Normal C-reactive Protein Levels Research Articles

A single-center experience with methotrexate in the treatment of Chinese Crohn's disease patients.

Methotrexate (MTX) can be used as an alternative for patients with Crohn's disease (CD) who are intolerant of thiopurine. This retrospective study aimed to provide some clues about MTX treatment in Chinese patients with CD. Medical records of 27 adult patients with CD who were treated with MTX between 2012 and 2017 at Renji Hospital were reviewed. MTX was administered at 15 mg or 20 mg intramuscularly once per week. The remission and response rates and adverse reactions of MTX were recorded and analyzed. Thirteen (48.1%) of the patients achieved remission for more than 12 months, whereas four (14.8%) responded clinically. Eight (29.6%) patients discontinued MTX due to adverse events. The mean age of those who maintained remission was significantly younger than that of those who did not ([35.62 ± 10.99] years vs. [45.43 ± 11.93] years, P < 0.05). The pretreatment C-reactive protein (CRP) level was higher in the group who maintained remission than that in those who did not ([17.20 ± 17.26] mg/L vs. [6.98 ± 5.66] mg/L, P < 0.05). MTX is effective and relatively safe for patients at doses of 15 mg/week or 20 mg/week and may be an alternative therapy for patients who are intolerant of thiopurine. Elderly patients with CD and patients with normal pretreatment CRP level may have a reduced response to MTX.

Molecular Typing of Multiple Isolates Is Essential to Diagnose Cutibacterium acnes Orthopedic Device-related Infection.

Cutibacterium acnes orthopedic device-related infections (ODRIs) range from obvious infections to solely culture-based diagnoses. Multilocus sequence typing of multiple isolates from the same procedure revealed that most cases with normal C-reactive protein levels that were classified as C. acnes ODRI would be considered contaminations when accounting for genotypic data.

The serum level of C-reactive protein alone cannot be used for the diagnosis of prosthetic joint infections, especially in those caused by organisms of low virulence.

The aim of this study was to determine the prevalence and characteristics of C-reactive protein (CRP)-negative prosthetic joint infection (PJI) and evaluate the influence of the type of infecting organism on the CRP level. A retrospective analysis of all PJIs affecting the hip or knee that were diagnosed in our institution between March 2013 and December 2016 was performed. A total of 215 patients were included. Their mean age was 71 years (sd 11) and there were 118 women (55%). The median serum CRP levels were calculated for various species of organism and for patients with acute postoperative, acute haematogenous, and chronic infections. These were compared using the Kruskal-Wallis test, adjusting for multiple comparisons with Dunn's test. The correlation between the number of positive cultures and serum CRP levels was estimated using Spearman correlation coefficient. Preoperative CRP levels were normal (< 10 mg/l) in 77 patients (35.8%) with positive cultures. Low-virulent organisms were isolated in 66 PJIs (85.7%) with normal CRP levels. When grouping organisms by species, patients with an infection caused by Propionibacterium spp., coagulase-negative staphylococci (CNS), and Enterococcus faecalis had significantly lower median serum CRP levels (5.4 mg/l, 12.2 mg/l, and 23.7 mg/l, respectively), compared with those with infections caused by Staphylococcus aureus and Streptococcus spp. (194 mg/l and 89.3 mg/l, respectively; p < 0.001). Those with a chronic PJI had statistically lower median serum CRP levels (10.6 mg/l) than those with acute postoperative and acute haematogenous infections (83.7 mg/l and 149.4 mg/l, respectively; p < 0.001). There was a significant correlation between the number of positive cultures and serum CRP levels (Spearman correlation coefficient, 0.456; p < 0.001). The CRP level alone is not accurate as a screening tool for PJI and may yield high false-negative rates, especially if the causative organism has low virulence. Aspiration of the joint should be used for the diagnosis of PJI in patients with a chronic painful arthroplasty, irrespective of CRP level. Cite this article: Bone Joint J 2018;100-B:1482-86.

Point-of-care CRP matters: normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care: a cluster randomized controlled trial

Objective: Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians’ (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines.Design: Cluster randomized controlled trial.Setting: Primary care, Flanders, Belgium.Intervention: Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP.Subjects: Acutely ill children consulting their FP.Main outcome measure: Immediate antibiotic prescribing.Results: 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aOR) 0.54 (95% Confidence Interval (CI) 0.33–0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11–0.50) or to withhold (aOR 0.31 (95%CI 0.17–0.57)). Elevated CRP levels did not increase antibiotic prescribing.Conclusion: Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.Key pointsWhat is previously known or believed on this topic•Antibiotics are prescribed too often for non-severe conditions. Point-of-care (POC) C-reactive Protein (CRP) testing without guidance does not reduce immediate antibiotic prescribing in acutely ill children in primary care.What this research adds•FPs clearly consider CRP once available: normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling.•Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.

ACE in the Hole: Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema as a Cause of Recurrent Abdominal Pain

As one of the most prescribed medications in the United States, angiotensin-converting-enzyme inhibitors (ACEI) have a 0.1-0.7% risk of angioedema. Oropharyngeal angioedema is well known and rarer is angioedema of the GI tract, which can present with nonspecific signs of abdominal pain, nausea, or vomiting. We report a case of angioedema of the small bowel in a patient with recurrent abdominal pain and small bowel segmental thickening of the jejunum. A 58-year-old African American woman with a history of hypertension on lisinopril presented with recurrent abdominal pain in the mid-abdomen associated with vomiting and diarrhea. Symptoms would resolve with supportive treatment and she had several admissions for the same complaint over the past year. On exam she was afebrile with normal vitals and a mildly tender but soft abdomen. Laboratory data was remarkable for mild leukocytosis (12.4 WBC/mm3) with normal eosinophils. Infectious workup was negative and she had a normal C-reactive protein level. CT imaging showed segmental thickening of the proximal jejunum with trace ascites. A push enteroscopy was performed that revealed slightly edematous mucosa with erosions. Pathology from the biopsies showed focal areas of eosinophils. Autoimmune antibodies including ANCA, anti-transglutaminase antibodies, and c1-esterase inhibitor testing were negative. Lisinopril was discontinued with resolution of her symptoms and a diagnosis of ACEI small bowel angioedema was made. ACEI small bowel angioedema is a rare side effect of ACEI therapy and can occur at any time during therapy with an ACEI. The diagnosis is made when other more likely causes are ruled out and symptoms resolve on cessation of the drug. Eosinophilic gastritis is an important differential diagnosis but ACEI small bowel angioedema will not present with systemic eosinophilia. Risk factors for ACEI angioedema include female gender, age 40-70, and African American race. C1-esterase inhibitor levels are normal and the jejunum is most commonly affected with associated ascites. The biochemical increase in bradykinin by inhibition of the angiotensin-converting-enzyme is thought to be responsible for the angioedema. Given how common ACEI therapy is prescribed, clinicians should be aware of this potential side effect in a patient taking an ACEI with unexplained recurrent abdominal pain and segmental small bowel wall thickening.2542_A Figure 1. Abdominal CT imaging showing segmental thickening and edema of the jejunum and trace ascites.2542_B Figure 2. Push enteroscopy showing a mildly edematous jejunum.2542_C Figure 3. Jejunal biopsies showing no granulomas and focal areas of eosinophils.

The usefulness of C-reactive protein in predicting malaria parasitemia in a sub-Saharan African region.

BackgroundMalaria remains a leading cause of childhood mortality in sub-Saharan Africa. Identifying patients who are at risk for severe manifestations at presentation still remains challenging. This study examines whether a semi-quantitative test on C-Reactive Protein (CRP) could be useful for rapidly predicting the presence or absence of malarial parasitemia in febrile children.MethodData were collected from children with fever or a history of fever at the Agogo Presbyterian Hospital in the Ashanti Region of Ghana. Haematological measurements, microscopic detection of plasmodium species and semi-quantitative CRP measurements with a membrane–based immunoassay for whole blood were performed. CRP was classified as positive when the measured level was ≥ 10 mg/l.ResultsDuring 548 visits, thick blood film results could be obtained from 541 patients, 270 (49.3%) yielded parasitemia with Plasmodium spp. Whereas malaria parasites were detected in only a few patients (7.1%) with normal CRP levels (< 10mg/l), more than a half of patients with an increased CRP concentration (≥ 10 mg/l) were parasite positive (OR 14.5 [CI 4.4–47.6], p<0.001). Patients with increased CRP levels had more than an eight-fold likelihood for parasitemia after correction for other parameters (adjusted OR 8.7 [CI 2.5–30.5], p<0.001). Sensitivity, specificity as well as positive predictive and negative predictive values of CRP for malaria were 99.3% (CI 96.2%-100%), 9.2% (CI 6.4%-12.8%), 31.7% (CI 27.4%-36.1%) and 97.0% (CI 84.2%-99.9%), respectively.ConclusionThe semi-quantitative method of measuring CRP is cheap, rapid and easy to perform but not useful in predicting parasitemia and malaria. However, due to its high negative predictive value, it could have a role in identifying those patients unlikely to be presenting with clinical malaria.

The Investigation of the Use of Prealbumin as a Tool for Nutritional Assessment in Adults Coinfected with HIV and Intestinal Helminth Parasites in KwaZulu-Natal, South Africa.

Serum prealbumin is considered to be as important as albumin in the nutritional status assessment. However, there is relatively little evidence of its advantage over the commonly used albumin. This study investigated the use of prealbumin compared to albumin as a marker of nutritional status in adults singly and dually infected with human immunodeficiency virus (HIV) and intestinal helminths, with or without inflammatory conditions, in different body mass index (BMI) categories. This cross-sectional study was conducted in a periurban setting in KwaZulu-Natal, South Africa. Multivariate multinomial logistic regression models were fitted to investigate the effect of prealbumin and albumin in nutritional assessment among HIV and helminth individuals with or without inflammation, indicated by elevated and normal C-reactive protein (CRP) levels. In normal CRP, albumin was significantly lower in unadjusted BMI [RRR = 0.8, p = 0.001] and in normal weight [RRR = 0.7, p = 0.003] and overweight [RRR = 0.5, p = 0.001] participants. In elevated CRP, albumin was significantly lower [RRR = 0.8, p = 0.050] and prealbumin was significantly higher in unadjusted BMI [RRR = 1.2, p = 0.034] and overweight [RRR = 1.4, p = 0.052] individuals. The current study found that prealbumin can differentiate between inflammation-induced reduction of albumin and true malnutrition in adults singly or coinfected with HIV and intestinal helminths in the presence or absence of inflammation in various BMI categories.

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Serum calprotectin may reflect inflammatory activity in patients with active rheumatoid arthritis despite normal to low C-reactive protein

Approximately half of patients with rheumatoid arthritis (RA) have normal C-reactive protein (CRP) levels. Calprotectin is a promising and likely more specific biomarker of disease activity than conventionally used acute phase reactants. We aimed to analyse the levels of serum calprotectin in RA patients with clinically active disease and with normal/low CRP. A total of 160 RA patients underwent clinical examination (DAS28-ESR and CDAI). The levels of calprotectin were analysed in patients with moderate to high disease activity with normal/low CRP levels and in 32 healthy subjects. The discriminatory capacity of calprotectin to identify clinically active patients in spite of normal/low CRP was assessed using ROC curves. Out of all RA patients, 74/160 (46.3%) were in remission or had low disease activity according to DAS28 and had normal/low CRP levels. However, 51/160 (32%) had normal/low CRP levels despite having moderate to high disease activity. In these patients, calprotectin levels were significantly higher than those in patients who had normal/low CRP and were in remission or showed low disease activity (2.7 ± 1.5 vs. 2.1 ± 1.2μg/mL, p = 0.043), which differed from those in healthy subjects (2.7 ± 1.5 vs. 1.9 ± 1.2μg/mL, p = 0.011). The discriminatory capacity for calprotectin to distinguish clinically active vs. inactive disease despite normal/low CRP using AUC of the DAS28 was 0.607 (95% CI 0.503 to 0.711, p = 0.043). The present study demonstrates that calprotectin may reflect inflammatory activity in RA patients where CRP fails to do so.

Addressing Acute Coronary Syndromes: New Challenges and Opportunities After the CANTOS Trial (Canakinumab Anti-inflammatory Thrombosis Outcomes Study).

In the mid-1980s, it became clear that plaque quality rather than plaque quantity explained coronary instability, as suggested by data deriving from retrospective angiographic studies, and, in 1985, M.J. Davies proposed that plaque fissure was the link between atherosclerosis and thrombosis. In 1994, we found that patients with acute coronary syndrome (ACS) and high levels of C-reactive protein (CRP), a prototypic marker of inflammation, had a worse outcome than patients with normal levels of CRP, and proposed that plaque inflammation was responsible for plaque fissure.1 Several other studies then confirmed an association between activation of inflammatory cells and ACS but without proving the causality. The recent publication of the CANTOS trial (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) has convincingly proved the inflammatory hypothesis of ACS we proposed 23 years ago.2 Indeed, CANTOS showed that interleukin-1β inhibition by canakinumab administration added to current optimal treatment in patients with a history of myocardial infarction and levels of high-sensitivity CRP >2 mg/L resulted in a 39% reduction of high-sensitivity CRP levels from baseline without any effect on lipids, and in a 15% reduction in the risk of the primary composite efficacy end point of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death, in comparison with placebo-treated patients.2 Yet, the benefit of canakinumab administration on ischemic events was rather modest and …

Prevalence of Propionibacterium acnes in the glenohumeral compared with the subacromial space in primary shoulder arthroscopies

We hypothesized that the prevalence of Propionibacterium acnes in patients undergoing primary shoulder arthroscopy is equal in the glenohumeral space compared with the subacromial space. Patients aged 18 years or older with shoulder arthroscopies were included. The exclusion criteria were prior shoulder operations, complete rotator cuff tears, systemic inflammatory diseases, tumors, shoulder injections within 6 months of surgery, and antibiotic therapy within 14 days preoperatively. After standardized skin disinfection with Kodan Tinktur Forte Gefärbt, a skin swab was taken at the posterior portal. Arthroscopy was performed without cannulas, prospectively randomized to start either in the glenohumeral space or in the subacromial space, with direct harvesting of a soft-tissue biopsy specimen. Sample cultivation was conducted according to standardized criteria for bone and joint aspirate samples and incubated for 14 days. Matrix-assisted laser desorption-ionization time-of-flight spectrometry was used for specimen identification in positive culture results. The study prospectively included 115 consecutive patients with normal C-reactive protein levels prior to surgery (54.8% men; mean age, 47.2 ± 14.6 years). P acnes was detected on the skin after disinfection in 36.5% of patients, in the glenohumeral space in 18.9%, and in the subacromial space in 3.5% (P = .016). The prevalence of P acnes is significantly higher in the glenohumeral space compared with the subacromial space in primary shoulder arthroscopies. The results do not confirm the contamination theory but also cannot clarify whether P acnes is a commensal or enters the joint hematologically or even lymphatically or via an unknown pathway. Despite standardized surgical skin disinfection, P acnes can be detected in skin swab samples in more than one-third of patients.

Detection of serum cytokines in patients with dermatomyositis and their clinical significance

Objective To explore the association of serum cytokine levels with disease activity in patients with dermatomyositis (DM) and clinically amyopathic dermatomyositis (CADM) , especially their association with skin lesions and interstitial lung disease (ILD) . Methods Enzyme-linked immunosorbent assay (ELISA) and cytometric beads array (CBA) were performed to detect the serum levels of interleukin (IL) -2, IL-4, IL-6, IL-10, IL-17A, IL-18, tumor necrosis factor (TNF) and interferon (IFN) -γ in 40 patients with DM or CADM, as well as in 16 health checkup examinees (healthy control group) . Then, the association of serum cytokine levels with skin lesions, inflammatory biomarkers and severity of ILD was analyzed. Results The patients with DM/CADM showed significantly higher serum levels of IL-6 (37.8 ± 45.8 pg/ml) , IL-10 (16.1 ± 7.2 pg/ml) and IL-18 (492.0 ± 193.1 pg/ml) compared with the healthy controls (12.0 ± 2.7 pg/ml, 7.7 ± 1.4 pg/ml, 191.1 ± 39.2 pg/ml, respectively, all P < 0.001) , and there were no significant differences in the serum levels of the other 5 cytokines between the above 2 groups. The serum level of IL-6 was significantly higher in patients with elevated erythrocyte sedimentation rate (ESR) than in those with normal ESR (49.7 ± 46.8 pg/ml vs. 29.1 ± 45.4 pg/ml, P= 0.008) . The patients with raised C-reactive protein (CRP) levels showed significantly higher serum levels of IL-6 (68.7 ± 59.7 pg/ml) and IL-18 (635.1 ± 232.8 pg/ml) compared with those with normal CRP levels (IL-6: 30.6 ± 40.3 pg/ml, P= 0.013; IL-18: 440.2 ± 164.7 pg/ml, P= 0.020) . Moreover, the patients with elevated levels of lactate dehydrogenase (LDH) showed significantly higher serum levels of IL-10 (18.4 ± 6.9 pg/ml) , IL-17A (19.6 ± 6.7 pg/ml) and IL-18 (529.4 ± 197.2 pg/ml) compared with those with normal LDH levels (IL-10: 10.7 ± 4.8 pg/ml, P < 0.001; IL-17A: 11.4 ± 6.6 pg/ml, P= 0.001; IL-18: 404.9 ± 158.0 pg/ml, P= 0.037) . No significant difference in the cytokine levels was observed between the patients with elevated creatine kinase (CK) levels and those with normal CK levels. The patients with Gottron′s papules/sign showed significantly higher serum levels of IL-18 (513.7 ± 187.2 pg/ml) compared with those without Gottron′s papules/sign (297.1 ± 140.4 pg/ml, P < 0.05) . The serum levels of IL-10 and IL-18 were significantly higher in the patients with DM/CADM complicated by ILD (18.0 ± 6.7 pg/ml, 552.3 ± 192.8 pg/ml, respectively) than in those without ILD (11.6 ± 6.5 pg/ml, 351.4 ± 101.0 pg/ml, respectively, both P= 0.001) . Conclusion Serum levels of IL-6, IL-10 and IL-18 are highly associated with inflammatory biomarkers, skin lesions and ILD in patients with DM/CADM. Key words: Dermatomyositis; Cytokines; Lung Diseases, Interstitial; Interstitial lung disease; Clinically amyopathic dermatomyositis

Association of Vedolizumab Level, Anti-Drug Antibodies, and α4β7 Occupancy With Response in Patients With Inflammatory Bowel Diseases

There are few data available on the real-life pharmacokinetic and pharmacodynamics features of vedolizumab, a monoclonal antibody against integrin α4β7. We performed a prospective study of patients with inflammatory bowel diseases (IBDs) treated with vedolizumab to determine serum drug concentrations, formation of antivedolizumab antibodies (AVAs), and integrin α4β7 saturation. We performed a prospective study of 106 patients with IBD (67 with Crohn's disease and 39 with ulcerative colitis) treated with vedolizumab from September 2014 through March 2017 at 2 tertiary medical centers in Israel. Clinical data and serum samples were collected before and during induction and maintenance therapy. Clinical remission was defined as Harvey-Bradshaw index scores below 5 or as Simple Clinical Colitis Activity Index scores of 3 or less. We measured serum levels of vedolizumab, AVAs, and markers of inflammation. Peripheral blood mononuclear cells were obtained from some patients at designated trough time points and CD3+ CD45RO+ T cells were isolated from 36 samples. Cells were incubated with fluorescent-conjugated vedolizumab and flow cytometry was used to quantify α4β7 integrin saturation. We also performed flow cytometry analyses of CD3+ CD45RO+ lamina propria T cells isolated from intestinal mucosa of patients without IBD (non-IBD controls, n= 6), patients with IBD not treated with vedolizumab (untreated IBD controls, n= 8), and patients with IBD treated with vedolizumab (n= 15). Clinical remission was achieved by 48 of 106 patients (45%) by week 6 and 50 of 106 patients (48%) by week 14 of treatment. The median level of vedolizumab at week 6 was higher in patients in clinical remission (40.2 μg/mL) than in patients with active disease (29.7 μg/mL; P= .05). The median serum level of vedolizumab was significantly higher in patients with a normal level of C-reactive protein (21.8 μg/mL vedolizumab) vs the level in those with a high level of C-reactive protein (11.9 μg/mL vedolizumab) during maintenance treatment (P= .0006). The other clinical outcomes measured were not associated with median serum level of vedolizumab at any time point examined. AVAs were detected in 17% of patients during induction therapy and 3% of patients during maintenance therapy, but did not correlate with clinical outcomes. Flow-cytometry analysis of peripheral blood memory T cells (n= 36) showed near-complete occupancy of α4β7 integrin at weeks 2 and 14 and during the maintenance phase, regardless of response status or drug levels. Most intestinal CD3+CD45RO+ memory T cells of healthy and IBD controls expressed α4β7 (72%; interquartile range, 56%-81%). In contrast, free α4β7 was detectable on only 5.6% of intestinal memory cells (interquartile range, 4.4%-11.2%) (P < .0001) from vedolizumab-treated patients, regardless of response. In a prospective study of real-life patients with IBD, we associated vedolizumab drug levels with remission and inflammatory marker level. Integrin α4β7 was blocked in almost all T cells from patients treated with vedolizumab, regardless of serum level of the drug or response to treatment. These findings indicate a need to explore alternative mechanisms that prevent response to vedolizumab.

Quality of life is associated with chronic inflammation in depression: A cross-sectional study

BackgroundInflammation may play a crucial role in the pathophysiology of depression. However, the association between chronic inflammation and health outcomes in depression remains unclear, particularly for patient-reported outcomes. MethodsThe aim of this study was to investigate the relationship between quality of life (QoL) (physical and mental health, assessed by the SF-36) and chronic inflammation assessed using C-reactive protein (CRP) in patients with current major depressive disorder. ResultsOne hundred eighty-one patients with depression were enrolled in this study. After adjusting for key socio-demographic, clinical and biological confounding factors, patients with high levels of CRP (> 3.0mg/L) had worse physical health than those with normal CRP levels (OR = 0.95, 95% CI = 0.92–0.99). Significant associations were found between a higher rate of metabolic syndrome (OR = 0.10, 95% CI = 0.02–0.41) and high CRP levels. LimitationsThe cut-off point for high cardiovascular risk was used to define the two groups: normal CRP level and high CRP level. CRP was the sole marker of inflammation in this study and was collected at only one time point. The design of this study is cross-sectional and there are no conclusions about the directionality of the association between QoL and inflammation in depression. QoL was assessed only by SF-36 scores. ConclusionThis study found an association between SF-36 physical health score and CRP in patients with depression, thereby showing the need to consider physical well-being in depression. This paves the way for interventions to act both on inflammation and QoL in patients with depression.

Features of 921 Patients With Spinal Tuberculosis: A 16-Year Investigation of a General Hospital in Southwest China.

Southwest China has a high burden of spinal tuberculosis (TB). Few large case studies of spinal TB in southwest China have been conducted. This study investigated the features of 921 patients who were treated for spinal TB at a general hospital in southwest China between 2001 and 2016. Demographic data, clinical data, laboratory data, imaging findings, treatment methods, and outcomes of patients who were admitted to the hospital for spinal TB were reviewed retrospectively. The annual incidence of spinal TB increased throughout the study period. The greatest number of patients were 41 to 50 years old (22.04%). Local pain was the most common symptom (97.8%). A significant difference in the duration of symptoms was observed between rural populations (28.40 months) and urban populations (10.17 months) (P=.041). Of the patients, 32.68% had a normal erythrocyte sedimentation rate and 25.84% had a normal C-reactive protein level. The lumbar spine was the most commonly involved spinal site (44.77%), followed by the thoracic spine (43.60%). All of the patients underwent chemotherapy, and 77.10% of patients underwent surgery. Most of the patients were cured, with the exception of 2.19% of patients who discontinued chemotherapy after early improvement of clinical status. Spinal TB is still a major public health problem in southwest China. Chemotherapy and surgery can yield satisfactory outcomes with timely diagnosis and long-term treatment. It is urgent to increase the attention paid to spinal TB and improve knowledge of this disease among the general public, especially in southwest China. [Orthopedics. 2017; 40(6):e1017-e1023.].

Necrotising fasciitis: a ticking time bomb?

Necrotising fasciitis (NF) is a destructive bacterial infection and has often been described in media reports as a ‘flesh-eating disease’, which if diagnosed late is associated with worse outcome. Unfortunately,...

Normal serum matrix metalloproteinase-3 levels can be used to predict clinical remission and normal physical function in patients with rheumatoid arthritis

This study aimed to evaluate whether normal serum matrix metalloproteinase-3 (MMP-3) levels can be used to predict clinical remission and normal physical function at a single time point when treating patients with rheumatoid arthritis (RA) in daily practice settings. Subjects were all 1321 RA patients who were treated at our hospital. The accuracy of serum MMP-3 levels was larger than those of C-reactive protein (CRP) levels for predicting clinical remission [Simplified Disease Activity Index (SDAI) ≤3.3], normal function [Disability Index of the Health Assessment Questionnaire (HAQ-DI) ≤0.5], and both in clinical remission and with normal function (clinical remission + normal function) using receiver operating characteristic curve analysis. Serum MMP-3 levels were significantly correlated with CRP levels [r 0.229 (men), r 0.476 (women)] using Pearson's correlation coefficients. Among patients with normal CRP levels (n=807), the percentage of patients in clinical remission, with normal function, and with clinical remission + normal function having normal serum MMP-3 levels was significantly higher than those with abnormal serum MMP-3 levels. In addition, among patients with the 28-point count Disease Activity Score-CRP (DAS28-CRP) remission (DAS28-CRP <2.3), the percentage of patients in clinical remission, with normal function, and with clinical remission + normal function having normal serum MMP-3 levels was significantly higher than those with abnormal serum MMP-3 levels. Our findings suggest that normal serum MMP-3 levels, in combination with CRP levels or disease activity, are useful for predicting clinical remission and normal physical function in patients with RA.

High C-reactive protein levels are associated with depressive symptoms in schizophrenia

BackgroundDepressive symptoms are frequently associated with schizophrenia symptoms. C - Reactive protein (CRP), a marker of chronic inflammation, had been found elevated in patients with schizophrenia and in patients with depressive symptoms. However, the association between CRP level and depressive symptoms has been poorly investigated in patients with schizophrenia. The only study conducted found an association between high CRP levels and antidepressant consumption, but not with depressive symptoms investigated with the Calgary Depression Rating Scale for Schizophrenia (CDSS). ObjectivesThe aim of this study was to evaluate CRP levels and depressive symptoms in patients with schizophrenia, and to determine whether high CRP levels are associated with depressive symptoms and/or antidepressant consumption, independently of potential confounding factors, especially tobacco-smoking and metabolic syndrome. MethodsThree hundred and seven patients with schizophrenia were enrolled in this study (mean age = 35.74 years, 69.1% male gender). Depressive symptoms was investigated with the CDSS. Patients were classified in two groups: normal CRP level (≤ 3.0mg/L) and high CRP level (> 3.0mg/L). Current medication was recorded. Results124 subjects (40.4%) were classified in the high CRP level group. After adjusting for confounding factors, these patients were found to have higher CDSS scores than those with normal CRP levels in multivariate analyses (p = 0.035, OR = 1.067, 95% CI = 1.004–1.132). No significant association between CRP levels and antidepressants consumption was found. LimitationsThe size sample is relatively small. The cut-off point for high cardiovascular risk was used to define the two groups. CRP was the sole marker of inflammation in this study and was collected at only one time point. The design of this study is cross-sectional and there are no conclusions about the directionality of the association between depression and inflammation in schizophrenia. ConclusionThis study found an association between high rates of CRP levels and depressive symptoms in patients with schizophrenia, but no association with antidepressant consumption. Further studies are needed to investigate the impact of inflammation in schizophrenia.

Rotator cuff surgery in patients with rheumatoid arthritis: clinical outcome comparable to age, sex and tear size matched non-rheumatoid patients.

Aims This study aimed to compare the clinical outcomes of rotator cuff repair in patients with rheumatoid arthritis with those of patients who have no known history of the disease. We hypothesised that the functional outcomes are comparable between patients and without rheumatoid arthritis and may be affected by the level of disease activity, as assessed from C-reactive protein (CRP) level and history of systemic steroid intake. Patients and methods We conducted a retrospective review of the institutional surgical database from May 1995 to April 2012. Twenty-nine patients with rheumatoid arthritis who had rotator cuff repair were enrolled as the study group. Age, sex, and tear size matched patients with no disease who were selected as the control group. The mean duration of follow-up was 46 months (range 24-92 months). Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) questionnaire, Constant score and visual analogue scale (VAS). All data were recorded preoperatively and at regular postoperative follow-up visits. CRP was measured preoperatively as the disease activity marker for rheumatoid arthritis. Medication history was thoroughly reviewed in the study group. Results In patients with rheumatoid arthritis, all shoulder functional scores improved after surgery (ASES 56.1-78.1, Constant 50.8-70.5 and VAS 5.2-2.5; P<0.001). The functional outcome of surgery in patients with rheumatoid arthritis was comparable to that of the control group (difference with control: ASES 78.1 vs. 85.5, P=0.093; Constant 70.5 vs. 75.9, P=0.366; VAS 2.5 vs. 1.8, P=0.108). Patients with rheumatoid arthritis who had an elevated CRP level (>1 mg/dl) showed inferior clinical outcomes than those with normal CRP levels. Patients with a history of systemic steroid intake showed inferior functional outcomes than those who had not taken steroids. Conclusions Surgical intervention for rotator cuff tear in patients with rheumatoid arthritis improved the shoulder functional outcome comparable to that in matched patients without rheumatoid arthritis. Elevated preoperative CRP level and history of systemic steroid intake portend inferior functional outcome in patients with rheumatoid arthritis.

Impact of obesity on the response to tumor necrosis factor inhibitors in axial spondyloarthritis

BackgroundFew studies have investigated the impact of obesity on the response to tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (axSpA). The aim of our study was to investigate the impact of different body mass index (BMI) categories on TNFi response in a large cohort of patients with axSpA.MethodsPatients with axSpA within the Swiss Clinical Quality Management (SCQM) program were included in the current study if they fulfilled the Assessment in Spondyloarthritis International Society (ASAS) criteria for axSpA, started a first TNFi after recruitment, and had available BMI data as well as a baseline and follow-up visit at 1 year (±6 months). Patients were categorized according to BMI: normal (BMI 18.5 to <25), overweight (BMI 25–30), and obese (BMI >30). We evaluated the proportion of patients achieving the 40% improvement in ASAS criteria (ASAS40), as well as Ankylosing Spondylitis Disease Activity Score (ASDAS) improvement and status scores at 1 year. Patients having discontinued the TNFi were considered nonresponders. We controlled for age, sex, HLA-B27, axSpA type, BASDAI, BASMI, elevated C-reactive protein (CRP), current smoking, enthesitis, physical exercise, and co-medication with disease-modifying antirheumatic drugs, as well as with nonsteroidal anti-inflammatory drugs in multiple adjusted logistic regression analyses.ResultsA total of 624 axSpA patients starting a first TNFi were considered in the current study (332 patients of normal weight, 204 patients with overweight, and 88 obese patients). Obese individuals were older, had higher BASDAI levels, and had a more important impairment of physical function in comparison to patients of normal weight, while ASDAS and CRP levels were comparable between the three BMI groups. An ASAS40 response was reached by 44%, 34%, and 29% of patients of normal weight, overweight, and obesity, respectively (overall p = 0.02). Significantly lower odds ratios (ORs) for achieving ASAS40 response were found in adjusted analyses in obese patients versus patients with normal BMI (OR 0.27, 95% confidence interval (CI) 0.09–0.70). The respective adjusted ASAS40 OR in overweight versus normal weight patients was 0.62 (95% CI 0.24–1.14). Comparable results were found for the other outcomes assessed.ConclusionsObesity is associated with significantly lower response rates to TNFi in patients with axSpA.