Converting between high- and low-sensitivity C-reactive protein in the assessment of periprosthetic joint infection

Association of Age at Menarche With Inflammation and Glucose Metabolism Biomarkers in US Adult Women: NHANES 1999-2018

CONTEXT

Early age at menarche (AAM) is a risk factor for type 2 diabetes later in life, but the pathogenic pathways that confer increased risk remain unknown.

OBJECTIVE

We examined the associations between AAM and inflammatory and glucose metabolism biomarkers among US adult women who were free of diabetes.

METHODS

Using the National Health and Nutrition Examination Survey (NHANES) 1999-2018, 19 228 women over 20 years old who were free of self-reported cancer and diabetes were included in this cross-sectional analysis. AAM was the self-reported age at first menstruation. C-reactive protein (CRP), fasting glucose, fasting insulin, and ferritin levels were measured as biomarkers of inflammation and glucose metabolism in adult blood samples using latex-enhanced nephelometry, enzymatic, and immunoassay methods. Multiple linear regression was used to relate AAM to the biomarkers.

RESULTS

The median age at the time of blood sample collection was 44 years (interquartile range, 33-62). After age adjustment, there was an association between a lower AAM and higher CRP (P-trend = .006), fasting glucose (P-trend < .0001), fasting insulin (P-trend < .0001), and ferritin (P-trend < .0001). These remained significant after additional adjustment for demographic, reproductive, lifestyle, and adiposity variables, except for ferritin. Smoking modified the effect of AAM on CRP (P-interaction = .014), fasting insulin (P-interaction < .001), and fasting glucose (P-interaction < .001). In stratified analysis, the observed associations became more pronounced in nonsmokers, while they were attenuated to nonsignificance in active smokers.

CONCLUSION

Earlier age at menarche is associated with an unfavorable inflammatory and glucose metabolic biomarker profile in a nationally representative sample of adult women free of diabetes, especially among nonsmokers.

Systematic review and meta-analysis of the diagnostic accuracy of inflammatory markers for infected diabetic foot ulcer

BACKGROUND

The aim was to evaluate the diagnostic value of ESR, CPR, PCT, and WBC in patients with infected diabetic foot ulcer (DFU).

METHODS

The MEDLINE, Embase, BIOSIS, Cochrane databases, and Web of Knowledge databases were searched, without language restriction, to July 2023. Original studies were selected that reported the performance of ESR, CPR, PCT, and WBC in diagnosing infected DFU. To assess the diagnostic value of biomarkers for infected DFU, pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic curve (ROC-AUC) were calculated.

RESULTS

Ten studies with 765 patients were identified in our meta-analysis. The pooled sensitivity and specificity of ESR was 0.82 (95 % CI: 0.68-0.91) and 0.83 (95 % CI: 0.69-0.91) respectively. The pooled sensitivity and specificity of CRP was 0.81 (95 % CI: 0.65-0.91) and 0.91 (95 % CI: 0.79-0.96) respectively. The pooled sensitivity and specificity of PCT was 0.76 (95 % CI: 0.65-0.85) and 0.89 (95 % CI: 0.78-0.95) respectively. The pooled sensitivity and specificity of WBC was 0.75 (95 % CI: 0.64-0.83) and 0.79 (95 % CI: 0.67-0.88) respectively. CRP showed the best diagnostic accuracy at distinguishing infected DFU from noninfected DFU with an AUC of 0.93, followed by PCT (AUC of 0.89), ESR (AUC of 0.89), and WBC (AUC of 0.84).

CONCLUSION

CPR levels had high efficiency in distinguishing infected DFU from noninfected DFU, followed by PCT, ESR and WBC. All of these biomarkers could be helpful for early diagnosis of infected DFU. New biomarkers for improving medical decision in diagnosis of infected DFU are highly desirable.

Different Associations of Coffee Consumption with the Risk of Incident Metabolic Dysfunction-Associated Steatotic Liver Disease and Advanced Liver Fibrosis

Although coffee has a potential hepatoprotective effect, evidence of the relationship between coffee consumption and metabolic dysfunction-associated steatotic liver disease (MASLD) remains conflicting. There is limited evidence regarding the most appropriate coffee intake to prevent advanced liver fibrosis (ALF) in patients with MASLD. We investigated the effect of coffee consumption on MASLD and ALF among 5266 participants without MASLD and 1326 with MASLD but without ALF. Participants were grouped by coffee intake: non-consumers, >0 and <1 cups/day, ≥1 and <2 cups/day, and ≥2 cups/day. Over a median follow-up of 11.6 years for MASLD and 15.7 years for ALF, coffee consumption did not significantly affect the incidence of MASLD, with 2298 new cases observed. However, a notable inverse association was found with ALF risk in patients with MASLD among those consuming coffee ≥2 cups/day (adjusted HR 0.57, 95% CI: 0.37-0.90, p = 0.014), especially among those consuming coffee ≥2 and <3 cups/day (adjusted HR 0.51, 95% CI: 0.30-0.89, p = 0.018). This suggests a potential hepatoprotective effect of coffee, especially in preventing the progression of liver fibrosis in patients with MASLD. These findings propose that coffee consumption could be a simple and effective approach to mitigate the risk of ALF in individuals with MASLD.

Early stages of diffuse idiopathic skeletal hyperostosis (DISH) and chronic inflammation: the Camargo Cohort Study

INTRODUCTION/OBJECTIVES

DISH has traditionally been considered a non-inflammatory rheumatic disorder. Currently, an inflammatory component has been theorized in the early phases of this condition (EDISH). The study is aimed at investigating a possible relationship between EDISH and chronic inflammation.

METHOD

Analytical-observational study: participants from the Camargo Cohort Study were enrolled. We collected clinical, radiological, and laboratory data. C-reactive protein (CRP), albumin-to-globulin ratio (AGR), and triglyceride-glucose (TyG) index were assessed. EDISH was defined by Schlapbach's scale grades I or II. A fuzzy matching with tolerance factor = 0.2 was performed. Subjects without ossification (NDISH), sex- and age-matched with cases (1:4), acted as controls. Definite DISH was an exclusion criterion. Multivariable analyses were performed.

RESULTS

We evaluated 987 persons (mean age 64 ± 8 years; 191 cases with 63.9% women). EDISH subjects presented more frequently obesity, T2DM, MetS, and the lipid pattern [↑TG ↓TC]. TyG index and alkaline phosphatase (ALP) were higher. Trabecular bone score (TBS) was significantly lower (1.310 [0.2] vs. 1.342 [0.1]; p = 0.025). CRP and ALP showed the highest correlation (r = 0.510; p = 0.0001) at lowest TBS level. AGR was lower, and its correlations with ALP (r =  - 0.219; p = 0.0001) and CTX (r =  - 0.153; p = 0.022), were weaker or non-significant in NDISH. After adjustment for potential confounders, estimated CRP means for EDISH and NDISH were 0.52 (95% CI: 0.43-0.62) and 0.41 (95% CI: 0.36-0.46), respectively (p = 0.038).

CONCLUSIONS

EDISH was associated with chronic inflammation. Findings revealed an interplay between inflammation, trabecular impairment, and the onset of ossification. Lipid alterations were similar to those observed in chronic-inflammatory diseases. Key Points • An inflammatory component has been theorized in early stages of DISH (EDISH) • In EDISH group compared to non-DISH, we observed significantly higher correlations between biomarkers and some relevant variables. In particular, with alkaline phosphatase (ALP) and with trabecular bone score (TBS) • EDISH has shown to be associated with chronic inflammation • The lipid alterations observed in the EDISH group were similar to those observed in chronic-inflammatory diseases.

The Effect of Dietary Patterns on Inflammatory Biomarkers in Adults with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Some evidence supports the fact that chronic low-grade inflammation contributes to the physiopathology of type 2 diabetes mellitus (T2DM), and circulating markers of inflammation (e.g., C-reactive protein (CRP), pro- and anti-inflammatory biomarkers (e.g., adiponectin), and endothelial function markers could indicate an ongoing pathology. Following certain dietary patterns (DPs) may result in favorable changes in inflammatory biomarkers. The overarching aim of this systematic review and meta-analysis is to explore the inflammatory effect of healthy DPs on inflammatory biomarkers in adults with T2DM. A systematic search of the literature was conducted using the electronic databases MEDLINE, SCOPUS, and Cochrane Central Register of Controlled Trials. A total of 10 randomized controlled clinical trials (RCTs) were analyzed. In our linear meta-analysis, the random-effects model was applied to estimate standardized mean differences (SMD) to associate the effect of the interventions. Dietary Approaches to Stop Hypertension (DASH), Diabetes UK healthy eating, Mediterranean Diet (MD), Diabetes Prevention Program (DPP), and the American Heart Association’s Therapeutic Lifestyle Changes diet were associated with a significant reduction in CRP (SMD: −0.83, 99% CI −1.49, −0.17, p < 0.001; I2 94%), while plasma levels of adiponectin were significantly higher with the intake of MD, DPP, and Diabetes UK healthy eating (SMD: 0.81, 99% CI 0.06,1.56, p < 0.005; I2 96%), both of which indicate less inflammation. Sensitivity analyses were carried out, and potential publication bias was examined. In conclusion, low- moderate-quality evidence from RCTs suggests that, for the DPs evaluated, there are favorable changes in CRP and adiponectin.

Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review

Objective

The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage.

Methods

We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs.

Results

Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients.

Conclusions

The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.

The Relationship Between Iron Status and Atherosclerotic Cardiovascular Disease Risk in Non-anemic Patients Without a History of Cardiovascular Diseases: A Cross-Sectional Study

Iron deficiency (ID) and iron status in non-anemic patients with atherosclerotic cardiovascular disease (ASCVD) risk without a history of cardiovascular diseases is still weakly explored. In this study, the authors evaluated the most common ID definitions in this group of patients. A total of 533 participants from the National Health and Nutrition Examination Survey (NHANES) were collected from 2005-2006, 2017-2018, and 2017-2020 records. Participants were divided according to their ASCVD risk score to the following groups: low (n=168, 32%), borderline (n=43, 8%), intermediate (n=200, 37%), and high (n=122, 23%). There was a higher prevalence of ID in low- and borderline-risk groups in contrast to intermediate- and high-risk groups. Higher serum ferritin concentrations were observed in groups with a greater ASCVD risk score. Transferrin saturation (TSAT) was comparable in all ASCVD categories. Lack of ID, defined by three different guidelines that are mainly based on serum ferritin levels, predisposed to a higher ASCVD risk category. Normal iron status, defined by these three guidelines, was positively associated with the male gender. The opposite association was observed for non-Hispanic Whites. The analyzed criteria of ID, based mostly on serum ferritin levels, demonstrated limited usefulness in patients with increased ASCVD risk. Further studies should be done to determine proper ID diagnostic criteria in non-anemic patients without a previous cardiovascular history with elevated ASCVD risk.

The efficacy of inflammatory markers in diagnosing infected diabetic foot ulcers and diabetic foot osteomyelitis: Systematic review and meta-analysis

Background

Diabetes foot ulcer (DFU) is a complication of diabetes mellitus. Accurate diagnosis of DFU severity through inflammatory markers will assist in reducing impact on quality of life. We aimed to ascertain the diagnostic test accuracy of commonly used inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and white cell count (WCC) for the diagnosis and differentiation between DFU grades based on the International Working Group on the Diabetic Foot classification system.

Methods

This systematic review explored studies that investigated one or more of the above-listed index tests aiding in diagnosing infected DFU. This review was registered on PROSPERO database (ID = CRD42021255618) and searched 5 databases including an assessment of the references of included studies. Records were manually screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 16 studies were included which were assessed for quality using QUADAS-2 tool and meta-analysed using Meta-Disc v1.4.

Results

CRP had the greatest area under the curve (AUC) of 0.893 for diagnosing grade 2 DFU. This returned a pooled sensitivity and specificity of 77.4% (95% CI: 72% to 82%) and 84.3% (95% CI: 79% to 89%) respectively. In terms of diagnosing grade 3 DFU, procalcitonin had the highest AUC value of 0.844 when compared with other markers. The pooled sensitivity of PCT was calculated as 85.5% (95% CI: 79% to 90%) and specificity as 68.9% (95% CI: 63% to 75%).

Conclusion

CRP and PCT are the best markers for diagnosing grade 2 and grade 3 DFU respectively. Other markers are also valuable when used in conjunction with clinical judgement. The findings accentuate the necessity of further research to establish standardised cut-off values for these inflammatory markers in diagnosing diabetic foot ulcers.

The effect of periodontitis on recipient outcomes after kidney transplantation

Background: Recent several reports have demonstrated that periodontitis is prevalent and adversely affects the survival in patients with chronic kidney disease (CKD) or end-stage kidney disease. However, its impact on transplant outcomes remains uncertain.Methods: This retrospective cohort study included 136 and 167 patients, respectively, who underwent living donor kidney transplantation (KT) at Seoul National University Hospital from July 2012 to August 2016 and Korea University Hospital from April 2008 to October 2018. We divided patients into three groups according to stages of periodontitis based on a new classification system. Results: Patients with severe periodontitis were older, had a higher prevalence of diabetes, a higher body mass index and C-reactive protein level, a lower cardiac output, and were more likely to be smokers, indicating its association with chronic systemic inflammation. After KT, stage IV periodontitis was independently associated with a lower incidence of acute T cell-mediated rejection, suggesting the possible effect of periodontitis on immune function. However, 1-year and 3-year estimated glomerular filtration rates were not different. Among the KT recipients followed up more than 3 years, new-onset cardiovascular disease occurred in nine patients, and coronary artery disease occurred more frequently in patients with stage IV periodontitis. However, diabetes was the independent predictor of new-onset coronary artery disease in multivariate logistic regression analysis.Conclusion: Our findings showed that periodontitis might be an important player in determining posttransplant outcomes in recipients. Further interventional trials to test whether treating periodontitis could modify transplant outcome are needed.

One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee

Objective

To assess the safety and effectiveness of one‐stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

This retrospective study included a total of 495 patients who had undergone one‐stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one‐stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF‐12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow‐up session.

Results

A total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram‐positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram‐negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow‐up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied.

Conclusion

One‐stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.

Oral turmeric/curcumin effects on inflammatory markers in chronic inflammatory diseases: A systematic review and meta-analysis of randomized controlled trials

Turmeric extract or active component curcumin may have anti-inflammatory effects in people with chronic inflammatory diseases. The effect of turmeric or curcumin on a wide range of inflammatory markers has not been evaluated in a systematic review. We performed a systematic review of randomized controlled trials (RCTs) evaluating the effects of oral turmeric or curcumin on inflammatory markers (CRP, hsCRP, IL-1, IL-6, TNF) in patients with a wide range of chronic inflammatory diseases. Pubmed, EMBASE, Scopus, the Web of Science, and the Cochrane library were evaluated until June 2018. Random effects meta-analyses with inverse variance methods and stratified by turmeric or curcumin were performed. Effects were expressed as mean differences (MD) and their 95% confidence intervals (CI). Risk of bias of RCTs was evaluated with the Cochrane tool. Nineteen RCTs were identified; included patients had rheumatic diseases, advanced chronic kidney disease with hemodialysis, metabolic syndrome, and cardiovascular diseases. Turmeric was the intervention in 5 RCTs (n = 356) and curcumin/curcuminoids in 14 RCTs (n = 988). Follow up times ranged between 4 and 16 weeks. One RCT had high risk of bias. In comparison to controls, turmeric or curcumin did not significantly decrease levels of CRP (MD -2.71 mg/L, 95%CI -5.73 to 0.31, p = 0.08, 5 studies), hsCRP (MD -1.44 mg/L, 95%CI -2.94 to 0.06, p = 0.06, 6 studies), IL-1 beta (MD -4.25 pg/mL, 95%CI -13.32 to 4.82, p = 0.36, 2 studies), IL-6 (MD -0.71 pg/mL, 95%CI -1.68 to 0.25, p = 0.15), and TNF alpha (MD -1.23 pg/mL, 95%CI -3.01 to 0.55, p = 0.18, 7 studies). There were no differences between turmeric and curcumin interventions. High heterogeneity of effects was observed for all markers across studies, except hsCRP. Other inflammatory markers such as IL-1 alpha, TNF beta, IL-17, and IL-22 had scarce data. Turmeric or curcumin did not decrease several inflammatory markers in patients with chronic inflammatory diseases.

Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review

BACKGROUND

Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI.

METHODS

This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model.

RESULTS

A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above.

CONCLUSIONS

The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Performance enhancement of procalcitonin by high-sensitivity C-reactive protein at the optimal cutoff in predicting bacteremia in emergency department adult patients

Pathogenic bacteremia portends a high mortality risk in adult patients admitted to an Emergency Department (ED). This study aims to investigate the effect of adding high-sensitivity C-reactive protein (hs-CRP) to procalcitonin (PCT) and lactate in predicting bacteremia, Gram-negative (GNB) and Gram-positive bacteremia (GPB), using the optimal cutoff derived from the receiver operating characteristics analysis. We evaluated the diagnostic measures, including the positive-test likelihood (LR+), the negative-test likelihood (LR-), and the diagnostic odds ratio (DOR) using a single-center retrospective analysis design. This Standards for Reporting Diagnostic-compliant study comprised 886 consecutive adults who were admitted to the ED in 2010; to this cohort, a 22.2% prevalence of true bacteremia was subsequently confirmed. At the cutoff of 3.9 μg/L, PCT had a DOR of 5.3 (95% confidence interval [CI]: 3.76-7.61) and LR + of 2.8 (95% CI: 2.3-3.4) in predicting overall bacteremia. Elevated PCT and lactate (cutoff at 2 mmol/L), increased the DOR and LR + to 6.3 (95% CI: 4.27-9.29) and 4.0 (95% CI: 3.1-5.2). The DOR and LR + were further improved to 7.1 (95% CI: 4.2-11.95) and 5.6 (95% CI: 3.7-8.6), respectively, when hs-CRP at the cutoff of 1238 nmol/L was added to PCT plus lactate. High-sensitivity CRP at the cutoff of 1,255 nmol/L can enhance the discriminative power raising DOR and LR + values for GPB. The elevation of hs-CRP at the optimal cutoff might improve the diagnostic performance to predict unspecified bacteremia and GPB, but not GNB.

Clinical significance of Glasgow Prognostic Score in patients with tuberculous pleurisy

Background

The Glasgow Prognostic Score (GPS) reflects the host systemic inflammatory response and is a validated, independent prognostic factor for various malignancies. We investigated the clinical significance of the GPS in patients with tuberculosis (TB) pleurisy, focusing on treatment outcomes including paradoxical response (PR).

Methods

This was a retrospective study performed between January 2010 and December 2015 in two referral and university hospitals in South Korea, with intermediate incidences of TB. In all, 462 patients with TB pleurisy were registered in the study. The patients were classified into three groups based on GPS score, as follows: (I) GPS of 2, elevated CRP level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL); (II) GPS of 1, elevated CRP level or hypoalbuminemia; and (III) GPS of 0, neither elevated CRP level nor hypoalbuminemia.

Results

A total of 367 patients with TB pleurisy were finally included. PR occurred in 102 (27.8%) patients after a mean of 75 days following initiation of anti-TB treatment. The proportion of PR occurrence was significantly lower in the GPS 2 group (P=0.007). Successful treatment outcomes including cure and completion were also significantly lower in the GPS 2 group (P=0.001), while all-cause mortality and TB-specific mortality were higher in the GPS 2 group (P=0.001 and <0.001, respectively). Old age over than 65 years old was an independent predicting factor for high mortality and lower PR occurrence. However, the TB relapse rate was not different among the three GPS groups.

Conclusions

Higher GPS value and elderly age were identified as prognostic factors for poor outcomes in TB pleurisy and as predicting factors for lower PR occurrence. More prospective studies are needed to clarify the utility of GPS in patients with TB pleurisy.

Single and persistent elevation of C-reactive protein levels and the risk of atrial fibrillation in a general population: The Ansan-Ansung Cohort of the Korean Genome and Epidemiology Study

BACKGROUND

Inflammation has been reported to cause atrial fibrillation (AF). However, it remains unclear whether C-reactive protein (CRP) levels predict AF. We investigated whether there was an association between serum CRP levels and the development of AF.

METHODS

A total of 10,030 subjects aged between 40 and 69 years were enrolled and followed biennially over a 12-year period in the Ansan-Ansung cohort study. Serum CRP levels were measured at baseline and high-sensitivity CRP (hsCRP) levels were measured at every revisit. AF was identified using 12-lead standard electrocardiography. Inverse probability of treatment weighting was applied to balance the confounders of AF development between groups.

RESULTS

Serum CRP levels were higher in subjects with AF at baseline and those with new-onset AF than in those without AF. Cox-regression analysis showed that high CRP levels (>3 mg/L) and intermediate CRP levels (1-3 mg/L) at baseline were not associated with a higher risk of new-onset AF compared with low CRP levels (<1 mg/L) after adjustments for covariates. The weighted incidences of AF also did not differ according to the CRP levels. In contrast, persistent elevation of CRP or hsCRP levels (≥1 mg/L at all visits) was associated with a higher risk of AF compared with nonpersistent elevation of CRP or hsCRP levels after adjustment for covariates in both unweighted and weighted cohorts.

CONCLUSION

A high CRP level at a single measurement was not associated with the risk of AF, whereas persistently elevated CRP levels independently predicted the development of AF.

Diagnostic value of serum procalcitonin, lactate, and high-sensitivity C-reactive protein for predicting bacteremia in adult patients in the emergency department

BACKGROUND

Few studies compared the diagnostic value of procalcitonin with a combination of other tests including lactate and high-sensitivity C-reactive protein in the prediction of pathogenic bacteremia in emergency department adult patients.

METHODS

We performed a retrospective study assessing the differences in performances of procalcitonin at a cutoff of 0.5 ng/mL, lactate at a cutoff of 19.8 mg/dL, high-sensitivity C-reactive protein at a cutoff of 0.8 mg/dL and their combinations for predicting bacteremia in emergency department adult patients. Sensitivity, specificity, overall accuracy, positive-test and negative-test likelihood, and diagnostic odds ratio with 95% confidence interval for each test combination were calculated for comparison. The receiver operating characteristic curve for every single test were compared using DeLong's method. We also performed a sensitivity analysis in two expanded patient cohorts to assess the discriminative ability of procalcitonin or test combination.

RESULTS

A total of 886 patients formed the initial patient cohort. The area under the receiver operating characteristic curve for discriminating positive blood culture was: procalcitonin = 0.72 (95% CI [0.69-0.75]) with a derived optimal cutoff at 3.9 ng/mL; lactate 0.69 (0.66-0.72) with an optimal cutoff at 17.9 mg/dL; high-sensitivity C-reactive protein 0.56 (0.53-0.59) with an optimal cutoff of 13 mg/dL; with pairwise comparisons showing statistically significant better performance of either procalcitonin or lactate outperforming high-sensitivity C-reactive protein. To predict positive blood cultures, the diagnostic odds ratio for procalcitonin was 3.64 (95% CI [2.46-5.51]), lactate 2.93 (2.09-4.14), and high-sensitivity C-reactive protein 0.91 (0.55-1.55; P = 0.79). About combined tests, the diagnostic odds ratio for procalcitonin and lactate increases were 3.98 (95% CI [2.81-5.63]) for positive blood culture prediction. Elevated procalcitonin level rendered a six-fold increased risk of positive gram-negative bacteremia with a diagnostic odds ratio of 6.44 (95% CI [3.65-12.15]), which showed no further improvement in any test combinations. In the sensitivity analysis, as a single test to predict unspecified, gram-negative and gram-positive bacteremia, procalcitonin performed even better in an expanded cohort of 2,234 adult patients in terms of the diagnostic odds ratio.

DISCUSSIONS

For adult emergency patients, procalcitonin has an acceptable discriminative ability for bacterial blood culture and a better discriminative ability for gram-negative bacteremia when compared with lactate and high-sensitivity C-reactive protein. High-sensitivity C-reactive protein at a cutoff of 0.8 mg/dL performed poorly for the prediction of positive bacterial culture.

Diagnostic accuracy of alpha-defensin in periprosthetic joint infection: a systematic review and meta-analysis

BACKGROUND

Alpha-defensin, a novel biomarker, has shown great potential for the accurate diagnosis of periprosthetic joint infection (PJI) in recent years: many published studies have presented encouraging results. Nevertheless, the diagnostic accuracy of alpha-defensin is inconsistent across published studies. Moreover, the optimum value of the diagnostic threshold urgently needs to be ascertained. This meta-analysis sought to estimate the precision of alpha-defensin for the diagnosis of PJI and, where possible, to confirm the threshold.

METHOD

We systematically searched PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov for relevant literature on alpha-defensin in the diagnosis of PJI (searching publications from the inception of each database until February 2017, with no language restriction). Pooled sensitivity, specificity, diagnostic odds ratios, and likelihood ratios were the indexes used for assessment, with the use of a random-effects model.

RESULT

Eleven of the 426 studies that evaluated the diagnostic accuracy of alpha-defensin in periprosthetic joint infection (PJI) were included in this analysis. The pooled diagnostic sensitivity of alpha-defensin for PJI was 0.96 (95% confidence interval [CI], 0.87 to 0.99) and the specificity was 0.95 (95% CI, 0.91 to 0.97). Since there was substantial heterogeneity among studies, based on the inconsistency index (I²), threshold, site of arthroplasty, study design and techniques for the alpha-defensin test, subgroup analyses were performed to estimate the impacts of these variables on heterogeneity.

CONCLUSION

In summary, this meta-analysis clearly lends support to the conclusion that alpha-defensin is a promising addition to the current methods for diagnosis of PJI.

Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty

BACKGROUND

Criteria for diagnosis of infected internal fixation implants at the time of conversion to total hip arthroplasty (THA) are not clear. The purpose of this study is to identify risk factors for infection in patients undergoing conversion to THA.

METHODS

We retrospectively reviewed patients at a single institution who underwent conversion to THA from 2009 to 2014. Patients were diagnosed with infection preoperatively using Musculoskeletal Infection Society criteria or postoperatively if they were found to have positive cultures intraoperatively at the time of conversion surgery. Medical comorbidities and preoperative inflammatory markers were compared between infected and noninfected groups. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors for infection. Receiver operating characteristic curves were generated to determine test performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A post hoc power analysis was performed.

RESULTS

Thirty-three patients were included in the study. Six patients (18%) were diagnosed with infection. We found no association between comorbidities and infection in this cohort. The mean ESR and CRP were higher in infected (ESR = 41.6 mm/h, CRP = 2.0 mg/dL) vs noninfected (ESR = 19.3 mm/h, CRP = 1.3 mg/dL) groups (both P < .01). ESR >30 mm/h (odds ratio 28.8, 95% confidence interval 2.6-315.4, P = .001) and CRP >1.0 mg/dL (odds ratio 11.5, 95% confidence interval 1.6-85.2, P = .01) were strongly associated with infection. Receiver operating characteristic curves for ESR (area under the curve [AUC] = 0.89) and CRP (AUC = 0.89) demonstrated good fit.

CONCLUSION

We report a high incidence of infection in patients who underwent conversion to THA. Preoperative ESR and CRP are effective screening tools though occult infections may still be missed. Patients with borderline or elevated inflammatory markers should raise strong suspicion for infection.

Infection post-total knee replacement: current concepts

Periprosthetic joint infection is a hot topic for investigation because it represents a challenging clinical problem with considerable burden for patients, institutions, and health systems. Despite our substantial knowledge, many details in prevention, pathophysiology, diagnosis, and treatment of infectious complications following total knee arthroplasty remain to be controversial with the available evidence being insufficient and at times conflictive. This manuscript is an attempt to approach the most recently published literature regarding the aforementioned details and aims to provide the reader with an updated perspective in the management of periprosthetic joint infection of the knee.