Normalization Of C-reactive Protein Research Articles

57-Year-Old Man With Atypical Chest Pain

57-Year-Old Man With Atypical Chest Pain

Distinct Thresholds of Infliximab Trough Level Are Associated with Different Therapeutic Outcomes in Patients with Inflammatory Bowel Disease: A Prospective Observational Study.

Several studies have reported a strong correlation between infliximab (IFX) trough levels (trough levels of infliximab [TLI]) and clinical remission (CR). We aimed to determine threshold values of TLI associated with the occurrence of CR, with or without normal inflammatory biomarkers, including serum C-reactive protein (CRP) and fecal calprotectin (fCal). We included prospectively all consecutive patients with inflammatory bowel disease under IFX therapy (5 mg/kg every 8 wk) for at least 6 months. Disease activity (using the Crohn's Disease Activity Index or Mayo score) was recorded, and TLI, CRP, and fCal were measured before IFX infusion. Two hundred thirteen patients (131 Crohn's disease) were included. The median TLIs were higher in patients who achieved CR compared with those in patients who did not (2.6 versus 1.2 μg/mL, P < 0.01). The median TLI were higher in patients achieving CR with CRP normalization or CR with fCal <250 μg/g in comparison with patients with persistent elevated CRP or fCal (3.5 versus 1.6 μg/mL, P < 0.01 and 4.9 versus 1.8 μg/mL, P < 0.001, respectively). Finally, the median TLIs were higher in patients achieving CR with normal CRP and fCal <50 μg/g in comparison with patients without strictly normal biomarkers (5.9 versus 2.1 μg/mL, P < 0.001). The more the expected level of response to IFX was stringent, the more the median TLI and optimal thresholds were high. Threshold values of TLI differ according to therapeutic outcomes expected in patients with inflammatory bowel disease under maintenance therapy with IFX.

Variation of C-Reactive Protein and White Blood Cell Counts in Spinal Operation: Primary Fusion Surgery Versus Revision Fusion Surgery.

ObjectiveSerum C-reactive protein (CRP) concentrations and white blood cell (WBC) count are commonly used to identify postoperative wound infections. We investigated whether changes in serum CRP levels and WBC counts actually differed between patients undergoing revision spinal fusion surgery and those undergoing a primary fusion.MethodsPatients who underwent posterolateral fusion (PLF) surgery at Pusan National University Yangsan Hospital between October 2013 and April 2015 were considered for this study. Sixty-seven patients with primary lumbar PLF (pPLF) and 21 with revision PLF (rPLF) were enrolled. A retrospective assessment of preoperative and postoperative CRP levels and WBC count was undertaken. Also, we gathered peak CRP day, and CRP normalization days. Comorbidity data were also obtained to evaluate any effects on the course of CRP and WBC count postoperatively.ResultsCRP levels peaked at 3 days after surgery. The maximum CRP values recorded for each group: 4.17 (standard deviation [SD], 4.18) mg/dL and 4.88 (SD, 3.03) mg/dL for pPLF and rPLF. This difference was not statistically significant (p=0.24). A rapid fall in CRP within 5–9 days was observed for both groups.ConclusionOut of our expectation, changes in CRP levels after spinal fusion surgery follow the same course regardless of whether it is a revision operation or not. Because of this result, both the primary PLF surgery and revision PLF surgery should be monitored using CRP in the similar way and the antibiotic administration should be determined.

P435 The mean corpuscular volume flow – prognostic value for inflammatory bowel disease under thiopurine treatment

Background: The difficult access to thiopurine metabolites therapeutic drug monitoring led to the search for accessible markers to estimate thiopurine's efficacy. The difference in mean corpuscular volume (ΔMCV) ≥7fL at week 26 of azathioprine monotherapy (Aza) or combined with infliximab (AzaI) was shown to be associated with favourable outcomes in Inflammatory Bowel Disease (IBD). Objective: To confirm the association of ΔMCV ≥7 at week 26–28 with favourable outcomes in IBD in a Portuguese population. Methods: Retrospective assessment of patients with IBD under Aza or AzaI at time-point: Week 26–28 of treatment. Demographic characterization and severity of pre-treatment disease was evaluated (location, previous surgery status, Mayo score and Crohn's disease activity index [CDAI]). Quantification of ΔMCV and association with time-point outcomes: Steroid-free clinical remission (Rem-sf, CDAI <150, Mayo <2); mucosal healing (MH); C-reactive protein (CRP) normalization <5. Patients with vitamin B12 deficiency were not included. Statistic: Chi-square test or Fisher exact test. Results: A total of 122 patients with IBD were evaluated [(71 Crohn's disease, 28% operated); 57.4% women; mean age 40±15.6 years] at week 26–28 of treatment with Aza (86.9%) or AzaI (13.1%). In both treatment groups the mean ΔMCV was ≥7 (Aza 7.9 vs. AzaI 8.1) and this was achieved in the same proportion of patients (66 vs. 62.5%). There was a strong association between ΔMCV ≥7 and remission outcomes (Rem-sf: p<0.05; CDAI <150/Mayo<2: p<0.001) and MH (p<0.05), but not with CRP normalization. However, CRP ≤10 was related to remission outcomes (Rem-sC: p<0.05; CDAI <150/Mayo <2: p<0.001) and MH (p=0.004). Conclusions: This work confirmed the prognostic importance of ΔMCV ≥7 in our population. The correlation of ΔMCV ≥7 with clinical remission and mucosal healing outcomes occurred in Crohn's disease and Ulcerative Colitis and was independent of the anti-TNF association.

Predictors of conservative treatment for pyogenic spondylitis.

Introduction Although initial treatments for pyogenic spondylitis include conservative approaches such as rest and antibiotics, some cases are refractory to conservative therapy. The objective of this study was to clarify the predictors for achievement of C-reactive protein (CRP) normalization in pyogenic spondylitis by conservative therapy. Methods In the present study, we enrolled 83 patients (51 men and 32 women) with conservatively treated pyogenic spondylitis from 2006 to 2015. Multiple logistic regression analysis was used to examine the association of achievement of CRP normalization with the number of infected vertebrae, bacterial strain, blood data, and the expansion of abscess to the epidural space by using functional magnetic resonance imaging. Results We found significant differences in the subjects with and without achievement of CRP normalization with respect to age, the number of affected vertebrae, ratio of resistant pathogenic bacteria, ratio of expansion of abscess to the epidural space, and blood data such as Hb, ALB, eGFR, Cr, and ALP levels. After adjustment for age and sex, the number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and Hb level showed significant associations with the normalization of CRP. In addition, we used multiple logistic regression analysis with age, sex, number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and serum Hb level as explanatory variables. We found that expansion of the abscess to the epidural and paravertebral spaces was significantly associated with the normalization of CRP level. Conclusions The number of infected vertebral bodies, resistant strains of pathogenic bacteria, expansion of abscess to the epidural and paravertebral spaces, and serum Hb level predicts the prognosis of patients with pyogenic spondylitis. Particularly, expansion of abscess to the epidural and paravertebral spaces was strongly associated with the achievement of CRP normalization.

The Utility of Acute-Phase Proteins in the Assessment of Treatment Response in Dogs With Bacterial Pneumonia.

BackgroundAcute‐phase proteins (APPs) are sensitive markers of inflammation, and serum C‐reactive protein (CRP) recently has been shown to be a useful diagnostic marker in dogs with bacterial pneumonia (BP). In humans with community‐acquired pneumonia, APPs also have great utility as follow‐up markers aiding in the assessment of treatment response.ObjectivesThe aim of our study was to investigate the applicability of APPs as markers of treatment response in dogs with BP.AnimalsNineteen dogs diagnosed with BP and 64 healthy dogs.MethodsThe study was conducted as a prospective longitudinal observational study. Serum CRP, serum amyloid A (SAA), and haptoglobin concentrations were followed during a natural course of BP. Normalization of serum CRP was used to guide the duration of antibiotic treatment (treatment was stopped 5–7 days after CRP normalized) in 8 of 17 dogs surviving to discharge; 9 of 17 dogs were treated according to conventional recommendations.ResultsAll measured APPs initially were significantly increased, but the magnitude of increase was not correlated to disease severity. C‐reactive protein and SAA concentrations decreased rapidly after initiation of antimicrobial treatment. When normalization of serum CRP was used to guide the duration of antibiotic treatment, treatment duration was significantly (P = .015) decreased without increasing the number of relapses.Conclusions and Clinical ImportanceSerum CRP and SAA reflected the recovery process well and therefore may be used as markers of treatment response. According to the results, the normalization of serum CRP may be used to guide the duration of antibiotic treatment in dogs with BP.

Serum tocilizumab trough concentration can be used to monitor systemic IL-6 receptor blockade in patients with rheumatoid arthritis: a prospective observational cohort study

Objectives: To investigate the pharmacokinetics (PK) and dynamics of tocilizumab (TCZ) in daily practice.Method: An observational study of 66 consecutive RA patients treated with TCZ 8 mg/kg once every 4 weeks intravenously, monitored for 24 weeks. Spearman’s rank test was used to investigate the correlation between TCZ concentration and C-reactive protein (CRP). Clinical improvement was assessed at week 24 using the Disease Activity Score in 28 joints (DAS28) compared to baseline, and its relationship with TCZ concentration was investigated using linear regression analyses. TCZ trough concentrations and anti-drug antibodies were measured using an enzyme-linked immunosorbent assay (ELISA) and antigen binding test, respectively.Results: At baseline, 26 patients (39.4%) had a CRP level above 10 mg/L with a median (interquartile range, IQR) of 37.7 (21.9–49.7) mg/L. A TCZ concentration above 1 mg/L was sufficient to normalize CRP levels. Spearman’s rank test showed a correlation coefficient of −0.460 (p < 0.0001). The TCZ concentration varied widely, with concentrations < 1 mg/L in 17–31% of patients, depending on the time point of measurement. Anti-TCZ antibodies were detected in one sample. Linear regression analyses showed a coefficient of 0.080 with a 95% confidence interval (CI) of 0.039–0.113 (p < 0.001) for the association between TCZ concentration and ΔDAS28. No confounders were identified.Conclusions: The TCZ standard regimen results in a wide variety of serum TCZ trough concentrations; this is mostly due to target binding and to a lesser extent to immunogenicity. The majority of patients obtained TCZ concentrations > 1 mg/L, which is sufficient for CRP normalization. Therefore, dose taper strategies might be possible in a substantial proportion of patients.

C-Reactive Protein as a Biomarker of Radiation Therapy and Chemotherapy Toxicity Monitoring in Patients With Head and Neck Cancer

C-reactive protein (CRP) is a serum protein elevated in a variety of illnesses, including cancer. Also some data exist that CRP level is correlated with acute mucositis in patients (pts) with head and neck cancer (HNC) treated with radiation therapy (RT) and significantly elevated when dose/fraction number is increased. The purpose of this study is to show how CRP behaves before and after HNC RT with or without chemotherapy. From 2010 to 2015, 401 pts (318 men and 83 women) with a mean age of 58 years (range 20-81) with oral cavity (5), nasopharynx (30), oropharynx (133), hypopharynx (47), larynx (180), or unknown primary (6) cancer were under treatment. Tumor stage was evaluated in all pts: T0-6, T1-60, T2-147, T3-119, T4-69, and N0-174, N1-52, N2-143, and N3-32. Four schedules of treatment have been used: RT alone (RTA, 178 pts), concurrent chemoradiation therapy (CRC, 93 pts), and induction chemotherapy (IC) followed by RTA (46 pts) or CRC (84 pts). CRP (normal level, <2.87mg/L) was measured as follows: before IC (if applied) or before RTA/CRC, every week during RTA/CRC, and, finally, 1 month after treatment. Total number of CRP measurements was 3622. Initial CRP level was normal in 56% of pts; in 44% it was elevated (median 6.05 mg/L) but not correlated with tumor advancement. After IC, normalization of CRP was observed in 73% of pts (median CRP decreased from 3.12 to 1.24 mg/L). During RT progressive, week by week up to week 6, elevation of CRP was observed for RTA and CRC with no difference between both treatments. However, evident impacts of initial CRP level and IC were noted; in patients who had abnormal initial CRP and/or IC, significantly higher CRP levels were observed over RTA and CRC. There was no correlation observed between CRP and total dose or overall volume of radiated tissue. CRP may be a useful laboratory parameter in monitoring of toxicity in HNC patients undergoing RTA and CRC. IC leads to significant reduction/normalization of CRP in the majority of patients, which may reflect an anti-inflammatory effect in tumor burden. Similar CRP levels in patients treated with RTA and CRC may suggest that tumor and normal tissue radiation sensitivity is an essential proinflammatory factor.

Magnetic resonance imaging-quantified small bowel motility is a sensitive marker of response to medical therapy in Crohn's disease.

Magnetic resonance enterography (MRE) can measure small bowel motility, reduction in which reflects inflammatory burden in Crohn's Disease (CD). However, it is unknown if motility improves with successful treatment. To determine if changes in segmental small bowel motility reflect response to anti-TNFα therapy after induction and longer term. A total of 46 patients (median 29 years, 19 females) underwent MRE before anti-TNFα treatment; 35 identified retrospectively underwent repeat MRE after median 55 weeks of treatment and 11 recruited prospectively after median 12 weeks. Therapeutic response was defined by physician global assessment (retrospective group) or a ≥3 point drop in the Harvey-Bradshaw Index (prospective group), C-reactive protein (CRP) and the MaRIA score. Two independent radiologists measured motility using an MRE image-registration algorithm. We compared motility changes in responders and nonresponders using the Mann-Whitney test. Anti-TNFα responders had significantly greater improvements in motility (median = 73.4% increase from baseline) than nonresponders (median = 25% reduction, P < 0.001). Improved MRI-measured motility was 93.1% sensitive (95%CI: 78.0-98.1%) and 76.5% specific (95% CI: 52.7-90.4%) for anti-TNFα response. Patients with CRP normalisation (<5 mg/L) had significantly greater improvements in motility (median = 73.4% increase) than those with persistently elevated CRP (median = 5.1%, P = 0.035). Individuals with post-treatment MaRIA scores of <11 had greater motility improvements (median = 94.7% increase) than those with post-treatment MaRIA score >11 (median 15.2% increase, P = 0.017). Improved MRI-measured small bowel motility accurately detects response to anti-TNFα therapy for Crohn's disease, even as early as 12 weeks. Motility MRI may permit early identification of nonresponse to anti-TNFα agents, allowing personalised treatment.

Polyarteritis nodosa confined to the breasts associated with polyenthesitis

Polyarteritis nodosa (PAN) was first described as an inflammatory arterial disorder by Kussmaul and Maier in 1866 [1]. PAN was characterized as a necrotizing vasculitis of small- to-medium-sized arteries. It was subclassified into systemic, cutaneous/subcutaneous, and microscopic types. Cutaneous/subcutaneous PAN is generally recognized to have a good prognosis [1]. PAN-associated vasculitis localized to the breast is very rare, with few reported cases [2–9]. Most of the cases were diagnosed as giant cell arteritis (GCA) [2–5], as PAN was considered uncommon [6–8]. We herein report a case of PAN of the breast associated with polyenthesitis. A 71-year-old Japanese woman presented with bilateral breast pain, myalgia, enthesitis of both patellar ligaments, fever, weight loss, and general fatigue. She was admitted to our hospital. Physical examination was significant for five tender breast nodules, approximately 1–2 cm in diameter, with associated erythema (Figure 1A). There were no other skin lesions. Laboratory tests demonstrated elevated levels of C-reactive protein (CRP) of 19.8 mg/dl, erythrocyte sedimentation rate (ESR) of 124 mm/1 h, and white blood cell count of 18.4 × 109/L. Anti-proteinase 3, myeloperoxidase neutrophil cytoplasmic antibodies, and anti-nuclear antibodies were all negative. Hepatic and renal functions were normal. Human leukocyte antigen (HLA) typing demonstrated positive A2, A31, B46, and B61 antigens. Physical examination, mammography, and ultrasonography did not show any architectural distortions and calcifications which are considered as the sign of breast cancer. A biopsy of a nodule in the left breast revealed leukocytoclastic medium-sized arteritis without giant cell invasion (Figure 1B and C), indicating PAN. Breast nodule did not reveal typical septal and lobular panniculitis. Flurodeoxyglucose (FDG)-positron emission tomography/computed tomography showed high FDG uptake in multiple entheses, including spinous processes (Figure 1D), both ischial tuberosities, and patellar ligaments (Figure 1E), indicating polyenthesitis. Ultrasonography of the left patellar ligament demonstrated a positive power Doppler signal in the tibial insertion, indicating tibial tuberosity enthesitis (Figure 1F). The patient was diagnosed with PAN limited to the breasts associated with polyenthesitis. Treatment with daily oral prednisolone (40 mg) was initiated, resulting in immediate improvement in the patient's symptoms and normalization of the serum CRP and ESR values. She was discharged and had experienced no subsequent complications or flare-ups for 3 years.

Predicting Endoscopic Crohn's Disease Activity Before and After Induction Therapy in Children: A Comprehensive Assessment of PCDAI, CRP, and Fecal Calprotectin.

Mucosal healing (MH) is a vital early endpoint in management of Crohn's disease (CD). MH depends on endoscopic assessment and there is increasing interest in non-invasive proxies, Pediatric Crohn's Disease activity Index (PDCAI), C-reactive protein (CRP) and fecal calprotectin (FC). These proxies must be validated against endoscopic disease activity (SES-CD) at diagnosis and after induction therapy in well characterized cohorts of children with CD. A prospective cohort of 24 newly diagnosed children (<16 yr) with luminal CD quantifiable on complete ileo-colonoscopy had paired PCDAI, CRP, FC and SES-CD at diagnosis and after 8 weeks therapy with exclusive enteral nutrition or steroids. At diagnosis: PCDAI had poor correlation (r = 0.33); CRP (r = 0.54) and FC (r = 0.46) had moderate correlation with SES-CD. After induction therapy: 11/24 had inactive disease (SES-CD 0-2); PCDAI (r = 0.34) and CRP (0.28) had poor correlation with SES-CD, many children with SES-CD ≥3 having normalization of both PCDAI and CRP. FC had good correlation (r = 0.50) but many with SES-CD 0-2 had FC >200 μg/gm stool. FC<500 (positive likelihood ratio, 3.2) and FC drop >50% (positive likelihood ratio, 3.8) had greater predictive value for inactive disease. Composite PCDAI (<10), CRP (<5 mg/dl) & FC <500 μg had excellent Negative LR (0.2) predicting inactive disease. PCDAI is unreliable for endoscopic disease severity assessment. Only FC correlates with endoscopic activity after therapy but cut off <200 μg is too high for defining endoscopic recovery in children. Composite normalized PCDAI, CRP and FC <500 μg should be considered the non-invasive endpoint for treatment response in pediatric CD.

Chronological Changes of C-Reactive Protein Levels Following Uncomplicated, Two-Staged, Bilateral Deep Brain Stimulation.

ObjectiveThe occurrence of acute cerebral infection following deep brain stimulation (DBS) is currently being reported with elevation of C-reactive protein (CRP) level. The aim of the present study was to establish normal range of the magnitude and time-course of CRP increases following routine DBS procedures in the absence of clinical and laboratory signs of infection.MethodsA retrospective evaluation of serial changes of plasma CRP levels in 46 patients undergoing bilateral, two-staged DBS was performed. Because DBS was performed as a two-staged procedure involving; implantation of lead and internal pulse generator (IPG), CRP was measured preoperatively and postoperatively every 2 days until normalization of CRP (post-lead implantation day 2 and 4, post-IPG implantation day 2, 4, and 6).ResultsCompared with preoperative CRP levels (0.12±0.17 mg/dL, n=46), mean CRP levels were significantly elevated after lead insertion day 2 and 4 (1.68±1.83 mg/dL, n=46 and 0.76±0.38 mg/dL, n=16, respectively, p<0.001). The mean CRP levels at post-lead implantation day 2 were further elevated at post-IPG implantation day 2 (3.41±2.56 mg/dL, n=46, respectively, p<0.01). This elevation in post-IPG day 2 rapidly declined in day 4 (1.24±1.29 mg/dL, n=46, p<0.05) and normalized to preoperative value at day 6 (0.42±0.33 mg/dL, n=46, p>0.05). Mean CRP levels after IPG implantation were significantly higher in patients whose IPGs were implanted at post-lead day 3 than those at post-lead day 5-6 (3.99±2.80 mg/dL, n=30, and 2.31±1.56 mg/dL, n=16, respectively, p<0.05). However, there was no difference in post-IPG day 2 and 4 between them (p>0.05).ConclusionThe mean postoperative CRP levels were highest on post-IPG insertion day 2 and decreased rapidly, returning to the normal range on post-IPG implantation day 6. The duration of post-lead implantation period influenced the magnitude of CRP elevation at post-IPG insertion day 2. Information about the normal response of CRP following DBS could help to avoid unnecessary diagnostic and therapeutic efforts.

Clinical Characteristics of Methicillin-resistant Staphylococcus aureus Infection for Chronic Periprosthetic Hip and Knee Infection.

PurposeDeep infection after hip and knee arthroplasty is a serious complication and is difficult to treat due to its toxicity. The aims of our study were to find out the differences of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) infection after hip and knee arthroplasty focusing on clinical course and laboratory findings.Materials and MethodsWe retrospectively reviewed 61 staphylococcal infection cases after hip and knee arthroplasty (MSSA in 25 patients, MRSA in 36 patients). Vital signs, laboratory tests, microbiology and clinical courses were analyzed. The average follow-up period was 3.8 years (range, 2 to 10.1 years).ResultsAt initial visit, MRSA group showed significant higher erythrocyte sedimentation rate, C-reactive protein (CRP) and neutrophil percentage. The average duration for the normalization of CRP was longer in MRSA group (MRSA: 36.7±25.1 days, MSSA: 24.7±13.6 days; P=0.008). The mean interval between staging operation was longer in MRSA group (MRSA: mean 8.7 weeks [range, 6.4 to 21.4 weeks], MSSA: mean 6.8 weeks [range, 6 to 13.1 weeks]; P=0.012). MRSA group (13.9%) revealed higher recurrence rate than MSSA group (4%). Two patients (5.6%) from MRSA group expired by sepsis. One limb amputation (2.7%) was carried out in MRSA group.ConclusionMRSA infection after arthroplasty showed more toxic serologic parameter and poorer prognosis. Aggressive treatment should be considered for MRSA infection following arthroplasty.

Factors Associated With Short- and Long-Term Outcomes of Therapy for Crohn’s Disease

Our post hoc analysis assessed the association of early (at weeks 26-30) clinical, endoscopic, biologic, and pharmacokinetic outcomes with corticosteroid-free remission at week 50 (CSFR50); CSFR50 was observed in 55.2% and 65.4% of patients treated with infliximab, alone or in combination with azathioprine, respectively. We analyzed data from 203 patients: 96 received infliximab monotherapy and 107 received combination therapy. Receiver operating characteristic analysis was used to set cut-off points for the week 30 trough serum infliximab concentration (SIC30) and percentage change, from baseline, in the C-reactive protein (CRP) level at week 26, to predict CSFR50. Univariate and multivariate procedures analyzed predictive parameters of CSFR50 (odds ratio [OR] and 95% confidence interval [CI]). Mucosal healing (MH, zero ulcers) and CRP normalization (<8.0 mg/L) also were assessed. Trough SIC30 was higher in patients with than without CSFR50. Patients given combination therapy had higher trough SIC30s than those given monotherapy. Median trough SIC30 was significantly higher in patients with than without CSFR50 among those on infliximab monotherapy (2.14 vs 0.80 μg/mL; P= .006), but not for those on combination therapy (3.56 vs 3.54 μg/mL; P=.31). In patients with increased baseline levels of CRP (n= 120), corticosteroid-free remission at week 26 (CSFR26) (OR, 4.09; 95% CI, 1.65-10.11), and trough SIC30s of 3.0 μg/mL or greater (OR, 3.20; 95% CI, 1.38-7.42) were associated significantly with CSFR50. In patients evaluable for MH (n= 123), trough SIC30s of 3.0 μg/mL or greater (OR, 3.34; 95% CI, 1.53-7.28) and CRP normalization (OR, 2.69; 95% CI, 1.10-6.54) were associated significantly with MH at week 26 (MH26). Furthermore, CSFR26 (OR, 4.43; 95% CI, 1.81-10.82) and MH26 (OR, 3.01; 95% CI, 1.33-6.81) were associated significantly with CSFR50. Trough SIC30 is associated positively with MH26; CSFR26 and MH26 are independent predictors of CSFR50. Trough SIC30 of 3.0 μg/mL or greater early during maintenance treatment is an important determinant of clinical and endoscopic Crohn's disease outcomes. ClinicalTrials.gov number, NCT00094458.

Oral Feeding in Necrotizing Pancreatitis

Background: Restoration of gastrointestinal function is a crucial determinant of favorable outcome in severe acute pancreatitis (SAP). The purpose of this study was to retrospectively review our experience with early oral feeding in patients with the necrotizing form of SAP. Over the last 10 years, we have routinely gradually increased oral feeds in order to restore gastrointestinal function.Methods: Early low volume oral (ELVO) feeds containing 248–330 kcal/daily were routinely provided for all patients to help stimulate gastrointestinal function. Patients who received ELVO feeding within 72 hours of admission were allocated to Group I; those who received ELVO feeds after 72 hours were allocated to Group II. The volume and calories of the feed, magnitude of systemic inflammation, levels of C-reactive protein (CRP) and lipase, incidence of organ dysfunction, main outcomes, and complications were analyzed.Results: In total, 129 patients received ELVO feedings. The mean CRP level on day 7 was 160 ± 77.6 mg/l in Group I compared to 200.2 ± 103.2 mg/l in Group II, p = 0.043. Normalization of CRP below 100 mg/l was observed on day 14 in both groups. The rate of infection and the need for surgical intervention (46.8% vs. 26%) were significantly higher in Group II (p = 0.026). Group II also had longer ICU/hospital stays (p = 0.039/p = 0.002). Overall mortality was 10%. Conclusions: ELVO feeding provides physiologic stimulation and promotes recovery of bowel function, preparing the gastrointestinal tract for low-fat hospital food in patients with necrotizing SAP. The majority of patients required no additional nutritional support.

GLP-1 receptor agonist-induced polyarthritis: a case report

Occasional cases of bilateral, symmetrical, seronegative polyarthritis have been reported in patients treated with dipeptidyl peptidase-4 inhibitors (Crickx et al. in Rheumatol Int, 2013). We report here a similar case observed during treatment with a GLP-1 receptor agonist. A 42-year-old man with type 2 diabetes treated with metformin 1,500mg/day and liraglutide 1.8mg/day. After 6months from the beginning of treatment, the patient complained of bilateral arthralgia (hands, feet, ankles, knees, and hips). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and leukocytes were increased. Rheumatoid factor, anticyclic citrullinated protein antibody, antinuclear antibodies, anti-Borrelia, and burgdorferi antibodies were all negative, and myoglobin and calcitonin were normal. Liraglutide was withdrawn, and the symptoms completely disappeared within 1week, with normalization of ESR, CRP, fibrinogen, and leukocytes. Previously described cases of polyarthritis associated with DPP4 inhibitors had been attributed to a direct effect of the drugs on inflammatory cells expressing the enzyme. The present case, occurred during treatment with a GLP-1 receptor agonists, suggests a possibly different mechanism, mediated by GLP-1 receptor stimulation, which deserved further investigation.

Going Beyond Colon-Clostridium difficile Enteritis: A Rare but Real Entity!

Purpose:Clostridium difficile infection (CDI), a common cause of health care-associated diarrhea, is usually considered being restricted to colon. We present a rare case of isolated CDI of small bowel in a young patient without any major risk factors. Results: A 22-year-old female presented to the emergency department (ED) with complaints of worsening abdominal pain, nausea, and vomiting for 3 days. Patient denied fever, chills, hematemesis, hematochezia, melena, sick contact, recent antibiotic use, or recent hospitalization. She had never been diagnosed with inflammatory bowel disease nor had family history of the disease. Abdominal examination was remarkable for hypoactive bowel sounds and peri-umblical tenderness. CT scan of the abdomen showed ileus with small bowel wall thickening concerning for enteritis. Laboratory investigations were notable for white blood cell count of 14.3K/mm3 with 85% granulocytes and C-Reactive Protein (CRP) >380mg/L and serum creatinine of 0.5mg/dl. Stool Clostridium difficile toxin PCR was positive, and fecal WBC were negative. Patient was started on IV metronidazole 500 mg TID with improvement of symptoms and normalization of CRP in 1 week period. Patient was able to tolerate diet. A repeat abdominal CT scan showed interval improvement of small bowel thickening. Patient remained stable and was discharged home. A follow-up colonoscopy in 4 weeks did not show any evidence of IBD. Repeat abdominal CT scan showed complete resolution of bowel wall thickening. Patient remained symptom free on follow-up appointment. Conclusion:Clostridium difficile is considered to be a colonic pathogen. Untreated cases are associated with significant morbidity and mortality. C. difficile enteritis is a rare entity and is usually associated with immune compromised states, old age, and surgically altered intestinal anatomies. The fact that this is a relatively young patient with no predisposing medical illnesses and risk factors makes it a unique case. Reporting such cases will help recognize and provide future clinical insight into community acquired C.difficile enteritis. Clinical recognition of C. difficile infection not only in colon but also in small intestine can improve clinical outcomes in patients.

Clinical disease activity, C-reactive protein normalisation and mucosal healing in Crohn's disease in the SONIC trial

Background and aimsThe Crohn's Disease Activity Index (CDAI) has been criticised due to heavy weighting on subjective clinical symptoms. C-reactive protein (CRP) and endoscopic lesions are objective measures of inflammation....

Advanced age influences the dynamic changes in circulating C-reactive protein following injury

BackgroundThe concentration of C-reactive protein (CRP), a biomarker of systemic inflammation, is determined by genetic, clinical and demographic factors including gender, smoking and body mass index (BMI). The influence of...

P.02.9 INCIDENT CASES OF CANCER IN IBD: CLINICAL CHARACTERISTICS OF IBD VS IMMUNOMODULATORS IN A PROSPECTIVE MULTICENTER CASE-CONTROL STUDY

effective non invasive monitoring could help clinicians in the management of Crohn’s disease (CD) patients treated with adalimumab. Aim of the study is to identify early predictors of long term clinical response during treatment with adalimumab. Material and methods: 68 patients with moderate to severe CD referred to a nurse-led outpatient clinic were prospectively enrolled from January 2009 to December 2011. All patients were treated with a 160–80 mg every other week (eow) induction protocol and maintained with 40 mg eow. Clinical activity (Harvey Bradshaw Index – HBI), faecal lactoferrin (LF), C reactive protein (CRP) were assessed at baseline, at the end of induction and 6 and 12 months after. Results: After induction, 42.3% of patients were in clinical remission and 37% responded showing at least a 2-points decrease in HBI. LF and CRP decreased significantly after the induction period (p<0.001 and p=0.02 respectively) and remained in the normal range throughout the maintenance period. 63% of patients in remission at the end of induction maintained remission at one year (p=0.02, OR=0.15), on the contrary only 36% of patients still active after induction were able to reach clinical remission at twelve months (p=0.009, OR=6.96). After twelve months 58.3% of patients were in remission according to HBI. 61% of patients achieving LF normalization at the end of induction were in clinical remission at one year (p=0.004, OR=0.06), while only 39% of patients with abnormal LF (p=0.004, OR=15.45). 95% patients with normal CRP after induction were in clinical remission at one year (p=0.003, OR=0.06), while only 4.5% of those showing abnormal CRP (p=0.003, OR=15.75). Linear regression models found that clinical remission combined with early CRP and LF normalization after induction is the best predictor of maintenance of clinical remission at one year. Conclusions: Clinical activity and biochemical markers performed at the end of induction proved to be reliable in predicting the course of CD in the long term maintenance treatment with adalimumab, therefore clinical and laboratory monitoring should be performed routinely in these patients.