitivity for CAR predicting IVIG-resistant KD was calculated as 0.65 (95% CI 0.58-0.72), specificity as 0.71 (95% CI 0.57-0.81), and the area under the curve (AUC) as 0.70 (95% CI 0.66-0.74) using the random-effects model. The combined positive likelihood ratio was 2.22 (95% CI 1.35-3.65), the combined negative likelihood ratio was 0.49 (95% CI 0.35-0.69), and the diagnostic odds ratio was 5 (95% CI 2-10).

CONCLUSION

CAR is an auxiliary predictive indicator with moderate diagnostic value that provides guidance in the early treatment of the disease, demonstrating a certain predictive value that warrants further investigation. However, CAR cannot yet be considered as a definitive diagnostic or exclusionary marker for IVIG-resistant KD. Therefore, multi-center, large sample, and high-quality long-term follow-up trials are warranted to confirm the current findings.

Intravenous immunoglobulin resistance in Kawasaki disease patients: prediction using clinical data

BACKGROUND

About 10-20% of Kawasaki disease (KD) patients are resistant to the initial infusion of intravenous immunoglobin (IVIG). The aim of this study was to assess whether IVIG resistance in KD patients could be predicted using standard clinical and laboratory features.

METHODS

Data were from two cohorts: a Korean cohort of 7101 KD patients from 2015 to 2017 and a cohort of 649 KD patients from San Diego enrolled from 1998 to 2021. Features included laboratory values, the worst Z-score from the initial echocardiogram or during hospitalization, and the five clinical KD signs at presentation.

RESULTS

Five machine learning models achieved a maximum median AUC of 0.711 [IQR: 0.706-0.72] in the Korean cohort and 0.696 [IQR: 0.609-0.722] in the San Diego cohort during stratified 10-fold cross-validation using significant laboratory features identified from univariate analysis. Adding the Z-score, KD clinical signs, or both did not considerably improve the median AUC in either cohort.

CONCLUSIONS

Using commonly measured clinical laboratory data alone or in conjunction with echocardiographic findings and clinical features is not sufficient to predict IVIG resistance. Further attempts to predict IVIG resistance will need to incorporate additional data such as transcriptomics, proteomics, and genetics to achieve meaningful predictive utility.

IMPACT

We demonstrated that laboratory, echocardiographic, and clinical findings cannot predict intravenous immunoglobin (IVIG) resistance to a clinically meaningful extent using machine learning in a homogenous Asian or ethnically diverse population of patients with Kawasaki disease (KD). Visualizing these features using uniform manifold approximation and projection (UMAP) is an important step to evaluate predictive utility in a qualitative manner. Further attempts to predict IVIG resistance in KD patients will need to incorporate novel biomarkers or other specialized features such as genetic differences or transcriptomics to be clinically useful.

Nomogram for predicting coronary artery lesions in patients with Kawasaki disease

BACKGROUND

Coronary artery lesions are the most important complications of Kawasaki disease. Approximately 25-30% of untreated patients develop coronary artery disease, which can lead to long-term cardiovascular sequelae.

AIM

The aim of this study is to evaluate the risk factors for coronary artery lesions in Kawasaki disease and to construct a nomogram for predicting the likelihood of developing such lesions.

METHODS

Data from 599 patients between January 2012 and June 2020 were reviewed retrospectively. Patients were randomly assigned to the training set (n = 450) and the validation set (n = 149). A comparison of clinical features and laboratory data was performed, followed by multivariate logistic regression analysis to identify independent risk factors and develop the nomogram. The predictive efficiency of the nomogram was evaluated using the calibration curve, area under the receiver operating characteristic curve (AUC), C-index, and decision curve analysis (DCA).

RESULTS

Intravenous immunoglobulin (IVIG) resistance, delayed IVIG treatment, C-reactive protein, and neutrophil/lymphocyte ratio were identified as independent risk factors for the development of coronary artery lesions. The nomogram was constructed based on these four variables. The calibration curve of the nomogram showed a high degree of agreement between the predicted probability and the actual probability. The AUC of the nomogram in the training and validation set was 0.790 and 0.711, respectively. In addition, DCA revealed that the nomogram provided a significant net benefit, further supporting its clinical utility.

CONCLUSIONS

The constructed nomogram demonstrates a strong and reliable performance in predicting coronary artery lesions, which enables clinicians to make timely and tailored clinical decisions.

Serum IL-41 might be a biomarker for IVIG resistance and coronary artery lesions in Kawasaki disease

BACKGROUND

This study aimed to evaluate serum IL-41 levels in IVIG resistance and CALs, and to elucidate the relationship between IL-41 and Kawasaki disease (KD)-related clinical parameters.

METHODS

93 children with KD were collected. Baseline clinical data were obtained by physical examination. Serum IL-41 levels were detected with an enzyme-linked immunosorbent assay. The correlations between IL-41 and the clinical parameter of KD were performed by Spearman correlation coefficient. Receiver operating characteristic curve analysis was performed to assess the predictive ability of IL-41 for IVIG resistance and CALs.

RESULTS

Serum IL-41 levels were significantly increased in the IVIG resistance group compared with the response group, and serum IL-41 levels in the CALs group were higher than those in the non-CALs group. Serum IL-41 levels were positively correlated with erythrocyte sedimentation rate, C-reactive protein and C-reactive protein/albumin ratio, but negatively correlated with albumin. Serum IL-41 levels was an independent risk factor for CALs, and total fever days and neutrophil-to-lymphocyte ratio (NLR) were independent predictors for IVIG resistance. The area under the curve (AUC) value for serum IL-41 to predict IVIG resistance was 0.73, yielding a sensitivity of 54.55% and a specificity of 81.71%. The AUC of serum IL-41 was 0.712, with a sensitivity of 63.16% and a specificity of 72.97% for predicting CALs. IL-41 was not inferior to NLR in predicting IVIG resistance (z = 0.282, p = 0.7783).

CONCLUSIONS

Serum IL-41 was increased in IVIG resistance and CALs. Serum IL-41 might be a new potential biomarker for IVIG resistance and CALs.

A machine learning model for distinguishing Kawasaki disease from sepsis

KD is an acute systemic vasculitis that most commonly affects children under 5 years old. Sepsis is a systemic inflammatory response syndrome caused by infection. The main clinical manifestations of both are fever, and laboratory tests include elevated WBC count, C-reactive protein, and procalcitonin. However, the two treatments are very different. Therefore, it is necessary to establish a dynamic nomogram based on clinical data to help clinicians make timely diagnoses and decision-making. In this study, we analyzed 299 KD patients and 309 sepsis patients. We collected patients' age, sex, height, weight, BMI, and 33 biological parameters of a routine blood test. After dividing the patients into a training set and validation set, the least absolute shrinkage and selection operator method, support vector machine and receiver operating characteristic curve were used to select significant factors and construct the nomogram. The performance of the nomogram was evaluated by discrimination and calibration. The decision curve analysis was used to assess the clinical usefulness of the nomogram. This nomogram shows that height, WBC, monocyte, eosinophil, lymphocyte to monocyte count ratio (LMR), PA, GGT and platelet are independent predictors of the KD diagnostic model. The c-index of the nomogram in the training set and validation is 0.926 and 0.878, which describes good discrimination. The nomogram is well calibrated. The decision curve analysis showed that the nomogram has better clinical application value and decision-making assistance ability. The nomogram has good performance of distinguishing KD from sepsis and is helpful for clinical pediatricians to make early clinical decisions.

The use of neutrophil-lymphocyte ratio for the prediction of refractory disease and coronary artery lesions in patients with Kawasaki disease

BACKGROUND

Kawasaki disease is a vasculitis that can lead to cardiac complications, including coronary artery disease and cardiogenic shock. Various scoring systems have been developed to determine those that will be refractory to routine intravenous immunoglobulin therapy or develop coronary artery disease. The objective of this study was to determine if the neutrophil-lymphocyte ratio could predict refractory disease and coronary artery lesions in patients with Kawasaki disease.

METHODS

A systematic review of the literature was performed to identify manuscripts describing comparisons of neutrophil-lymphocyte ratio between those who had refractory disease and those who did not, and between those who developed coronary artery lesions and those who did not. Mean difference was compared between groups. Areas under the curve were utilised to determine the pooled area under the curve.

RESULTS

12 studies with 5593 patients were included in the final analyses of neutrophil-lymphocyte ratio for the prediction of refractory disease. Neutrophil-lymphocyte ratio before therapy was higher in refractory disease with a mean difference of 2.55 (p < 0.01) and pooled area under the curve of 0.724. Neutrophil-lymphocyte ratio after therapy was higher in refractory disease with a mean difference of 1.42 (p < 0.01) and pooled area under the curve for of 0.803. Five studies with 1690 patients were included in the final analyses of neutrophil-lymphocyte ratio for the prediction of coronary artery lesions. Neutrophil-lymphocyte ratio before therapy was higher in coronary artery lesions with a mean difference of 0.65 (p < 0.01).

CONCLUSION

The use of neutrophil-lymphocyte ratio may help physicians in the identification of patients at risk of refractory disease and coronary artery lesions in patients with Kawasaki disease.

A novel model for predicting intravenous immunoglobulin-resistance in Kawasaki disease: a large cohort study

Background

Predicting intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) can aid early treatment and prevent coronary artery lesions. A clinically consistent predictive model was developed for IVIG resistance in KD.

Methods

In this retrospective cohort study of children diagnosed with KD from January 1, 2016 to December 31, 2021, a scoring system was constructed. A prospective model validation was performed using the dataset of children with KD diagnosed from January 1 to June 2022. The least absolute shrinkage and selection operator (LASSO) regression analysis optimally selected baseline variables. Multivariate logistic regression incorporated predictors from the LASSO regression analysis to construct the model. Using selected variables, a nomogram was developed. The calibration plot, area under the receiver operating characteristic curve (AUC), and clinical impact curve (CIC) were used to evaluate model performance.

Results

Of 1975, 1,259 children (1,177 IVIG-sensitive and 82 IVIG-resistant KD) were included in the training set. Lymphocyte percentage; C-reactive protein/albumin ratio (CAR); and aspartate aminotransferase, sodium, and total bilirubin levels, were risk factors for IVIG resistance. The training set AUC was 0.825 (sensitivity, 0.723; specificity, 0.744). CIC indicated good clinical application of the nomogram.

Conclusion

The nomogram can well predict IVIG resistance in KD. CAR was an important marker in predicting IVIG resistance in Kawasaki disease.

The state of play in tools for predicting immunoglobulin resistance in Kawasaki disease

INTRODUCTION

Intravenous immunoglobulin (IVIG) resistance is an independent risk factor for the development of coronary artery lesions (CAL) in patients with Kawasaki disease (KD). Accurate identification of IVIG-resistant patients is one of the biggest clinical challenges in the treatment of KD.

AREAS COVERED

In this review article, we will go over current IVIG resistance scoring systems and other biological markers of IVIG resistance, with a particular focus on advances in machine-based learning techniques and high-throughput omics data.

EXPERT OPINION

Traditional scoring models, which were developed using logistic regression, including the Kobayashi score and Egami score, are inadequate at identifying IVIG resistance in non-Japanese populations. Newer machine-learning methods and high-throughput technologies including transcriptomic and epigenetic arrays have identified several potential targets for IVIG resistance including gene expression of the Fc receptor, and components of the interleukin (IL)-1β and pyroptosis pathways. As we enter an age where access to big data has become more commonplace, interpretation of large data sets that are able take into account complexities in patient populations will hopefully usher in a new era of precision medicine, which will enable us to identify and treat KD patients with IVIG resistance with increased accuracy.

Evaluation of Formosa score and diagnostic sensitivity and specificity of four Asian risk scores for predicting intravenous immunoglobulin resistance in Kawasaki disease: a bivariate meta-analysis

Background

In 2016, Lin et al. developed a prediction score of non-responsiveness to intravenous immunoglobulin (IVIG) in patients with Kawasaki disease (KD) (Lin et al., 2016). Various studies have attempted to validate the Formosa score, but inconsistent results have given us new opportunities and challenges. The aim of this meta-analysis is to explore the role of the Formosa score as a risk score in detecting IVIG-resistant KD patients and then compare the pooled sensitivity and specificity of four Asian risk scores, Egami, Formosa, Kobayashi, and Sano risk scores.

Methods

A comprehensive search of Cochrane, Embase, and PubMed was conducted through 20 December 2021, using key terms relevant to the research question "What are the sensitivities and specificities of the four Asian predicting scores, Egami, Formosa, Kobayashi, and Sano, in Kawasaki disease patients with IVIG resistance?" The reference lists of the included studies were manually reviewed to identify pertinent references. A random-effects bivariate model was used to estimate the summary of sensitivity and specificity of the tools.

Results

We found 41 relevant studies of the four Asian risk scores that were eligible to analyze for pooled accuracy. Eleven studies involving 5,169 KD patients reported the diagnostic performance of the Formosa score for the risk of IVIG resistance. The overall performance of the Formosa score was as follows: pooled sensitivity, 0.60 [95% confidence interval (CI), 0.48-0.70]; pooled specificity, 0.59 (95% CI, 0.50-0.68); and area under the hierarchical summary receiver operating characteristic curve, 0.62. The Formosa score exhibited the highest sensitivity 0.76 (95% CI, 0.70-0.82) for detecting IVIG-resistant KD patients among the 21,389 children included in the 41 studies. In terms of specificity estimates, Formosa had the lowest specificity of 0.46 (95% CI, 0.41-0.51).

Conclusion

Patients at high risk for IVIG resistance may receive adjunctive treatment to reduce coronary lesions and thus also cardiovascular morbidity. Among all of the included studies, we found Formosa score to have the best sensitivity (0.76) but unsatisfactory specificity (0.46) for predicting IVIG resistance in Kawasaki disease. In the future, network meta-analysis should also incorporate the accuracy of the new scores after they have undergone a certain degree of validation around the world.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO CRD42022341410.

Elevated Neutrophil-to-Lymphocyte Ratio Is Associated with Severe Asthma Exacerbation in Children

Asthma is the most common chronic respiratory disease in children. The neutrophil-to-lymphocyte ratio (NLR) is a marker of a chronic inflammatory state; however, data on the association of NLR with acute asthma exacerbations in children is lacking. In this cross-sectional study, between 2016 and 2021, children aged 2-18 years who were referred to the emergency department (ED) due to asthma exacerbation, were included. NLR, calculated from complete blood count upon arrival, was assessed as a continuous variable and was classified into four groups according to quartiles. The association between severity parameters and NLR quartiles was examined. A total of 831 ED visits for asthma exacerbation were included in the study. The median NLR was 1.6, 3.8, 6.7, and 12.9 in quartiles 1-4, respectively (p < 0.001). Demographic parameters, background diseases, and chronic medications were similar between the quartiles. Higher heart rate, body temperature, systolic blood pressure, and respiratory rate were observed in the higher NLR quartiles, as well as lower oxygen saturation. Higher urgency scale and higher rates of intravenous magnesium sulfate were observed in the higher NLR quartiles, with higher admission rates and prolonged hospitalizations. In summary, NLR upon admission is associated with the severity of asthma exacerbation and higher chances of hospitalization among children in the ED.

Is There a Role for Laboratory Parameters in Predicting Coronary Artery Involvement in Kawasaki Disease?

BACKGROUND

Kawasaki disease (KD) may cause cardiac and coronary complications. Since definite markers to accurately predict coronary involvement is not present, we aimed to analyze the role of hematological indices [neutrophil-to lymphocyte ratio (NLR), platelet-to lymphocyte ratio (PLR), lymphocyte-to monocyte ratio (LMR), and mean platelet volume (MPV)-to lymphocyte ratio (MPVLR)], prognostic nutritional index (PNI) and systemic immune-inflammation index (SII) in predicting coronary involvement of KD. Patients The medical records of 134 KD patients admitted between January 2008 and December 2019 were investigated. Also, 268 age-matched healthy controls (HCs) were included in the study.

METHODS

KD patients were divided into two groups: KD with coronary artery lesions (KD-CALs) and KD without CALs. Logistic regression analysis was performed to determine parameters that may predict coronary involvement in children with KD.

RESULTS

Among KD patients, 39 (29.1%) had CALs. When compared with HCs, the median levels of WBC, neutrophils, monocytes, eosinophils, platelets, MPV and, the values of NLR, PLR, MPVLR, SII were significantly higher; whereas lymphocyte count, PNI, platelet distribution width (PDW), LMR were markedly lower in the KD group (p˂0.001 for all, except for p=0.010 for eosinophil count). The CALs group's SII, PLR, and PNI values were significantly lower than those without (p=0.030, p=0.032, and p ˂0.001; respectively). Multivariable regression analysis revealed that PNI, SII, and gender (male) were associated with CALs in KD.

CONCLUSION

Our analysis revealed that male sex, lower PNI, and lower SII levels were independently associated with CALs in children with KD.

Establishment and Validation of a Multivariate Predictive Scoring Model for Intravenous Immunoglobulin-Resistant Kawasaki Disease: A Study of Children From Two Centers in China

Background

Early identification of intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) is important for making a suitable therapeutic strategy for children with KD.

Methods

This study included a training set and an external validation set. The training set included 635 children (588 IVIG-sensitive and 47 IVIG-resistant KD) hospitalized in Wuhan Children’s Hospital, Hubei, China. Univariate analyses and binary logistic regression equation was incorporated to find the associated variables of the IVIG-resistant KD. A scoring model for predicting IVIG-resistant KD was established according to odds ratio (OR) values and receiver operating characteristic curves. The external validation set consisted of 391 children (358 IVIG-sensitive and 33 IVIG-resistant KD) hospitalized in Peking University First Hospital, Beijing, China. The predictive ability of the model of IVIG-resistant KD were externally validated by the real clinically diagnosed KD cases.

Results

Fifteen variables in the training set were statistically different between IVIG-sensitive and IVIG-resistant KD children, including rash, duration of fever, peripheral blood neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), percentage of monocytes and percentage of eosinophils, and serum alanine aminotransferase, aspartate aminotransferase, total bilirubin (TB), direct bilirubin, glutamyl transpeptidase, prealbumin, sodium ion, potassium ion and high-sensitivity C-reactive protein. According to logistic equation analysis, the final three independent correlates to IVIG-resistant KD were serum TB ≥ 12.8 μmol/L, peripheral blood NLR ≥ 5.0 and peripheral blood PNI ≤ 52.4. According to the OR values, three variables were assigned the points of 2, 2 and 1, respectively. When the score was ≥ 3 points, the sensitivity to predict IVIG-resistant KD was 80.9% and the specificity was 77.6%. In the validation set, the sensitivity, specificity and accuracy of the predictive model of IVIG-resistant KD were 72.7%, 84.9%, and 83.9%, respectively.

Conclusion

A scoring model was constructed to predict IVIG-resistant KD, which would greatly assist pediatricians in the early prediction of IVIG-resistant KD.

Refractory Kawasaki disease: modified methylprednisolone regimen decreases coronary artery dilatation

BACKGROUND

The use of corticosteroids in Kawasaki disease (KD) is still controversial. The aim of this study was to investigate the safety and effectiveness of modified methylprednisolone (mPSL) regimen as an initial treatment for refractory KD.

METHODS

This is a real-world observational study. We identified refractory KD with a self-developed scoring system. Patients were divided into the intravenous immunoglobulin (IVIG) + mPSL group and the IVIG group. Clinical outcomes and changes in coronary arteries after the treatment during a 12-week period were observed. Propensity-score matching was used to analyze those patients with similar baseline characteristics.

RESULTS

Of a total of 168 patients, 104 patients were assigned into the IVIG group and 64 patients into the IVIG + mPSL group. The therapeutic response rate of the IVIG + mPSL group was significantly higher than that of the IVIG group (98.4 vs 76.0%, P < 0.05). The IVIG + mPSL group had a shorter duration of fever and a higher rate of C-reactive protein decline than the IVIG group (1.17 ± 0.64 vs 1.81 ± 1.16 days; 88.1 vs 83.5%; P < 0.05). The luminal diameter and Z-score of the left circumflex coronary artery (LCX) were significantly smaller and lower in the IVIG + mPSL group than that in the IVIG group at weeks 2 and 12.

CONCLUSIONS

Modified mPSL regimen has minimal side effects. It might improve the initial response to IVIG and decrease the dilation of LCX for refractory KD.

IMPACT

Modified mPSL regimen (2-4 mg/kg/day, divided into 2-3 doses for 3-5 days, then 1 mg/kg/day, once a day for 3-5 days, then oral prednisone was tapered over 3-5 weeks in 5-7 days steps) as an intensive initial treatment can decrease LCX dilation in high-risk IVIG-resistant KD patients. Our self-developed scoring system has been proven validated and can be used to identify high-risk IVIG-resistant KD patients in North China. The present study provides an alternative therapeutic regimen for high-risk refractory KD patients.

Multiple intravenous antibiotics usage is associated with intravenous immunoglobulin resistance in Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is a form of systemic vasculitis that primarily affects children under the age of 5 years old. Antibiotics are often prescribed for KD patients even before a diagnosis is made due to their prolonged fever and elevated inflammatory markers. Therefore, the purpose of this study was to investigate the impact of antibiotics usage on the disease outcome of KD.

METHODS

We carried out a retrospective chart review of children between 2005 and 2017 for initial immunoglobulin (IVIG) treatment of KD. KD children with initial IVIG treatment more than 10 days after the onset of symptoms were excluded.

RESULTS

In total, 280 children were eligible for this study, among which 209 had been treated with antibiotic(s) and 71 had not been. The IVIG resistance rates were 5.6% (4/71), 8.9% (10/112), and 21.6% (21/97) in non-users, single-drug users, and multiple-drug users, respectively (r = 0.205, p = 0.003). The IVIG resistance rate of the multiple antibiotics drug users in KD patients was significantly higher than the other two groups. Furthermore, the likelihood of IVIG resistance was found to increase with elevated C-reactive protein (CRP) values (1.010/unit, p < 0.001) but not with total white blood cell (WBC) count (p = 0.466).

CONCLUSION

The probability of IVIG resistance increases with elevated CRP values and the use of multiple IV antibiotics, thus indicating that physicians should be prudent in administering multiple IV antibiotics when treating assumed infections in KD children.

Predictive Role of IL-2R and IL-10 in the Anti-inflammatory Response and Antiplatelet Therapy of Kawasaki Disease: A Retrospective Study

To date, Kawasaki disease (KD) has only been able to be diagnosed and evaluated using clinical characteristics. Additionally, the therapeutic effect and cardiovascular complications could not be verified until its occurrence. The present retrospective study analyzed the dynamic alterations of inflammatory cytokines, platelet (PLT) count, and subgroups of lymphocytes, such as cluster of differentiation (CD) 8+ T cells and CD19+ B cells, under different conditions in 64 children with KD. The percentage distribution of lymphocyte subgroups and the altered neutrophil lymphocyte ratio demonstrated that the inflammatory response was dominated by the B cell-mediated humoral immune response before intravenous immunoglobulin (IVIG) treatment, but mainly by T cells via cellular cytotoxic effects after IVIG treatment. Among the different types of inflammatory cytokines, the results of the present study revealed that the altered levels of interleukin-2 receptor (IL-2R) and interleukin-10 (IL-10) were closely associated with the percentage of CD8+ T cells and CD19+ B cells. Additionally, the two cytokines exhibited more sensitive fluctuations based on the status of the children with KD in various circumstances compared with other indexes, such as the percentages of CD8+ T cells and CD19+ B cells or the PLT count. These results suggested that children with KD who are ≥4 years old may benefit from IVIG but will not benefit from decreased platelet activation or suffer less cardiovascular complications. Additionally, starting clopidogrel usage earlier as an antiplatelet strategy should be considered based on the observed continuous rise in the PLT count in children with KD receiving IVIG. In conclusion, dynamically monitoring the levels of IL-2R and IL-10 has the potential to provide indications of the intensity and development of the inflammatory response in children with KD and may contribute to the early prediction and adjustment of pathological and pharmacological effects of therapy.

Value of blood inflammatory markers for predicting intravenous immunoglobulin resistance in Kawasaki disease: A systematic review and meta-analysis

BACKGROUND

Previous studies have assessed the diagnostic accuracy of blood inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP), and CRP to albumin ratio (CAR) to predict the resistant Kawasaki disease (KD). The aim of the current meta-analysis and systematic review is to compare the prognostic ability of these inflammatory markers to predict the resistance to IVIG in patients with Kawasaki disease.

METHODS

A systematic search of online academic databases and search engines such as EMBASE, PubMed Central, MEDLINE, Cochrane library, Google Scholar, and ScienceDirect was conducted for papers that report the diagnostic accuracy of inflammatory markers for resistant KD. Meta-analysis was performed using STATA software.

RESULTS

Twenty-two studies met the inclusion criteria. Pooled sensitivity and specificity of NLR as a predictor of resistant Kawasaki disease was 72% (95% CI: 62%, 80%) and 71% (95% CI: 63%, 78%), with AUC of 0.77 for PLR was 60% (95% CI: 50%, 69%) and 68% (95% CI: 61%, 75%), with area under the curve (AUC) of 0.69. Pooled sensitivity and specificity of CRP was 75% (95% CI: 68%, 81%) and 66% (95% CI: 55%, 76%), respectively, with an AUC value of 0.78. Pooled sensitivity and specificity of combined NLR and PLR was 58% (95% CI: 46%, 69%) and 73% (95% CI: 65%, 79%), respectively, with an AUC value of 0.72.

CONCLUSION

Our study found that NLR, CRP, PLR, and combined NLR/PLR have a good prognostic value in patients with resistant Kawasaki disease, with moderate to high sensitivity and specificity. More research on the accuracy of these indexes in multiple combinations is needed.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322165].

Predictive Value of the Systemic Immune-Inflammation Index for Intravenous Immunoglobulin Resistance and Cardiovascular Complications in Kawasaki Disease

Background: The prediction of intravenous immunoglobulin (IVIG) resistance and cardiovascular complications are critically clinical issues in Kawasaki disease (KD). This prospective study firstly aimed to determine the predictive ability of the systemic immune inflammation index (SII) for IVIG resistance and cardiovascular complications and compare the prognostic accuracy of SII with that of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR).

Methods: Patients with KD were divided into different groups according to the presence of IVIG resistance or cardiovascular complications (coronary artery lesions, valve regurgitation, myocarditis, pericardial effusion, and Kawasaki disease shock syndrome [KDSS]). The clinical and laboratory parameters were compared. Further analysis stratified by platelet level was performed. Multivariate logistic regression analysis was used to identify predictors for IVIG resistance and cardiovascular complications. The receiver operating characteristic (ROC) curve was applied to assess and compare the ability of SII, NLR, and PLR for predicting IVIG resistance and cardiovascular complications.

Results: SII was significantly higher in KD patients with IVIG-resistance, myocarditis, valve regurgitation, and KDSS. It was identified as an independent risk factor for IVIG resistance, myocarditis, and valve regurgitation. For KD patients with thrombocytopenia, there were no significant differences in SII between KD patients with IVIG resistance/cardiovascular complications and those without. The best cutoff values of SII for IVIG resistance, myocarditis, valve regurgitation, and KDSS prediction in the whole cohort were 1331.4 × 10⁹, 1368.6 × 10⁹, 1002.4 × 10⁹, and 1485.4 × 10⁹, with a corresponding sensitivity of 0.525, 0.614, 0.754, and 0.670, a specificity of 0.711, 0.723, 0.584, and 0.730, respectively. The predictive value of SII for both IVIG resistance and cardiovascular complications were not superior to that of NLR.

Conclusion: Although the parameter of SII may predict IVIG resistance, myocarditis, valve regurgitation, and KDSS in KD as a single parameter, its predictive ability was not good enough and not superior to NLR. SII might not be applicable in patients with KD having thrombocytopenia.

Association between adropin and coronary artery lesions in children with Kawasaki disease

Kawasaki disease (KD) is an acute systemic vasculitis in children. Coronary artery lesions (CALs) are the most serious complications in KD, but the pathogenesis is still unclear so far. Adropin, a new biopeptide, plays an important role in metabolism and cardiovascular function. The aim of this study was to explore the relationship between adropin and KD. 66 KD patients and 22 healthy controls (HCs) were included in the study. KD patients were divided into KD with coronary artery lesions (KD-CALs) group and KD without CALs (KD-NCALs) group. The levels of serum adropin were determined by enzyme-linked immunosorbent assay (ELISA). Compared with the HC group, adropin concentrations were significantly increased in the KD group (p < 0.05), and the KD-CAL group had higher levels of adropin than those in the KD-NCAL group (p < 0.05). Pct (Procalcitonin) and DD (D-dimer) were positively correlated with adropin in the KD group (p < 0.05). Moreover, adropin had positive correlations with CRP (C-reactive protein) and DD in the KD-NCAL group and positive correlations with Pct, PLR (platelet-to-lymphocyte ratio), and DD in the KD-CAL group (p < 0.05). The receiver operating characteristic (ROC) curve showed that the best threshold value of serum adropin level was more than 2.8 ng/mL, with 72.2% sensitivity and 71.4% specificity for predicting CALs in children with KD.Conclusion: Adropin might be involved in the pathogenesis of KD and CALs and can be used as an auxiliary diagnostic biomarker of KD. What is Known: • CALs in KD were mainly caused by inflammation, immune imbalance, and vascular endothelial dysfunction, and adropin is involved in metabolic diseases and cardiovascular diseases. What is New: • In this study, we have found the relationship between adropin and KD, and serum adropin level can be used as an auxiliary diagnostic biomarker to predict CALs in KD.

Prognostic value of pretreatment prognostic nutritional index in intravenous immunoglobulin-resistant Kawasaki disease

The aim of the present study was to investigate the potential predictive significance of pretreatment prognostic nutritional index (PNI) in intravenous immunoglobulin (IVIG) resistant Kawasaki disease (KD). The PNI, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were analyzed in 1257 eligible patients with KD. Receiver operating curve analysis was used to explore the prediction accuracy for IVIG-resistant KD. The optimal cut-off values were identified as 49.5 for PNI, 3.58 for NLR and 164.00 for PLR, respectively. Lower pretreatment PNI (< 49.5) was demonstrated to be associated with lower age, serum sodium levels and platelet counts, and with a higher incidence of IVIG resistance and higher C-reactive protein levels. There was a significantly negative association between the PNI and NLR, and PLR. Univariate and multivariate analyses revealed that PNI, NLR and PLR were independent predictive factors for IVIG resistance. The discriminatory ability of PNI was not inferior to NLR, PLR and their combination (NLR > 3.58 and PLR > 164) for predicting IVIG resistance, respectively. Pretreatment PNI may serve as a novel surrogate independent predictor for IVIG-resistant KD.

Kawasaki disease: Shedding light on a mysterious diagnosis

Kawasaki disease is an acute systemic febrile vasculitis of medium and small arteries, most often occurring in children under age 5 years. This condition is the most common cause of acquired heart disease in children in the developed world. The cause is unclear but is thought to be a hyperimmune reaction to an infectious agent. Diagnosis is clinical; the classic presentation includes persistent fever, lymphadenopathy, oral mucosal changes, conjunctivitis, and rash. Although the disease technically is self-limiting, treatment with IV immunoglobulin (IVIG) and high-dose aspirin is necessary to prevent cardiac complications, such as coronary artery aneurysm, pericarditis, or myocarditis. This article reviews the pathophysiology, clinical presentation, diagnosis, and treatment of Kawasaki disease.

The Relationship between Retinol-Binding Protein 4 and Markers of Inflammation and Thrombogenesis in Children with Kawasaki Disease

Background

Kawasaki disease (KD) is a self-limited vasculitis with unknown etiologies, and coronary artery lesions (CALs) are the most common and serious complications. Retinol-binding protein 4 (RBP4) has been confirmed effects on vasodilation, platelet activation inhibition, and cardiovascular diseases by researches. Therefore, this study was aimed at investigating the relationship between RBP4 and inflammation as well as thrombogenesis in children with KD.

Methods

79 subjects were from 62 children with KD and 17 healthy controls (HCs). The KD group was divided into KD with CALs (KD-CALs) and KD without CALs (KD-NCALs), and the serum RBP4 levels were measured by enzyme-linked immunosorbent assay (ELISA).

Results

Compared with the HC group, serum RBP4 levels in the KD group were significantly decreased (p < 0.05). RBP4, hemoglobin (Hb), and mean platelet volume (MPV) levels were higher, while platelet counts (Plt) and thrombin time (TT) levels were lower in the KD-NCALs group than in the KD-CALs group (p < 0.05). RBP4 had positive correlation with time point of intravenous immunoglobulin (IVIG), Hb, and percentage of leukomonocytes (L%) and negative correlation with the percentage of neutrophils (N%), MPV, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), prothrombin time (PT), fibrinogen (Fbg), and D-dimer (DD) in the KD group; RBP4 had positive correlation with the time point of IVIG and L% and negative correlation with N%, MPV, and NLR in the KD-NCALs group; and RBP4 had positive correlation with Hb and L% and negative correlation with N%, CRP, NLR, and PT in the KD-CALs group (p < 0.05). Multiple linear regression analysis confirmed that Hb and CRP in the KD group, MPV and N% in the KD-NCALs group, and PT and CRP in the KD-CALs group were independent predictors of RBP4 (p < 0.05).

Conclusion

Lower RBP4 was observed in the KD group than in the HC group, and RBP4 had associations with markers of inflammation and thrombogenesis in children with KD.

Changes in Peripheral Blood Neutrophils, Lymphocytes and IL-10 in Children with Kawasaki Disease from Different Age Groups Undergoing Intravenous Immunoglobulin: A Retrospective Study

Immunoglobulin intravenous (IVIG) is widely used in mucocutaneous lymph node syndrome, known as Kawasaki disease (KD). However, the patients' inflammatory response during usage remains unclear. In the present study, the association between inflammatory response and lymphocyte count in children with KD from different ages was evaluated before and after IVIG. The medical records of 50 children with KD were retrospectively reviewed and divided into five groups according to age. As compared with the data from healthy children, the relative neutrophil count of all children with KD was increased, and that of lymphocytes was decreased. The neutrophil/lymphocyte ratio (NLR) was different among all groups and was higher in children aged ≥4 years, as compared with other groups. Following IVIG, the relative neutrophil and lymphocyte counts of all children with KD returned to normal levels. The altered levels of neutrophils and lymphocytes were found to be linearly correlated. The correlation coefficient in the five groups was 0.99, 0.87, 0.91, 0.97 and 0.99, from young to old, respectively (p < 0.01). The age of children with KD was positively correlated with older age (r = 0.91, p = 0.03). In patients aged ≥4 years, the absolute CD19⁺ B cell count prior to IVIG increased, and that increase was linearly correlated with the decrease in interleukin-10 (IL-10) following IVIG (r = 0.71, p < 0.05). The older the child's age, the better the regulatory effect of IVIG on the KD child's immune response and the recovery of immune equilibrium it achieved. In KD patients aged ≥4 years, the abnormally proliferating CD19⁺ B cells may be involved in the secretion of IL-10 to balance the humoral immunity. In such patients, the combination of the absolute CD19⁺ B cell count prior to IVIG and the decreased levels of IL-10 following IVIG may play a crucial role in evaluating the effect of IVIG in the inflammation.

Prediction of intravenous immunoglobulin resistance in Kawasaki disease in children

BACKGROUND

We aimed to explore predictive measures for intravenous immunoglobulin (IVIG) resistance in children with Kawasaki disease (KD).

METHODS

Patients diagnosed with KD were enrolled in this study. Univariate analysis and multiple logistic regression were utilized to analyze the clinical features and laboratory results prior to IVIG-treatment of the two groups. Independent predictors of IVIG resistance were analyzed, and a predictive model for KD children with IVIG resistance was constructed.

RESULTS

A total of 277 children with KD, 180 boys and 97 girls, aged 2-128 (median 23) months, were enrolled in the study. Compared with the IVIG-responsive group, the IVIG-resistant group had higher levels of the peripheral neutrophil count, mean platelet volume, mean platelet volume-to-lymphocyte ratio and C-reactive protein, and total serum bilirubin, but lower levels of peripheral lymphocyte count, serum albumin and serum prealbumin. Age (in months), peripheral neutrophil count, lymphocyte count and mean platelet volume and serum albumin were independent indicators for IVIG resistance by multivariate logistic regression analysis. A logistic regression model and a scoring system were set up, where cut-off values of - 0.46 and 6.5 points yielded sensitivities of 83.9% and 77.4%, and specificities of 74.8% and 61.0%, respectively. The areas under the curve (AUC) were 0.808 in the logistic regression model, and 0.750 in the scoring system.

CONCLUSION

Our model for predicting IVIG-resistant children with KD, involving age (months), peripheral neutrophil count, lymphocyte count and mean platelet volume and serum albumin prior to IVIG-treatment, is helpful for clinical prediction of children with IVIG-resistant KD.

Neutrophil-to-lymphocyte ratio and scoring system for predicting coronary artery lesions of Kawasaki disease

BACKGROUND

Kawasaki disease (KD) causes coronary artery lesions (CAL) and is the leading cause of acquired heart disease in children. The aim of this study is to evaluate the risk factors and set-up a scoring system for predicting CAL of KD.

METHODS

We retrospectively reviewed a total of 478 patients diagnosed with KD. We compared age, gender, laboratory data, and treatment response in two groups and developed a scoring system for predicting CAL.

RESULTS

During the study period, 365 of these patients had complete medical records of coronary surveys by echocardiography. Anemia, hypoalbuminemia, C reactive protein (CRP), alanine aminotransferase, neutrophil count, and neutrophil/lymphocyte ratio (NLR) showed significant differences with CAL formation. We determined the cut-off value using a receiver-operating-characteristic (ROC) curve, and following multivariate logistic regression analysis, four independent risk factors demonstrated a significant difference with CAL formation, including CRP > 103 mg/L, NLR > 3.5, male gender, and intravenous immunoglobulin (IVIG) resistance. We established a score system based on the above evaluation, for which a ROC curve was performed, and a total score of ≥ 2 points showed a sensitivity of 60.8% and a specificity of 70.6%, with an area under the ROC curve of 0.696.

CONCLUSIONS

Identifying children at risk is important in order to prevent CAL from developing. Four independent risk factors that can predict CAL formation were CRP > 103 mg/L, NLR > 3.5, male gender, and IVIG resistance. This first report incorporated NLR into score systems to predict CAL reinforces previously well-known risk factors for the CAL formation among KD patients.

The combination of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios as a novel predictor of intravenous immunoglobulin resistance in patients with Kawasaki disease: a multicenter study

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been reported to be a predictor for intravenous immunoglobulin (IVIG) resistance in patients with Kawasaki disease (KD) recently. The objective of the present study was to elucidate the predictive validity of this new marker in a multicenter study.

MATERIALS AND METHODS

We retrospectively reviewed the clinical records of 520 consecutive KD patients (development data set) and 332 subsequent patients (validation data set) at 7 hospitals in Japan.

RESULTS

Both NLR and PLR were significantly higher in the IVIG-resistant group than in the IVIG-responsive group. When we set the cut-off point as NLR ≥ 4.11 and PLR ≥ 119, multiple logistic regression analyses showed that a high NLR and PLR before initial IVIG were independent predictors of IVIG resistance, and their combination was a stronger predictor than either alone. The sensitivity and specificity of the combination of NLR ≥ 4.11 and PLR ≥ 119 were 0.58 and 0.73 in the development data set. Validated using an independent data set, they were 0.54 and 0.72 in the validation data set. On comparing the AUC of this predictor with those of the Gunma and Kurume scores, the AUC was highest for this predictor, followed by the Gunma score and Kurume score (0.70, 0.68, and 0.64, respectively).

DISCUSSION

The predictive validity of the combination of a high NLR and PLR, which is a simple and convenient indicator, was equal to or better than that of the existing scoring systems. The new predictive marker may be a suitable indicator for predicting IVIG resistance in KD patients.

Prospective Evaluation of Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio for Intravenous Immunoglobulin Resistance in a Large Cohort of Kawasaki Disease Patients

The evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for intravenous immunoglobulin resistance prediction was prospectively performed in a large cohort of Kawasaki disease patients. It was found that the predictive values of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, alone or combined, were not good enough although they were identified as independent risk factors for intravenous immunoglobulin resistance.

Platelet Count Variation and Risk for Coronary Artery Abnormalities in Kawasaki Disease

BACKGROUND

Platelet count is considered as a biomarker for the development of coronary artery abnormalities (CAAs) among Kawasaki disease (KD) patients. However, previous studies have reported inconsistent results. We addressed the controversial association of platelet count with CAAs using a large-scale dataset.

METHODS

A retrospective cohort study was conducted using KD survey data from Japan (2015-2016; n = 25,448). Classifying patients by intravenous immunoglobulin (IVIG) responsiveness, we described the trends in platelet count using the lowest and highest values along with the specific illness days. Multivariate logistic regression analysis was performed to evaluate the association between platelet count and CAAs, adjusting for relevant factors.

RESULTS

Platelet counts rapidly decreased from admission, reached the lowest count at 6-7 days, and peaked after 10 days. Platelet counts in IVIG non-responders decreased with a lower minimum value than IVIG responders, but subsequently rebounded toward a higher maximum. Compared with patients with normal platelet counts (150-450 × 10/L), patients with abnormally high platelet counts (>450 × 10/L) were more likely to have CAAs at admission (adjusted odds ratio: IVIG responders, 1.50 [95% confidence interval 1.20-1.87] and non-responders, 1.46 [1.01-2.12]). By contrast, IVIG non-responding patients whose counts were below normal (<150 × 10/L) after hospitalization were at higher risk for developing CAAs (2.27 [1.44-3.58]).

CONCLUSIONS

Platelet count varied widely by illness day and was confounded by IVIG responsiveness, which might have contributed to previous inconsistent findings. KD patients with abnormally high platelet counts at admission or abnormally low counts after hospitalization were at higher risk for CAAs.

Neutrophil-to-lymphocyte ratio as a biomarker for predicting the intravenous immunoglobulin-resistant Kawasaki disease

BACKGROUND

In recent years, many studies focused on the association between the neutrophil-to-lymphocyte ratio (NLR) and the risk of intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (rKD), with inconsistent results. Therefore, we aimed to investigate the role of NLR as a biomarker in detecting rKD.

METHODS

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure through May 18th, 2019. Meta-disc 1.4 and STATA 15.1 were used to perform this metaanalysis in a fixed/random-effect model.

RESULTS

A total of 7 relevant studies were eligible to analyze pooled accuracy. The overall performance of NLR detection was: pooled sensitivity, 0.66 (95% confidence interval [CI], 0.63 - 0.70); pooled specificity, 0.71 (95%CI, 0.69 - 0.73); and area under the summary receiver operating characteristic curves value (SROC), 0.7956. The meta-regression analysis showed that the type of samples was the sources of heterogeneity. The subgroup analysis suggested that NLR detection after the initial treatment of IVIG had the largest area under curve of SROC in all the subgroups: pooled sensitivity, 0.58 (95%CI, 0.53 - 0.63); pooled specificity, 0.77 (95%CI, 0.75 - 0.79); and SROC, 0.8440.

CONCLUSIONS

This is the first meta-analysis demonstrated that NLR might be a biomarker for detecting rKD, especially NLR value after the initial treatment of IVIG. More well-designed researches need to be done to launch the application of NLR for predicting rKD in the clinic.

Clinical Characteristics for Differentiating Febrile Children With Suspected Kawasaki Disease Diagnosis

Background: Kawasaki disease (KD) is a form of vasculitis that primarily affects children under the age of 5 years old. Patients may be missed or diagnosis delayed when initial clinical symptoms do not fulfill the traditional criteria or a normal echocardiography was found. In this study, we aimed to analyze factors that clinicians could use to differentiate febrile children suspected of KD. Method: We retrospectively enrolled in this study a total of 50 febrile children who were initially suspected of KD, but they did not meet the American Heart Association (AHA) criteria for a diagnosis. However, some of these patients were diagnosed with KD during their second visit. We analyzed patients' characteristics, clinical symptoms, and laboratory data (initial data in the first visit). Results: In total, 50 patients were enrolled in the study. Of those, ten patients were diagnosed with KD on their second visit (group 1), while the other 40 patients still did not fit a KD diagnosis (group 2). A higher neutrophil-to-lymphocyte ratio (NLR, p = 0.037) and higher C-reactive protein levels (CRP, p = 0.02) were found in group 1 when compared to group 2. A patient with a NLR >1.33 combined with a CRP more than 33 mg/L was more likely to have KD (Sensitivity 90%, specificity 69.2%, p = 0.001; Odds ratio 20.25, 95% confident interval 2.3-178.25). Conclusion: Among patients suspected of KD that did not initially meet the criteria, clinicians should pay special attention to elevated neutrophil-to-lymphocyte ratios and CRP levels and closely follow up such patients.

Shared and unique individual risk factors and clinical biomarkers in children with allergic rhinitis and obstructive sleep apnea syndrome

INTRODUCTION

Rhinitis and obstructive sleep apnea syndrome (OSAS) are different diseases, but have some similar risk factors.

OBJECTIVE

The aims of this study were to compare the risk factors and clinical biomarkers for rhinitis and OSAS in children.

METHODS

We examined 3917 children (age 4-13 years) who were enrolled in a cross-sectional study conducted in Seongnam, Korea. Their parents completed the Pediatric Sleep Questionnaire (PSQ) for evaluation of OSAS and the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire for evaluation of rhinitis. Clinical biomarkers, including total eosinophil count and neutrophil-lymphocyte ratio (NLR), were measured in a subset of these children.

RESULTS

OSAS and rhinitis had prevalences of 4.0% and 43.5%, respectively. Body mass index (P < 0.001) and prematurity (P = 0.016) were significantly associated with OSAS, but not with rhinitis. Higher parental education and income increased the risk for rhinitis, but decreased the risk for OSAS. Having more siblings and birth by Cesarean delivery decreased the risk for rhinitis, but living in a new household increased the risk for rhinitis. A short distance of the residence to a main road during pregnancy significantly increased the risk of OSAS. Males, increased exposure to mould, and firstborns had increased risk of OSAS and rhinitis. The NLR was higher in OSAS patients than in those with allergic rhinitis (P = 0.001).

CONCLUSION

OSAS and rhinitis shared some risk factors, whereas other factors had inverse association with the two disorders. These results imply that different strategies might be used for prevention of rhinitis and OSAS.

The Platelet-to-Lymphocyte Ratio as an Inflammatory Marker in Rheumatic Diseases

The platelet-to-lymphocyte ratio (PLR) has emerged as an informative marker revealing shifts in platelet and lymphocyte counts due to acute inflammatory and prothrombotic states. PLR has been extensively examined in neoplastic diseases accompanied by immune suppression and thrombosis, which can be predicted by combined blood cell counts and their ratios. Several large observational studies have demonstrated the value of shifts in PLR in evaluating the severity of systemic inflammation and predicting infections and other comorbidities, in inflammatory rheumatic diseases. The value of PLR as an inflammatory marker increases when its fluctuations are interpreted along with other complementary hematologic indices, particularly the neutrophil-to-lymphocyte ratio (NLR), which provides additional information about the disease activity, presence of neutrophilic inflammation, infectious complications, and severe organ damage in systemic lupus erythematosus. PLR and NLR have high predictive value in rheumatic diseases with predominantly neutrophilic inflammation (e.g., Behçet disease and familial Mediterranean fever). High PLR, along with elevated platelet count, is potentially useful in diagnosing some systemic vasculitides, particularly giant-cell arteritis. A few longitudinal studies on rheumatic diseases have demonstrated a decrease in PLR in response to anti-inflammatory therapies. The main limitations of PLR studies are preanalytical faults, inadequate standardization of laboratory measurements, and inappropriate subject selection. Nonetheless, accumulating evidence suggests that PLR can provide valuable information to clinicians who encounter multisystem manifestations of rheumatic diseases, which are reflected in shifts in platelet, lymphocyte, neutrophil, or monocyte counts. Interpretation of PLR combined with complementary hematologic indices is advisable to more accurately diagnose inflammatory rheumatic diseases and predict related comorbidities.

Neutrophil-to-Lymphocyte Ratio Predicts Intravenous Immunoglobulin-Resistance in Infants Under 12-Months Old With Kawasaki Disease

Objective: We evaluated the ability of peripheral blood neutrophil-to-lymphocyte ratio (NLR) to predict the intravenous immunoglobulin (IVIG) resistance in Kawasaki disease (KD) patients under 1-year of age. Methods: A total of 92 KD patients under the age of 1-year and who were hospitalized in Peking University First Hospital from June 2007 to August 2016 were recruited in this study. The clinical and laboratory data were analyzed to see if peripheral blood NLR was useful for predicting the IVIG-resistance in KD. Results: Totally 81 out of 92 patients were IVIG responders while 11 resistant to IVIG, with no significant difference in age, gender, ratio of the number of the incomplete to the number of complete KD, and the number of patients with coronary artery lesion between two groups (p > 0.05). Peripheral blood NLR was increased significantly in IVIG-resistant children compared to the IVIG responders [2.6 (interquartile range: 1.4, 3.8) vs. 1.7 (interquartile range: 0.9, 2.3), p = 0.039]. A cut-off value of NLR of 2.51 in KD patients younger than 1-year old yielded a sensitivity of 0.545 and specificity of 0.840, respectively, in the prediction of IVIG resistance. An area under the curve of 0.692 (95% confidence interval 0.526-0.859, p = 0.039) was determined. Conclusions: The peripheral blood NLR ≥ 2.51 is useful to predict the IVIG resistance in KD patients younger than 1-year old.

Naturally occurring antibodies against serum amyloid A reduce IL-6 release from peripheral blood mononuclear cells

Serum amyloid A (SAA) is a sensitive inflammatory marker rapidly increased in response to infection, injury or trauma during the acute phase. Resolution of the acute phase and SAA reduction are well documented, however the exact mechanism remains elusive. Two inducible SAA proteins, SAA1 and SAA2, with their variants could contribute to systemic inflammation. While unconjugated human variant SAA1α is already commercially available, the variants of SAA2 are not. Antibodies against SAA have been identified in apparently healthy blood donors (HBDs) in smaller, preliminary studies. So, our objective was to detect anti-SAA and anti-SAA1α autoantibodies in the sera of 300 HBDs using ELISA, characterize their specificity and avidity. Additionally, we aimed to determine the presence of anti-SAA and anti-SAA1α autoantibodies in intravenous immunoglobulin (IVIg) preparations and examine their effects on released IL-6 from SAA/SAA1α-treated peripheral blood mononuclear cells (PBMCs). Autoantibodies against SAA and SAA1α had a median (IQR) absorbance OD (A₄₅₀) of 0.655 (0.262–1.293) and 0.493 (0.284–0.713), respectively. Both anti-SAA and anti-SAA1α exhibited heterogeneous to high avidity and reached peak levels between 41–50 years, then diminished with age in the oldest group (51–67 years). Women consistently exhibited significantly higher levels than men. Good positive correlation was observed between anti-SAA and anti-SAA1α. Both anti-SAA and anti-SAA1α were detected in IVIg, their fractions subsequently isolated, and shown to decrease IL-6 protein levels released from SAA/SAA1α-treated PBMCs. In conclusion, naturally occurring antibodies against SAA and anti-SAA1α could play a physiological role in down-regulating their antigen and proinflammatory cytokines leading to the resolution of the acute phase and could be an important therapeutic option in patients with chronic inflammatory diseases.

A comparison of efficacy of six prediction models for intravenous immunoglobulin resistance in Kawasaki disease

Background

Kawasaki disease (KD) is the most common pediatric vasculitis. Several models have been established to predict intravenous immunoglobulin (IVIG) resistance. The present study was aimed to evaluate the efficacy of prediction models using the medical data of KD patients.

Methods

We collected the medical records of patients hospitalized in the Department of Cardiology in Children’s Hospital of Soochow University with a diagnosis of KD from Jan 2015 to Dec 2016. IVIG resistance was defined as recrudescent or persistent fever ≥36 h after the end of their IVIG infusion.

Results

Patients with IVIG resistance tended to be younger, have higher occurrence of rash and changes of extremities. They had higher levels of c-reactive protein, aspartate aminotransferase, neutrophils proportion (N%), total bilirubin and lower level of albumin. Our prediction model had a sensitivity of 0.72 and a specificity of 0.75. Sensitivity of Kobayashi, Egami, Kawamura, Sano and Formosa were 0.72, 0.44, 0.48, 0.20, and 0.68, respectively. Specificity of these models were 0.62, 0.82, 0.66, 0.91, and 0.48, respectively.

Conclusions

Our prediction model had a powerful predictive value in this area, followed by Kobayashi model while all the other prediction models had less excellent performances than ours.

Evaluation of the NMP22 BladderChek test for detecting bladder cancer: a systematic review and meta-analysis

Background

We examined the usefulness of the nuclear matrix protein 22 (NMP22) BladderChek test for detecting bladder cancer.

Materials and Methods

A literature search was performed using PubMed, Embase, the Cochrane Library, and Web of Science. The diagnostic accuracy of the NMP22 BladderChek test was evaluated via pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under curve (AUC). Inter-study heterogeneity was explored using meta-regression and subgroup analyses.

Results

We included 23 studies in the systematic review and 19 in the quantitative meta-analysis. Overall sensitivity and specificity were 56% (52-59%) and 88% (87-89%), respectively; pooled PLR and NLR were 4.36 (3.02-6.29) and 0.51 (0.40-0.66), respectively; DOR was 9.29 (5.55-15.55) with an AUC of 0.8295. The mean sensitivity for Ta, T1, ≥ T2, Tis, G1, G2, and G3 disease was 13.68%, 29.49%, 74.03%, 34.62%, 44.16%, 56.25%, and 67.34%, respectively.

Conclusions

The NMP22 BladderChek test shows good discrimination ability for detecting bladder cancer and a high-specificity algorithm that can be used for early detection to rule out patients with higher bladder cancer risk. It also has better potential for screening higher-grade and higher-stage tumors, and better diagnostic performance in Asians.