The Role of Neutrophil-to-Lymphocyte Ratio in the Diagnosis of Acute Appendicitis

BACKGROUND

Acute appendicitis (AA), a common reason for episodes of acute abdomen, is a surgical emergency. Its immediate diagnosis and management are of immense significance, as its diagnosis can become challenging at times, especially in resource-limited setups. The goal of this study was to ascertain the threshold value for the neutrophil-to-lymphocyte ratio (NLR) in diagnosing AA and to calculate the validity parameters for the NLR.

METHODOLOGY

 A cross-sectional study was carried out involving 108 patients who were admitted to the surgical wards of Ayub Teaching Hospital, Abbottabad with suspicion of AA and subsequently underwent open appendectomy. Data was collected regarding the demography of the patients, physical examination findings, clinical presentations, and investigations including the histopathology and complete blood count, from which the NLR value was computed, and the Statistical Package for Social Sciences (SPSS), version 25.0 (IBM Corp., Armonk, NY) was utilized for the computation. Receiver operating characteristic (ROC) analysis was done to calculate the cut-off value of the NLR for diagnosing AA, and validity parameters were computed, taking into account statistical significance with a p-value < 0.05.

RESULTS

Based on the ROC analysis, a threshold value for NLR indicating a positive appendectomy was determined to be 2.49 (sensitivity = 71.4% and 1-specificity = 12.5%) with an area under the curve of 90.6% (95% confidence interval {CI} 0.818-0.994, p<0.001). The sensitivity, specificity, and diagnostic accuracy of NLR for diagnosing AA were 71.43%, 87.5%, and 72.73%, respectively.

CONCLUSION

 There is a strong correlation between NLR at a cut-off value of 2.49 and the diagnosis of AA. We suggest that NLR should be utilized as a complementary biomarker to clinical examination, aiding in the diagnosis of AA.

The Diagnostic Accuracy of Neutrophils to Lymphocytes Ratio, Platelets to Lymphocytes Ratio, Monocytes to Lymphocytes Ratio, and Platelets to Mean Platelet Volume Ratio in Diagnosing Periprosthetic Knee Infections. Are Gender-Specific Cutoff Values Needed?

BACKGROUND

This study aimed to assess the most appropriate thresholds for neutrophils to lymphocytes ratio (NLR), platelets to lymphocytes ratio, monocytes to lymphocytes ratio (MLR), and platelets to mean platelet volume ratio in patients who had a suspected prosthetic knee infection. Furthermore, we evaluated the diagnostic accuracy of our proposed thresholds by men and women.

METHODS

A total of 261 consecutive patients affected by painful total knee arthroplasty were included. International Consensus Meeting diagnostic criteria were used to identify periprosthetic infections. Sensitivity, specificity, positive, and negative predictive values were calculated for each cutoff value obtained. The area under the receiver operating characteristic curve was evaluated.

RESULTS

NLR reported the best diagnostic accuracy. MLR and NLR reported higher area under the curves in men and women. We obtained an MLR value ≥0.30 (optimal cutoff value for men) and ≥0.17 (optimal cutoff value for women). In men, the sensitivity and the specificity were 0.71 and 0.77, respectively, versus 0.82 and 0.29, in women. For NLR, we obtained a value ≥2.52 (best cutoff value for men) and ≥2.46 (best cutoff value for women). These cutoffs reported a sensitivity and specificity of 0.71 and 0.88 versus 0.54 and 0.76 in men and women, respectively.

CONCLUSION

These biomarkers present a low diagnostic accuracy in periprosthetic joint infection detection. Men whose MLR and NLR were above cutoff values had a 77 and 88% probability of presenting a septic prosthetic failure. NLR of at least 2.46 was reasonably sensitive for women who have a periprosthetic knee infection.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Serum Inflammatory Biomarkers in the Diagnosis of Periprosthetic Joint Infections

Accurate preoperative diagnosis of periprosthetic joint infections (PJIs) can be very challenging, especially in patients with chronic PJI caused by low-virulence microorganisms. Serum parameters, such as serum C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR), are—among other diagnostic test methods—widely used to distinguish septic from aseptic failure after total hip or knee arthroplasty and are recommended by the AAOS in the preoperative setting. However, they are systemic parameters, and therefore, unspecific. Nevertheless, they may be the first and occasionally the only preoperative indication, especially when clinical symptoms are lacking. They are easy to obtain, cheap, and are available worldwide. In the last decade, different novel serum biomarkers (percentage of neutrophils, neutrophils to lymphocytes ratio, platelet count to mean platelet volume ratio, fibrinogen, D-Dimer, Il-6, PCT) were investigated to find a more specific and accurate serum parameter in the diagnosis of PJI. This article reviews the diagnostic value of established (serum CRP, ESR, WBC) and ‘novel’ serum inflammatory biomarkers (fibrinogen, D-dimer, interleukin-6 (IL-6), procalcitonin, percentage of neutrophils (%N), neutrophils to lymphocytes ratio (NLR), platelet count to mean platelet volume ratio (PC/mPV)) for the preoperative diagnosis of periprosthetic joint infections.

Clinical efficacy of atorvastatin calcium combined with aspirin in patients with acute ischemic stroke and effect on neutrophils, lymphocytes and IL-33

Clinical efficacy of atorvastatin calcium combined with aspirin in patients with acute ischemic stroke (AIS) and its effect on neutrophils to lymphocytes ratio (NLR) and interleukin-33 (IL-33) were investigated. In total, 108 patients with AIS in Luoyang Central Hospital Affiliated to Zhengzhou University from April 2016 to October 2017 were selected. There were 56 cases treated with atorvastatin calcium combined with aspirin as the observation group, and 52 cases were treated with aspirin alone as the control group. The clinical effect was observed. The NLR and IL-33 levels were measured by routine blood test and enzyme linked immunosorbent assay (ELISA) before and after treatment. The scores of the National Institutes of Health Stroke scale (NIHSS) and the occurrence of complications were collected before and after treatment in the two groups. Modified Rankin Scale (MRS) was used to evaluate the curative effect. Score ≤2 points is effective in the treatment. Pearson's analysis was used to analyze the correlation between NLR, IL-33 and NIHSS score. The total hospitalization time and 1 year survival rate were compared. The total effective rate of treatment in the observation group was higher than that in the control group (P<0.05). There was no difference in NLR and IL-33 levels between the two groups before treatment (P>0.05). After treatment, the NLR in the observation group was significantly lower than that in the control group (P<0.05). After treatment, the NIHSS score, the total number of complications and the total hospitalization time in the observation group were significantly lower than those in the control group (P<0.05). Pearson's analysis showed a positive correlation between NLR and NIHSS score (r=0.681, P<0.001), and a negative correlation between IL-33 and NIHSS score (r=-0.708, P<0.001). In conclusion, atorvastatin calcium combined with aspirin has a better effective rate in the treatment of acute ischemic stroke than aspirin alone. The combination can better reduce the NLR, increase the expression level of IL-33 in serum, reduce the occurrence of complications and hospitalization time, and increase the survival rate of patients.

Mean Platelet Volume in Early Diagnosis of Adnexal Torsion

BACKGROUND

Adnexal torsion (AT) is among the gynecological emergencies; more common in reproductive age, if diagnosed late, this can cause ovarian failure and infertility, but rarely thrombophlebitis and peritonitis. Despite these severe complications, preoperative diagnostic tests are not enough for early diagnosis. There are certain pieces of literature on the subject that reveal changes in mean platelet volume (MPV) values occur in inflammatory and ischemic diseases and that these changes have diagnostic and prognostic significance. However, there are no studies investigating this relationship with adnexal torsion.

AIMS

The aim of the study is to investigate the diagnostic and prognostic significance of the mean platelet volume value in the early diagnosis of patients with adnexal torsion.

STUDY DESIGN

Case-control study.

METHODS

Pre-operative demographic data, MPV, leukocyte count and neutrophils to lymphocytes (N/L) ratio in the blood samples of 51 patients, who were operated on preliminary adnexal torsion and diagnosed as adnexal torsion with a benign ovarian cyst (AT group) were retrospectively compared with those of 50 patients who were operated upon because of benign ovarian cysts and without torsion (control group) at this hospital between 2006 and 2014.

RESULTS

The mean MPV level was found to be 8.1 (7.1-10.7) fL in the AT group and 7.9 (6.6-10.2) fL in the control group; no statistically significant difference was found between the groups (p>0.05). Leukocyte count and N/L ratio in the AT group were, on average, 12×10(3)/mm(3) and 82% respectively and in control group; they were, on average, 7.2×10(3)/mm(3) and 59%, respectively. A statistically significant increase was found in the leukocyte count and N/L ratio of the AT group compared to the control group (p<0.001). The platelet count in the AT group was, on average, 253×10(3)/mm(3) and in the control group it was, on average, 280×10(3)/mm(3); no statistically significant difference was detected between these two groups (p>0.05). No correlation was detected between the MPV, platelet and leukocyte counts. The sensitivity of the leukocytosis to the AT cases was found to be 66.7%, and selectivity was 94%.

CONCLUSION

The AT diagnostic and prognostic importance of MPV value has not been determined in this study.