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Tarabichi S, Goh GS, Fraval A, Lizcano JD, Abe EA, Courtney PM, Namdari S, Parvizi J. Serum and Synovial Markers in the Diagnosis of Periprosthetic Joint Infection of the Hip, Knee, and Shoulder: An Algorithmic Approach. J Bone Joint Surg Am 2024; 106:1221-1230. [PMID: 38776388 DOI: 10.2106/jbjs.23.00669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
➤ No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI).➤ Physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help to guide preoperative decision-making.➤ Several organizations have proposed criteria for the diagnosis of hip or knee PJI on which we now rely.➤ Given that shoulder arthroplasty has only recently become popular, it is possible that a shoulder-specific definition of PJI will be introduced in the coming years.➤ Although a number of serum and synovial markers have demonstrated high accuracy for the diagnosis of PJI of the hip and knee, further research is needed in order to identify markers that may be more suitable for the diagnosis of shoulder PJI and for the potential development and identification of specific serological tests as screening tools for PJI.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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2
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Kaye AD, Greene D, Alvarez-Amado AV, Townsend HL, Forte M, Vasterling M, Hirsch JD, Howard J, Ahmadzadeh S, Willett O, Kaye AM, Shekoohi S, Varrassi G. Pathophysiology and Evolving Treatment Options of Septic Arthritis: A Narrative Review. Cureus 2024; 16:e65883. [PMID: 39219968 PMCID: PMC11364462 DOI: 10.7759/cureus.65883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Pyogenic (septic) arthritis is a severe joint infection characterized by the invasion of microorganisms into the synovium, causing inflammation and joint destruction. This review article provides a comprehensive overview of pyogenic arthritis, focusing on etiology, pathogenesis, clinical manifestations, diagnosis, and management strategies. This review explores routes of microbial entry into joints, emphasizing the importance of prompt identification and treatment to prevent irreversible joint damage. Clinical manifestations, such as joint pain, swelling, and limited range of motion, are discussed, along with the challenges in differentiating pyogenic arthritis from other joint disorders. Diagnostic approaches, including joint aspiration and imaging modalities, are critically examined for accuracy in confirming diagnosis. This review also addresses the significance of early intervention through antimicrobial therapy and joint drainage, highlighting the role of multidisciplinary collaboration in optimizing patient outcomes. In summary, the present investigation underscores the complexities of pyogenic arthritis and the need for a comprehensive understanding of pathophysiology for timely and effective management to improve patient prognosis and quality of life.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Driskell Greene
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Horace L Townsend
- School of Medicine, American University of the Caribbean, Cupecoy, SXM
| | - Michael Forte
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, USA
| | - Megan Vasterling
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, USA
| | - Jon D Hirsch
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jeffrey Howard
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Olga Willett
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Altsitzioglou P, Avgerinos K, Karampikas V, Gavriil P, Vlachos A, Soucacou F, Zafiris I, Kontogeorgakos V, Papagelopoulos PJ, Mavrogenis AF. Point of care testing for the diagnosis of periprosthetic joint infections: a review. SICOT J 2024; 10:24. [PMID: 38847648 PMCID: PMC11160401 DOI: 10.1051/sicotj/2024019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). METHODS This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. RESULTS POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. DISCUSSION While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.
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Affiliation(s)
- Pavlos Altsitzioglou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Konstantinos Avgerinos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Karampikas
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Gavriil
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Apostolos Vlachos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Fotini Soucacou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Zafiris
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Kontogeorgakos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis J Papagelopoulos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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4
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Dey M, Al-Attar M, Peruffo L, Coope A, Zhao SS, Duffield S, Goodson N. Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1740-1756. [PMID: 36264140 PMCID: PMC10152293 DOI: 10.1093/rheumatology/keac606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/15/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential for avoiding unnecessary antibiotics and hospital admissions. We evaluated the utility of synovial fluid (SF) and serum tests in differentiating causes of acute hot joints. METHODS We performed a systematic literature review of diagnostic testing for acute hot joints. Articles were included if studying ≥1 serum or SF test(s) for an acute hot joint, compared with clinical assessment and SF microscopy and culture. English-language articles only were included, without date restriction. The following were recorded for each test, threshold and diagnosis: sensitivity, specificity, positive/negative predictive values and likelihood ratios. For directly comparable tests (i.e. identical fluid, test and threshold), bivariate random-effects meta-analysis was used to pool sensitivity, specificity, and areas under the curves. RESULTS A total of 8443 articles were identified, and 49 were ultimately included. Information on 28 distinct markers in SF and serum, differentiating septic from non-septic joints, was extracted. Most had been tested at multiple diagnostic thresholds, yielding a total of 27 serum markers and 156 SF markers. Due to heterogeneity of study design, outcomes and thresholds, meta-analysis was possible for only eight SF tests, all differentiating septic from non-septic joints. Of these, leucocyte esterase had the highest pooled sensitivity [0.94 (0.70, 0.99)] with good pooled specificity [0.74 (0.67, 0.81)]. CONCLUSION Our review demonstrates many single tests, individually with diagnostic utility but suboptimal accuracy for exclusion of native joint infection. A combination of several tests with or without a stratification score is required for optimizing rapid assessment of the hot joint.
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Affiliation(s)
- Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Queen Elizabeth Hospital, London, UK
| | | | - Leticia Peruffo
- School of Medicine, Federal University of Parana, Curitiba, Brazil
| | - Ashley Coope
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sizheng Steven Zhao
- Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Stephen Duffield
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Nicola Goodson
- Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Diniz SE, Ribau A, Vinha A, Oliveira J, Abreu M, Sousa R. Simple and inexpensive synovial fluid biomarkers for the diagnosis of prosthetic joint infection according to the new EBJIS definition. J Bone Jt Infect 2023; 8:109-118. [PMID: 37032977 PMCID: PMC10077577 DOI: 10.5194/jbji-8-109-2023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction: diagnosis of periprosthetic joint infection (PJI) is challenging, as no single test has absolute accuracy. The purpose of this study was to assess the utility of different simple synovial biomarkers in the diagnosis of PJI as defined by the European Bone and Joint Infection Society (EBJIS). Methods: we retrospectively identified all patients undergoing revision hip or knee arthroplasty from 2013 to 2019 on our prospectively maintained database. Only patients with minimum required infection diagnostic workup were included in the study. Patients with comorbidities that may influence the accuracy of synovial biomarkers were excluded. Receiver operator characteristic (ROC) curves were utilised to assess the diagnostic utility of synovial fluid white blood cell (WBC) count, polymorphonuclear leukocyte percentage (PMN %), C-reactive protein (CRP), adenosine deaminase (ADA), and alpha-2-microglobulin (A2M). Results: in total, 102 patients met the inclusion criteria. Of these, 58 were classified as infection unlikely, 8 as infection likely, and 36 as infection confirmed. Synovial WBC count (area under the curve (AUC) 0.94) demonstrated the best utility for the diagnosis of PJI, followed by PMN % (AUC 0.91), synovial CRP (AUC 0.90), ADA (AUC 0.82), and A2M (AUC 0.76). We found added value in the combined interpretation of different biomarkers. We calculated high sensitivity and negative predictive value if at least two of them are negative and high specificity and positive predictive value if at least two are elevated. Conclusion: current results show that synovial fluid investigation is a useful tool for the diagnosis of PJI, and the combined interpretation of simple and inexpensive biomarkers demonstrated improved diagnostic accuracy.
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Affiliation(s)
- Sara Elisa Diniz
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Ana Ribau
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - André Vinha
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - José Carlos Oliveira
- Department of Laboratory Pathology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Miguel Araújo Abreu
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- part of the Porto Bone and Joint Infection Group (GRIP), Porto, Portugal
| | - Ricardo Sousa
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- part of the Porto Bone and Joint Infection Group (GRIP), Porto, Portugal
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Gazendam A, Wood TJ, Tushinski D, Bali K. Diagnosing Periprosthetic Joint Infection: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:219-229. [PMID: 35368214 PMCID: PMC9107560 DOI: 10.1007/s12178-022-09751-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an up to date understanding of the utility and limitations of the current tests utilized in the diagnosis of periprosthetic joint infection (PJI) in total knee and hip arthroplasty. RECENT FINDINGS Despite the growth in literature surrounding PJI diagnosis, there remains challenges in establishing a diagnosis of PJI. A combination of clinical, serum, and synovial tests and microbiologic and histologic examinations can yield a diagnosis in the majority of cases. Novel molecular and imaging studies may be beneficial for indeterminant cases. A number of emerging diagnostic tests have been proposed and may be incorporated into diagnostic algorithms in the future. Recently proposed stepwise diagnostic algorithms have shown high sensitivity and specificity. The diagnosis of PJI remains challenging due to a lack of tests that can definitively rule out infection. Diagnosis and investigations should occur in a stepwise fashion. There has been a plethora of new diagnostic tests introduced in attempts to improve the accuracy of diagnostic algorithms. The definition and algorithms for the diagnoses of PJI will continue to evolve as new techniques and tests are introduced.
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Affiliation(s)
- Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Wood
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Tushinski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kamal Bali
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
- Juravinski Hospital, 711 Concession St, Hamilton, Ontario, L8V 1C3, Canada.
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Boffa A, Merli G, Andriolo L, Lattermann C, Salzmann GM, Filardo G. Synovial Fluid Biomarkers in Knee Osteoarthritis: A Systematic Review and Quantitative Evaluation Using BIPEDs Criteria. Cartilage 2021; 13:82S-103S. [PMID: 32713185 PMCID: PMC8808867 DOI: 10.1177/1947603520942941] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to analyze the evidence about the efficacy of the several synovial fluid (SF) biomarkers proposed for knee osteoarthritis (OA), categorizing them by both molecular characteristics and clinical use according to the BIPEDs criteria, to provide a comprehensive and structured overview of the current literature. DESIGN A systematic review was performed in May 2020 on PubMed, Cochrane Library, and Embase databases about SF biomarkers in patients with knee OA. The search was limited to articles in the last 20 years on human studies, involving patients with knee OA, reporting SF biomarkers. The evidence for each selected SF biomarker was quantified according to the 6 categories of BIPEDs classification. RESULTS A total of 159 articles were included in the qualitative data synthesis and 201 different SF biomarkers were identified. Among these, several were investigated multiple times in different articles, for a total of 373 analyses. The studies included 13,557 patients with knee OA. The most promising SF biomarkers were C4S, IL-6, IL-8, Leptin, MMP-1/3, TIMP-1, TNF-α, and VEGF. The "burden of disease" and "diagnostic" categories were the most represented with 132 and 106 different biomarkers, respectively. CONCLUSIONS The systematic review identified numerous SF biomarkers. However, despite the high number of studies on the plethora of identified molecules, the evidence about the efficacy of each biomarker is supported by limited and often conflicting findings. Further research efforts are needed to improve the understanding of SF biomarkers for a better management of patients with knee OA.
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Affiliation(s)
- Angelo Boffa
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giulia Merli
- Applied and Translational Research (ATR)
Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Lattermann
- Department of Orthopaedic Surgery,
Center for Cartilage Repair and Sports Medicine, Brigham and Women’s Hospital,
Harvard Medical School, Chestnut Hill, MA, USA
| | - Gian M. Salzmann
- Department of Orthopaedic Surgery, Hip
and Knee Department, Schulthess Clinic, Zürich, Switzerland
| | - Giuseppe Filardo
- Applied and Translational Research (ATR)
Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Plate A, Anagnostopoulos A, Glanzmann J, Stadler L, Weigelt L, Sutter R, Kästli M, Zinkernagel AS, Zingg PO, Achermann Y. Synovial C-reactive protein features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI). J Infect 2019; 78:439-444. [PMID: 30965066 DOI: 10.1016/j.jinf.2019.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Synovial fluid C-reactive protein (syCRP) has been recently described as a new biomarker in preoperative diagnostics to identify periprosthetic joint infections (PJI). The aim of this study was to evaluate syCRP in a large cohort of patients with suspected PJI and to calculate the optimal cut-off to diagnose PJI. METHODS Between September 2015 and June 2017, we prospectively included patients with suspected PJI, in which syCRP was additionally measured along with routine preoperative diagnostic serum and synovial biomarkers. We analysed the sensitivity and specificity of syCRP using receiver operating characteristic curves. RESULTS We included 192 cases (hip n = 80, knee n = 91, shoulder n = 21) with a final diagnosis of PJI in 26 cases (14.0%). Combined for all joints, the syCRP values were significantly higher in the PJI group than in the no PJI group (median: 13.8 vs. 0 mg/l; p < 0.001). The optimal cut-off (Youden Index: 0.71) for the PJI diagnosis combined for all joints was at a syCRP value of 2.9 mg/l with a sensitivity of 88%, a specificity of 82%, and a negative predictive value of 98%. CONCLUSIONS SyCRP features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI).
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Affiliation(s)
- A Plate
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - A Anagnostopoulos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - J Glanzmann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - L Stadler
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - L Weigelt
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - R Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - M Kästli
- Zentrallabour Zurich, Zurich, Switzerland
| | - A S Zinkernagel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - P O Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Y Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Tsai TT, Huang TH, Chen CA, Ho NYJ, Chou YJ, Chen CF. Development a stacking pad design for enhancing the sensitivity of lateral flow immunoassay. Sci Rep 2018; 8:17319. [PMID: 30470789 PMCID: PMC6251899 DOI: 10.1038/s41598-018-35694-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/09/2018] [Indexed: 11/20/2022] Open
Abstract
Lateral flow immunoassays (LFIAs) have wide application in point-of-care testing, particularly in resource-poor settings. To achieve signal amplification in a gold nanoparticle-based lateral flow assay without an additional procedure or the need for complex fabrication, a new and simple method was developed for using a “stacking pad” configuration that adds an additional membrane between the conjugation pad and test pad to the conventional AuNP-based LFIA format. This design helps to accumulate the antibody and antigen on the stacking pad, hence extending the antigen/antibody binding interactions to enhance the test’s detection sensitivity. With the enhanced lateral flow assay, as low as 1 ng/mL of Protein A and 15.5 ng/mL of C-reactive protein can be visualized with the naked eye. We also successfully applied the stacking pad system in the analysis of C-reactive protein in human serum and synovial fluid samples. These results suggest that this stacking pad LFIA can provide sensitive and on-site prognosis for detection in synovial fluid and serum samples in resource-limited settings.
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Affiliation(s)
- Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Tse-Hao Huang
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Chung-An Chen
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Natalie Yi-Ju Ho
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Yi-Ju Chou
- Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Chien-Fu Chen
- Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan.
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10
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Sousa R, Serrano P, Gomes Dias J, Oliveira JC, Oliveira A. Improving the accuracy of synovial fluid analysis in the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers. Bone Joint J 2017; 99-B:351-357. [DOI: 10.1302/0301-620x.99b3.bjj-2016-0684.r1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 11/25/2016] [Indexed: 12/16/2022]
Abstract
Aims The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin. Patients and Methods Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis. The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker. Results There were 23 PJIs and 32 patients with aseptic loosening. The levels of total leucocyte count, proportion of polymorphonuclear leucocytes (PMNs), CRP, ADA and α2M in the synovial fluid were all significantly higher in those with a PJI than in those with aseptic loosening. The levels of procalcitonin were comparable in the two groups. Cutoff values for the optimal performance in the diagnosis of infection were: total leucocyte count > 1463 cells/μL (sensitivity (Sens) 100%, specificity (Spec) 71.9%, positive predictive value (PPV) 71.9%, negative predictive value (NPV) 100%); proportion of PMNs > 81% (Sens 78.3%, Spec 75.0%, PPV 69.2%, NPV 82.8%); CRP > 6.7mg/L (Sens 78.3%, Spec 93.8%, PPV 90.0%, NPV 85.7%); ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%) and α2M > 958 mg/L (Sens 47.8%, Spec 96.9%, PPV 91.7%, NPV 72.1%). The addition of a raised level of CRP or ADA to the total leukocyte count increased the specificity: total leukocyte count > 1463 cells/μL and CRP > 6.7mg/L (Sens 78.3%, Spec 100%, PPV 100%, NPV 86.5%) or with ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%). Conclusion The total leucocyte count in the synovial fluid offers great negative predictive value in the diagnosis of PJI and the addition of more specific markers such as CRP and ADA improves the positive predictive value. Thus the addition of simple and inexpensive markers to the measurement of the leucocyte count in the synovial fluid may reduce the number of equivocal results which demand more expensive investigation. Cite this article: Bone Joint J 2017;99-B:351–7.
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Affiliation(s)
- R. Sousa
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - P. Serrano
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - J. Gomes Dias
- Administração Regional de Saúde do
Norte, Rua Anselmo Braancamp, 144;
4000-078 Porto, Portugal
| | - J. C. Oliveira
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - A. Oliveira
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
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11
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Cronstein BN, Sitkovsky M. Adenosine and adenosine receptors in the pathogenesis and treatment of rheumatic diseases. Nat Rev Rheumatol 2016; 13:41-51. [PMID: 27829671 DOI: 10.1038/nrrheum.2016.178] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Adenosine, a nucleoside derived primarily from the extracellular hydrolysis of adenine nucleotides, is a potent regulator of inflammation. Adenosine mediates its effects on inflammatory cells by engaging one or more cell-surface receptors. The expression and function of adenosine receptors on different cell types change during the course of rheumatic diseases, such as rheumatoid arthritis (RA). Targeting adenosine receptors directly for the treatment of rheumatic diseases is currently under study; however, indirect targeting of adenosine receptors by enhancing adenosine levels at inflamed sites accounts for most of the anti-inflammatory effects of methotrexate, the anchor drug for the treatment of RA. In this Review, we discuss the regulation of extracellular adenosine levels and the role of adenosine in regulating the inflammatory and immune responses in rheumatic diseases such as RA, psoriasis and other types of inflammatory arthritis. In addition, adenosine and its receptors are involved in promoting fibrous matrix production in the skin and other organs, and the role of adenosine in fibrosis and fibrosing diseases is also discussed.
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Affiliation(s)
- Bruce N Cronstein
- NYU-HHC Clinical and Translational Science Institute, NYU School of Medicine, 550 First Avenue, New York, New York 10016, USA
| | - Michail Sitkovsky
- New England Inflammation and Tissue Protection Institute, Northeastern University, 360 Huntington Avenue, 312 MU, Boston, Massachusetts 02115, USA
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Omar M, Ettinger M, Reichling M, Petri M, Guenther D, Gehrke T, Krettek C, Mommsen P. Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty. Bone Joint J 2015; 97-B:173-6. [DOI: 10.1302/0301-620x.97b2.34550] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to assess the role of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic hip infection. We prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN). Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings. The high viscosity of the synovial fluid precluded the analyses in nine patients permitting the results in 80 patients to be studied. There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort. According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity of 93.3%. The area under the curve was 0.96. Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value. According to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic periprosthetic hip infection. Cite this article: Bone Joint J 2015; 97-B:173–6.
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Affiliation(s)
- M. Omar
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
| | - M. Ettinger
- Hannover Medical School, Anna-von-Borries-Str.
1-7, 30625 Hannover, Germany
| | - M. Reichling
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
| | - M. Petri
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
| | - D. Guenther
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
| | - T. Gehrke
- ENDO Clinic Hamburg, Holstenstr.
2, 22767 Hamburg, Germany
| | - C. Krettek
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
| | - P. Mommsen
- Hannover Medical School (MHH), Carl-Neuberg-Str.
1, 30625 Hannover, Germany
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CORR Insights: Is synovial C-reactive protein a useful marker for periprosthetic joint infection? Clin Orthop Relat Res 2014; 472:4004-5. [PMID: 25135852 PMCID: PMC4397775 DOI: 10.1007/s11999-014-3882-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/05/2014] [Indexed: 01/31/2023]
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Is synovial C-reactive protein a useful marker for periprosthetic joint infection? Clin Orthop Relat Res 2014; 472:3997-4003. [PMID: 25070920 PMCID: PMC4397770 DOI: 10.1007/s11999-014-3828-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 07/15/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Serum C-reactive protein (CRP) is a general marker of inflammation, and recent studies suggest that measurement of CRP in synovial fluid may be a more accurate method for diagnosing periprosthetic joint infection (PJI). QUESTIONS/PURPOSES We aimed to (1) determine if there is a correlation between serum and synovial CRP values, (2) establish cutoff values for diagnosing infection based on serum and synovial CRP, and (3) compare the utility of measuring CRP in synovial fluid versus serum for the diagnosis of PJI using standard assay equipment available at most hospitals. METHODS Between February 2011 and March 2012, we invited all 150 patients scheduled for revision TKA (84) or THA (66) to participate in this prospective study, of whom 100% agreed. Data ultimately were missing for 31 patients, leaving 60 patients undergoing revision TKA and 59 undergoing revision THA (71% and 89% of the original group, respectively) for whom CRP level was measured in serum and synovial fluid samples. Patients were deemed to have a PJI (32) or no infection (87) using Musculoskeletal Infection Society criteria. Serum and synovial CRP levels were assayed using the same immunospectrophotometer and the correlation coefficient was calculated. Receiver operating characteristic curve analyses were performed to compare utility in diagnosing PJI, which included area under the curve, diagnostic threshold, and test sensitivity, specificity, predictive values, and accuracy. In 22 of 150 patients (14.7%), synovial CRP could not be measured because the sample was too viscous or hemolyzed. RESULTS In the analyzed 119 samples, there was a strong correlation (r = 0.76; p < 0.001) between synovial and serum CRP. The area under the curve was 0.90 both for the synovial fluid (95% CI, 0.82-0.97) and serum (95% CI, 0.84-0.96) CRP assays. The diagnostic thresholds were 6.6 mg/L for synovial fluid and 11.2 mg/L for serum. Sensitivities, specificities, positive predictive value, negative predictive value, and accuracies were similar for synovial fluid and serum assays. CONCLUSIONS Although recent studies have suggested a superiority of synovial fluid CRP over serum CRP for the diagnosis of PJI, we found that measurement of CRP in synovial fluid rather than serum using readily available assay equipment does not offer a diagnostic advantage in detection of PJIs. LEVEL OF EVIDENCE Level II, diagnostic study. See the Instructions to Authors for a complete description of levels of evidence.
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Ronde-Oustau C, Diesinger Y, Jenny JY, Antoni M, Gaudias J, Boeri C, Sibilia J, Lessinger JM. Diagnostic accuracy of intra-articular C-reactive protein assay in periprosthetic knee joint infection--a preliminary study. Orthop Traumatol Surg Res 2014; 100:217-20. [PMID: 24582652 DOI: 10.1016/j.otsr.2013.10.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/12/2013] [Accepted: 10/03/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Periprosthetic joint infection often raises diagnostic challenges, as the published criteria are heterogeneous. New markers for predicting periprosthetic infection have been evaluated. Here, we assessed one of these markers, C-reactive protein (CRP), in joint fluid. HYPOTHESIS We hypothesised that intra-articular CRP levels would perform better than serum CRP concentrations in diagnosing knee prosthesis infection. PATIENTS AND METHODS We prospectively included 30 patients including 10 with native-knee effusions, 11 with prosthetic-knee aseptic effusions, and 11 with prosthetic-knee infection defined using 2011 Musculoskeletal Society criteria. Serum CRP was assayed using turbidimetry or nephelometry and intra-articular CRP using nephelometry. Appropriate statistical tests were performed to compare the three groups; P values < 0.05 were considered significant. RESULTS Serum and intra-articular CRP levels were 5- to 16-fold higher in the group with periprosthetic infection than in the other two groups. Although the areas under the ROC curves were not significantly different, the likelihood ratios associated with the selected cut-offs suggested superiority of intra-articular CRP: a value > 2.78 mg/L suggested possible infection (100% sensitivity and 82% specificity) and a value > 5.37 mg/L probable infection (90% sensitivity and 91% specificity). DISCUSSION Our findings suggest a possible role for intra-articular CRP assay in diagnosing knee prosthesis infection and perhaps periprosthetic infection at any site. LEVEL OF EVIDENCE Level III, diagnostic study, development of a diagnostic criterion in consecutive patients comparatively to a reference standard.
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Affiliation(s)
- C Ronde-Oustau
- Service de rhumatologie, Hôpitaux Universitaires de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - Y Diesinger
- Centre de chirurgie orthopédique et de la main, Hôpitaux Universitaires de Strasbourg, 10, avenue Baumann, 67400 Illkirch, France
| | - J-Y Jenny
- Centre de chirurgie orthopédique et de la main, Hôpitaux Universitaires de Strasbourg, 10, avenue Baumann, 67400 Illkirch, France.
| | - M Antoni
- Centre de chirurgie orthopédique et de la main, Hôpitaux Universitaires de Strasbourg, 10, avenue Baumann, 67400 Illkirch, France
| | - J Gaudias
- Centre de chirurgie orthopédique et de la main, Hôpitaux Universitaires de Strasbourg, 10, avenue Baumann, 67400 Illkirch, France
| | - C Boeri
- Centre de chirurgie orthopédique et de la main, Hôpitaux Universitaires de Strasbourg, 10, avenue Baumann, 67400 Illkirch, France
| | - J Sibilia
- Service de rhumatologie, Hôpitaux Universitaires de Strasbourg, avenue Molière, 67200 Strasbourg, France
| | - J-M Lessinger
- Laboratoire de biochimie et biologie moléculaire, Hôpitaux Universitaires de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
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Esalatmanesh K, Jamali R, Jamali A, Jamali B, Nikbakht M. Serum anti-cyclic citrullinated peptide antibodies may predict disease activity in rheumatoid arthritis. Rheumatol Int 2012; 32:3799-3805. [PMID: 22187060 DOI: 10.1007/s00296-011-2282-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/10/2011] [Indexed: 10/14/2022]
Abstract
To define the relationship between serum anti-cyclic citrullinated peptide antibodies (anti-CCP) and disease activity, and to construct a new disease activity index by using anti-CCP in rheumatoid arthritis (RA). One hundred and five RA patients were included. Disease activity based on DAS28-ESR and serum anti-CCP was measured. There was correlation between serum anti-CCP and DAS28-ESR. (R (2) = 0.71, P value < 0.01). New disease activity index was developed by replacing anti-CCP with ESR in DAS28-ESR. There was correlation between new model and DAS28-ESR. (R (2) = 0.91, P value < 0.01) The new composite index best cut-off values corresponding to DAS28-ESR values of 2.6, 3.2, and 5.1 were 3.21, 3.38, and 4.74, respectively. There was agreement between new model and DAS28-ESR for determination of patients in different disease activity categories. (Kappa = 0.71, P value < 0.01). The new disease activity index that applies serum anti-CCP may predict disease activity in RA.
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Affiliation(s)
- Kamal Esalatmanesh
- Internal Medicine Ward, Division of Rheumatology, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
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Jones NR, Pegues MA, McCrory MA, Singleton W, Bethune C, Baker BF, Norris DA, Crooke RM, Graham MJ, Szalai AJ. A Selective Inhibitor of Human C-reactive Protein Translation Is Efficacious In Vitro and in C-reactive Protein Transgenic Mice and Humans. MOLECULAR THERAPY. NUCLEIC ACIDS 2012; 1:e52. [PMID: 23629027 PMCID: PMC3511672 DOI: 10.1038/mtna.2012.44] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Observational studies of patients with established rheumatoid arthritis (RA) document a positive correlation between C-reactive protein (CRP) blood concentration and worsening of RA symptoms, but whether this association is causal or not is not known. Using CRP transgenic mice (CRPTg) with collagen-induced arthritis (CIA; a rodent model of RA), we explored causality by testing if CRP lowering via treatment with antisense oligonucleotides (ASOs) targeting human CRP mRNA was efficacious and of clinical benefit. We found that in CRPtg with established CIA, ASO-mediated lowering of blood human CRP levels improved the clinical signs of arthritis. In addition, in healthy human volunteers the ASO was well tolerated and efficacious i.e., treatment achieved significant CRP lowering. ASOs targeting CRP should provide a specific and effective way to lower human CRP levels, which might be an effective therapy in patients with established RA.
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Affiliation(s)
- Nicholas R Jones
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Parvizi J, McKenzie JC, Cashman JP. Diagnosis of periprosthetic joint infection using synovial C-reactive protein. J Arthroplasty 2012; 27:12-6. [PMID: 22560655 DOI: 10.1016/j.arth.2012.03.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 03/13/2012] [Indexed: 02/01/2023] Open
Abstract
The diagnosis of periprosthetic joint infection (PJI) is a considerable challenge. This study examines the quantification of C-reactive protein (CRP) in synovial fluid for diagnosis of PJI. Synovial fluid samples were collected prospectively from 63 patients undergoing revision or primary joint arthroplasty. All patients were divided into septic vs aseptic groups. There were 43 patients in the aseptic group and 20 patients in the septic group. There was a statistically significant difference in the mean synovial CRP between the septic cohort at 40 mg/L vs a mean of 2 mg/L for aseptic failure (P < .0001). The sensitivity was 85% with 95% specificity at a threshold of 9.5 mg/L. The area under the curve was 0.92. We believe that synovial CRP assay holds great promise as a diagnostic marker for PJI.
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Affiliation(s)
- Javad Parvizi
- Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, Pennsylvania 19107, USA
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Zamani B, Jamali R, Jamali A. Serum adenosine deaminase may predict disease activity in rheumatoid arthritis. Rheumatol Int 2012; 32:1967-1975. [PMID: 21461854 DOI: 10.1007/s00296-011-1912-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 03/13/2011] [Indexed: 12/23/2022]
Abstract
To determine the relationship between serum adenosine deaminase (ADA) and disease activity, and to develop a new disease activity index based on serum ADA in rheumatoid arthritis (RA). Seventy RA patients were included. Disease activity based on Disease Activity Score 28-ESR (DAS28-ESR) and Disease Activity Score 28-CRP (DAS28-CRP) and serum ADA were measured. There were correlations when serum ADA compared with DAS28-ESR and DAS28-CRP. (R (2) = 0.014, 0.175, respectively, P values < 0.00). New disease activity index was developed by replacing ADA with ESR and CRP in DAS28-ESR and DAS28-CRP. There were strong correlations when new model compared with DAS28-ESR and DAS28-CRP. (R (2) = 0.94 and 0.95, respectively, P values < 0.00) The best new model values corresponding to DAS28-ESR values of 2.6, 3.2, and 5.1 were 2.79, 3.4, and 4.82, respectively; and new model values corresponding to DAS28-CRP values of 2.3, 2.7, and 4.1 were 2.1, 2.9, and 4, respectively. There were agreements when the new model compared with DAS28-ESR and DAS28-CRP for determination of patients in different disease activity categories. (Kappa = 0.81 and 0.71, respectively, P values < 0.00). The new disease activity index that applies serum ADA may help in predicting disease activity in RA.
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Affiliation(s)
- Batool Zamani
- Division of Rheumatology, Internal Medicine Ward, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
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Parvizi J, Jacovides C, Adeli B, Jung KA, Hozack WJ. Mark B. Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res 2012; 470:54-60. [PMID: 21786056 PMCID: PMC3237977 DOI: 10.1007/s11999-011-1991-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND C-reactive protein (CRP) serum assays are a standard element of the diagnostic workup for periprosthetic joint infection (PJI). However, because CRP is a marker for systemic inflammation, this test is not specific to PJI. QUESTIONS/PURPOSES Our purpose was to assess whether synovial fluid and serum assays alone could differentiate between infected and uninfected revision knee arthroplasties and to determine which of these methods had the greatest diagnostic accuracy. METHODS We collected synovial fluid specimens from 66 patients undergoing revision total knee arthroplasty. Patients were judged uninfected or infected by standardized criteria. Synovial CRP levels were measured using an individual CRP assay (15 samples; 10 infected, five uninfected) and a multiplex immunoassay platform (59 samples; 25 infected, 34 uninfected). Results from preoperative standard serum CRP assays conducted were also collected (55 samples; 25 infected, 30 uninfected). Sensitivity, specificity, and receiver operating characteristic curve analyses were performed for each assay with a diagnosis of infection based on previously established criteria. RESULTS Synovial CRP concentrations differed between infected and uninfected joints in the multiplex and serum analyses. The area under the curve was 0.84 for the individual assay, 0.91 for the multiplex assay, and 0.88 for the serum CRP assay. Sensitivity and specificity were 70.0% and 100.0% for the individual enzyme-linked immunosorbent assay, 84.0% and 97.1% for the multiplex assay, and 76.0% and 93.3% for the serum CRP assay. CONCLUSIONS An assay measuring CRP in synovial fluid may be more accurate in diagnosing PJI than the standard serum CRP assay. We believe such an assay holds promise as a new diagnostic marker for PJI.
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Affiliation(s)
- Javad Parvizi
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Christina Jacovides
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Bahar Adeli
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - Kwang Am Jung
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
| | - William J. Hozack
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 USA
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Jones NR, Pegues MA, McCrory MA, Kerr SW, Jiang H, Sellati R, Berger V, Villalona J, Parikh R, McFarland M, Pantages L, Madwed JB, Szalai AJ. Collagen-induced arthritis is exacerbated in C-reactive protein-deficient mice. ARTHRITIS AND RHEUMATISM 2011; 63:2641-50. [PMID: 21567377 PMCID: PMC3168703 DOI: 10.1002/art.30444] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Blood C-reactive protein (CRP) is routinely measured to gauge inflammation. In rheumatoid arthritis (RA), a heightened CRP level is predictive of a poor outcome, while a lowered CRP level is indicative of a positive response to therapy. CRP interacts with the innate and adaptive immune systems in ways that suggest it may be causal in RA and, although this is not proven, it is widely assumed that CRP makes a detrimental contribution to the disease process. Paradoxically, results from animal studies have indicated that CRP might be beneficial in RA. This study was undertaken to study the role of CRP in a mouse model of RA, the collagen-induced arthritis (CIA) model. METHODS We compared the impact of CRP deficiency with that of transgenic overexpression of CRP on inflammatory and immune responses in mice, using CRP-deficient (Crp-/-) and human CRP-transgenic (CRP-Tg) mice, respectively. Susceptibility to CIA, a disease that resembles RA in humans, was compared between wild-type, Crp-/-, and CRP-Tg mice. RESULTS CRP deficiency significantly altered the inflammatory cytokine response evoked by challenge with endotoxin or anti-CD3 antibody, and heightened some immune responses. Compared to that in wild-type mice, CIA in Crp-/- mice progressed more rapidly and was more severe, whereas CIA in CRP-Tg mice was dramatically attenuated. Despite these disparate clinical outcomes, anticollagen autoantibody responses during CIA did not differ among the genotypes. CONCLUSION CRP exerts an early and beneficial effect in mice with CIA. The mechanism of this effect remains unknown but does not involve improvement of the autoantibody profile. In humans, the presumed detrimental role of a heightened blood CRP level during active RA might be balanced by a beneficial effect of the baseline CRP (i.e., levels manifest during the preclinical stages of disease).
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Affiliation(s)
- Nicholas R. Jones
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
| | - Melissa A. Pegues
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
| | - Mark A. McCrory
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
| | - Steven W. Kerr
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Huiping Jiang
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Rosemarie Sellati
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Valentina Berger
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Jorge Villalona
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Rajvee Parikh
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Mary McFarland
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Lynn Pantages
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Jeffrey B. Madwed
- Department of Cardiovascular Disease, Research and Development Center, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut 06877, USA
| | - Alexander J. Szalai
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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