Normal CRP Levels Research Articles

Myocarditis in the modern era: analysing the impact of high-sensitivity troponin & C-reactive protein in predicting the extent of myocarditis and LV systolic dysfunction on cardiac magnetic resonance

Abstract Background The diagnostic yield of acute myocarditis has improved considerably since the advent of high-sensitivity troponin (hs-Tn) assays and adoption of the 2018 Lake Louise criteria for cardiac magnetic resonance (CMR)-based imaging for myocardial oedema and injury (1). Yet, a seminal 1997 study, predating these technological advances, remains widely cited for highlighting an absence of troponin rise in two-thirds of myocarditis cases (2). We hypothesize that all cases of myocarditis exhibit hs-Tn rise. However, whether such elevations in hs-Tn or inflammatory markers correlate with the extent of myocardial injury and left ventricular systolic dysfunction (LVSD) on CMR remain unclear. To provide insight into this, we examined a contemporary cohort of cases between 2019-2023. Methods Two authors independently conducted case-notes reviews to verify the diagnosis of myocarditis. CMR findings were stratified into regional (e.g. inferolateral) and global myocarditis (e.g. subepicardial LGE in all segments). This classification aimed to explore potential correlations with LVSD severity, peak hs-Tn and other inflammatory markers. Receiver operating characteristics (ROC) curves was calculated to determine any cut-off value for predicting CMR findings and adverse patient outcomes. Results 103 inpatients were clinically coded as ‘myocarditis’ upon discharge, but subsequent CMR (within 4 weeks) reclassified 23 patients into other causes (Figure 1). Analysis of the myocarditis cohort revealed a predominantly male population (76%) with median age 53, commonly presenting with chest pain without a viral prodrome (Figure 2A-D). Elevated hs-Tn levels were observed universally, with a median peak hs-TnT of 610ng/L (IQR 1081.5ng/L) and hs-TnI of 3820ng/L (IQR 12416ng/L). In contrast, peak CRP ranged between 2mg/L (normal) and 600mg/L. Global myocarditis was detected in 11/80 patients (13.8%); however, this finding did not correlate with adverse patient outcomes which included all-cause mortality (9.6%) and cardiac re-admissions within 12 months (9.6%, namely for chest pains). No arrhythmic deaths were noted. COVID was present in 4% on admission. CRP cut-off of 140mg/L predicted the occurrence of global myocarditis with a sensitivity of 72.7% and specificity of 87.0% (AUC 0.74, 95% CI 0.52-0.96, p=0.014) (Figure 2E). However, neither hs-Tn or CRP levels correlated with the degree of LVSD (Figure 2F) or adverse outcomes. This is likely limited by the small sample. Conclusion Although all cases of myocarditis exhibited raised hs-Tn, this did not correlate with the degree of LV systolic impairment on CMR. Myocarditis with regional LV involvement can have normal CRP levels, while a CRP cut-off >140mg/L may predict the occurrence of global myocarditis. However, CMR stratification into regional and global was not associated with adverse patient outcome within 12 months. A larger sample size is required to verify this finding, including longer term follow-ups.Flowchart of patients included in studyMain findings

Elevated serum 25-hydroxyvitamin D: a potential indicator of remission in Takayasu arteritis patients with normal ESR and CRP levels.

The goal of the present study was to investigate the correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and disease remission in Takayasu arteritis (TAK) patients. This retrospective study included 59 patients in the study group and 80 patients in the validation cohort with TAK. After 6months of therapy, patients were re-evaluated, and serum 25(OH)D levels were compared before and after treatment. Correlations between changes in 25(OH)D levels and changes in disease activity scores (NIH, ITAS2010, ITAS.A) were analyzed. Additionally, a predictive cut-off value for disease remission was determined. After 6months of therapy, serum 25(OH)D levels in TAK patients significantly increased compared to baseline [(18.33 ± 7.25)µg/L vs (11.77 ± 4.14) µg/L] (P < 0.001). Positive correlations were observed between the increasing changes in the 25(OH)D level and the decreasing changes in the reduced NIH, ITAS2010, and ITAS.A scores (r = 0.455, P < 0.001; r = 0.495, P < 0.001; and r = 0.352 P = 0.006, respectively). A change of 8.45µg/L in 25(OH)D level was identified as the predictive cut-off value for TAK remission (sensitivity 54.1%, specificity 90.9%, area under the curve = 0.741). Similarly for patients with normal baseline ESR, sensitivity is 68.0%, specificity is 92.3%, and area under the curve is 0.831, and for patients with normal baseline CRP, sensitivity is 58.3%, specificity is 90.0%, and area under the curve is 0.748. Validation in an additional 80 patients demonstrated a higher remission rate in those with a 25(OH)D level change > 8.45µg/L. Serum 25(OH)D levels significantly increased after treatment in TAK patients, and an increase of ≥ 8.45µg/L was predictive of disease remission, especially in individuals with normal baseline ESR and/or CRP levels. Key Points • Following treatment, there was a significant increase in serum 25(OH)D levels among TAK patients. • The elevated changes in 25(OH)D levels before and after treatment demonstrated a positive correlation with the reduction in disease activity scores. • In patients with TAK before and after treatment, an elevation in serum 25(OH)D levels exceeding 8.45µg/L serves as an indicator for disease remission, particularly prominent in individuals with normal baseline ESR and/or CRP levels.

P199 External validation of Intestinal Ultrasound score: IBUS-SAS with clinical (CDAI), biomarkers and endoscopic scoring system (SES-CD)

Abstract Background Intestinal ultrasound (IUS) is a non-invasive tool for assessing disease activity in patients with Inflammatory bowel disease. International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) is a comprehensive score proposed by an expert consensus with good reliability. We aim to assess the correlation of the IBUS-SAS with clinical and endoscopic scores and biomarkers in patients with Crohn’s disease (CD) in a point-of-care setting. Methods This retrospective study was conducted from October 2021 to September 2023. All patients with CD who underwent colonoscopy at initial presentation or assessing disease activity on follow-up were included. At the clinic visit, Crohn’s disease activity index (CDAI), C-reactive protein levels (CRP), Faecal calprotectin (FC) were documented. IUS was performed in the clinic and IBUS-SAS was documented. A colonoscopy was done within 1 week of the clinic visit. Endoscopic disease activity was documented using Simple Endoscopic Score in Crohn’s disease (SES-CD). Statistical Analysis Pearson’s correlation was performed between IBUS-SAS and the clinical and endoscopic scores and the biomarkers. ROC analysis was done to assess the threshold value of IBUS-SAS to predict the presence of endoscopic disease activity. Results 181 patients were included in the study. In patients with clinical remission, the median IBUS-SAS was 8 (± 23.5). The median IBUS-SAS was 62 (± 21.47), 70 (± 15.47) &amp; 64 (± 0.58) in patients with mild, moderate to severe &amp; severe CDAI respectively. The Pearson correlation coefficient between IBUS-SAS &amp; CDAI was 0.7 (95% CI 0.62-0.77; p &amp;lt; 0.001). The IBUS-SAS in patients with normal CRP levels (&amp;lt; 5mg/L) was 8 (± 19.54) &amp; in patients with elevated CRP was 64 (± 18.99). The IBUS-SAS in patients with normal FC was 8 (± 19.65) &amp; elevated FC (&amp;gt;250mcg/g) was 64.5 (± 22.66). The Pearson correlation coefficient between IBUS-SAS &amp; CRP was 0.49(95% CI 0.37-0.60; p &amp;lt; 0.001) and with FC was 0.58 (95% CI 0.46-0.68; p &amp;lt; 0.001). The IBUS-SAS correlated well with SES-CD score with IBUS SAS scores of 8 (± 12.92), 53.5 (± 16.35), 65 (± 20.83) &amp; 65 (± 8.62) in patients with inactive, mild, moderate, &amp; severe SES-CD respectively. The Pearson correlation coefficient between IBUS-SAS &amp; SES-CD was 0.77 (95% CI 0.7-0.82; p &amp;lt; 0.001). The IBUS-SAS score of &amp;gt; 37.5 revealed an area under the curve of 0.96 (95% CI 0.92 – 0.99) with a sensitivity of 94% &amp; specificity of 91% to predict endoscopic disease activity (SES-CD &amp;gt; 3). Conclusion The IBUS-SAS score correlated very well with clinical and endoscopic disease activity as well as biomarkers. A score &amp;gt; 37.5 had a sensitivity of 94% and specificity of 91% to predict the presence of endoscopic disease activity.

Significance of F-18 FDG PET/MRI in the search for the etiology of inflammation of unclear origin and fever of unknown origin

PurposeTo evaluate the contribution of F-18 FDG-PET/MRI in the search for the etiology of the inflammation of unknown origin (IUO) and fever of unknown origin (FUO). Material and methodsThe study included 104 patients who underwent F-18 FDG-PET/MRI for IUO or FUO. The sensitivity, specificity, predictive values of the PET/MRI findings in relation to the final diagnosis of IUO/FUO were evaluated. A five-point Likert scale was used to semiquantitatively assess the probability of the cause of IUO/FUO based on PET/MRI finding. Furthermore, clinical (fever, arthralgia, weight loss, night sweats, age) and laboratory (C-reactive protein, leukocytes) parameters were monitored and compared with the true positivity rate of PET/MRI. ResultsIn patients with definitively identified etiology of FUO and IUO, FDG-PET/MRI achieved a sensitivity of 96 %, specificity of 82 %, and positive and negative predictive values of 92 and 90 %. The cause of the IUO was determined in 71 patients (68.3 %). In 33 (31.7 %) patients, the etiology of IUO/FUO remained unknown, while in 25 (75.8 %) of them the symptoms resolved spontaneously and in 8 (24.2 %) patients they persisted without explanation even after 12 months of the follow-up. The most significant parameter in relation to subsequent PET/MRI finding was increased level of CRP, which was present in 96 % of true positive PET/MRI and normal CRP level was present in 56 % of true negative PET/MRI. ConclusionBased on this study, FDG-PET/MRI is a suitable alternative for the investigation of IUO/FUO, this imaging technique has a very high sensitivity and negative predictive value.

Diagnostic value of serum CRP, PCT and IL-6 in children with nephrotic syndrome complicated by infection: a single center retrospective study.

The purpose was to look into the diagnostic value of serum CRP, PCT and IL-6 in children with nephrotic syndrome co-infection. One hundred and forty-nine children with nephrotic syndrome who met the inclusion and exclusion criteria were included in this study. The children were divided into three groups: bacterial infection group, non-bacterial infection group, and non-infection group. The diagnostic value was analyzed and compared using the ROC curve. There was no statistically significant difference in the Leukocyte counts among three groups. The mean results of serum CRP, PCT and IL-6 were significantly higher in the bacterial infection group compared to those in the non-infection group (p < 0.05). AUC of CRP, PCT, IL-6 in bacterial infection were 0.791, 0.859, 0.783. The following combinations CRP + PCT + IL-6, IL-6 + PCT, CRP + PCT significantly increased the efficiency of bacterial infection diagnosis, the AUCs were 0.881, 0.884, and 0.884, respectively. AUC of PCT in non-bacterial infection was 0.663. The combinations of these three clinical indicators performed no better than PCT in ROC analysis. Normal CRP or IL-6 levels do not rule out the diagnosis of bacterial infection in children on long-term glucocorticoid therapy. The appropriate combination of two or three indicators can improve the diagnostic value. This study evaluated the diagnostic value of the serum concentrations of CRP, PCT and IL-6 and assessed whether the value of their combined application is better than when used alone for diagnosing primary nephrotic syndrome complicated by infection. The elevation in leukocyte count cannot be used to diagnose children with nephrotic syndromes on long-term glucocorticoid treatment who have bacterial infections. Normal CRP or IL-6 levels do not rule out the diagnosis of bacterial infection in children on long-term glucocorticoid therapy. The appropriate combination of two or three indicators can improve diagnostic value, sensitivity, and specificity.

Evaluation of CRP as Predictor of Chorioamnionitis in Premature Rupture of Membranes

Background: Early identification of sepsis is essential as the mother has a risk of chorioamnionitis. C-reactive protein levels are done along with placental histopathology to detect chorioamnionitis. It is one of the most significant causes of high perinatal morbidity and mortality. Aim and Objective: To determine c-reactive protein levels and placental histopathology in premature rupture of membranes for maternal chorioamnionitis. Methodology: A prospective study was conducted in a tertiary care university medical college hospital and research center in western Maharashtra. A total of 250 pregnant women were reported per vaginal leak during the study period and CRP levels were sent along with urine culture sensitivity and high vaginal swab, post-delivery the placenta was sent for histopathology and were included in the study analysis. Results: The histopathology was done in all 250 pregnant women, and chorioamnionitis was evident in 46 pregnant women. This gives the incidence of 18.4% of chorioamnionitis in the study population. The sensitivity for CRP was calculated to be 15.22%, with a specificity of 99.02%, positive and negative predictive values of 77.78% and 83.82%, respectively, with an accuracy of 83.60%. Conclusion: Normal CRP level has good predictive values to rule out maternal chorioamnionitis. A raised single CRP level has low sensitivity to predict histological chorioamnionitis prior to its clinical expression.

Primary Antiphospholipid Syndrome Presenting with Cerebellar Stroke and Positive Titres of Anti-β2 Glycoprotein-1 Antibody Only: A Case Report (P9-5.026)

<h3>Objective:</h3> To describe a case of Primary Antiphospholipid Syndrome presenting with Cerebellar Stroke and positive titres of anti-β2 glycoprotein-1 antibody only. <h3>Background:</h3> Antiphospholipid syndrome (APS) is an autoimmune disease where the presence of antiphospholipid antibodies leads to the development of arterial and/or venous thromboses and obstetric complications. Amongst the myriad of presentations, APS can manifest in the form of cerebrovascular stroke. However, overlapping clinico-radiological findings and a lack of classic APS features can sometimes pose a diagnostic dilemma. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 31-year-old female presented with occipital headache and difficulty in walking. Neurological examination revealed ataxia, dysdiadochokinesia and intention tremor. Preliminary laboratory findings revealed raised ESR along with normal CRP, aPTT and PT levels. MRI brain showed an acute infarct in the right cerebellar hemisphere and right postero-lateral upper medulla. MRA Head &amp; Neck revealed an occluded intracranial right vertebral artery with an extracranial segment showing multifocal occlusions with aorta and its major branches unaffected. These features and the absence of fever, rash, joint pain or obstetric complications led to the consideration of stroke due to Takayasu Arteritis. Treatment was initiated with corticosteroids, anticoagulants and antiplatelet drugs. However, on review of other laboratory tests, notably the auto-immune profile showed the presence of anti-ß2 glycoprotein-I antibodies with negligible titres of lupus anticoagulant and anti-cardiolipin antibody. This pointed towards a diagnosis of Primary Antiphospholipid Syndrome, which was confirmed after 12 weeks when repeat laboratory tests indicated the presence of IgM anti-ß2 glycoprotein-I antibodies. The patient is now on lifelong Warfarin therapy and is leading a symptom-free life. <h3>Conclusions:</h3> This case illustrates the potential of anti-β2 glycoprotein-1 antibody to cause a cerebellar stroke in the absence of other commonly involved antibodies. It also highlights the value of a holistic stroke workup. Recognition of APS is imperative for the timely administration of treatment and to prevent a recurrence. <b>Disclosure:</b> Mr. Shah has nothing to disclose. Mr. Shah has nothing to disclose. Dr. Nagrani has nothing to disclose.

P124 Rheumatoid Arthritis with Normal CRP: an Underappreciated, Persistent Phenotype: Equally at Risk of Severe Disease

Abstract Background/Aims A subset of seropositive rheumatoid arthritis (RA) with normal CRP levels during ultrasound-proven flairs was previously identified. They experienced worse outcomes, with delays in initiation of conventional DMARDs, more joint damage and higher disease activity scores, with an increased likelihood of needing biologic therapy. The aims were to longitudinally assess this group over 5 years - to determine the persistence of the phenotype and establish if differences in outcome were sustained; and to estimate the prevalence of this phenotype among the wider seropositive RA cohort at UCLH. Methods The initial study described two groups: those with high CRP during flare (hCRP) and those with normal CRP during flare (nCRP). The electronic health records of the initial cohort were interrogated. CRP measurements at 1-, 2- and 5-years post recruitment were collated. Clinical notes were examined to determine if episodes of raised CRP were due to RA activity, or alternative causes. Because of its CRP lowering properties, patients on Tocilizumab were excluded from this analysis. To screen for the nCRP phenotype in the larger population, DAS-28-CRP results were analysed from the 312 most recently reviewed patients in the UCLH seropositive RA database (data extracted 8th October 2019). The clinic letter from the time of the CRP value was examined, and patients were defined as having active disease if DAS-28 &amp;gt; 4.5. Results Patients classified as nCRP at initial recruitment continued to have lower CRP (nCRP group median 1.1, maximum 6.4, hCRP group median 4, maximum 55.2, P = 0.0117). 1 patient originally classified as nCRP had a result &amp;gt;5 at 5 years (6.4). Among the original cohort, at 5 years, patients originally defined as nCRP were more likely to require a biologic (76.67%) than hCRP (44.4%) (P = 0.0324). There was no significant difference in DAS-28 scores between groups at 5 years (hCRP median 3.2, nCRP median 2.9 P = 0.8775) . Patients with nCRP phenotype were as likely to have erosive disease as those in the hCRP cohort (hCRP 66.67%, nCRP 56.52%, P = 0.7356). Among the larger sample of 312 patients, 28 had CRP levels &amp;lt; 5 and DAS-28 &amp;gt;4.5. Of these, on longitudinal analysis of CRP at the time of clinic visits, 16/28 never mounted a CRP in response to active arthritis - likely the most representative of the nCRP patients from the original ultrasound cohort. These data suggest the nCRP phenotype represents at least 5% of the seropositive rheumatoid arthritis cohort at UCLH. Conclusion The subgroup of patients exhibiting normal CRP levels during disease flair maintain this phenotype over time. They remain more likely to require biologic treatment, while having equivalent DAS-28 scores and risk of damage to hCRP patients. Their presence as a significant minority of the wider population has implications for clinical care and resource use. Disclosure M. Hutchinson: None. B. Sethi: None. G. Sritharan: None. B. Greenaway: None. E. Jury: None. J. Manson: None.

The effectiveness of CRP and leukocyte examinations as a detection of risk factors for pre-eclampsia in pregnant women

Introduction: Preeclampsia is an important problem in obstetrics because it is a pregnancy complication often found and results in high morbidity and mortality in both mother and baby. Preeclampsia is one of the complications of pregnancy that needs to be detected or monitored for symptoms, because in addition to being risky for the mother, it will also have an impact on the occurrence of preterm birth and even further impact, namely fetal death in the womb. This study aimed to determine the effectiveness of CRP and leukocyte examination to detect preeclampsia. Method: This research was conducted at the Jagir Health Center Surabaya in March-July 2022. The research used case control with 30 pregnant women as samples divided into 15 as a control group of normal pregnant women and 15 pregnant women with preeclampsia. Result: The results showed that of the 15 respondents who had preeclampsia more than half (60%) had high leukocyte and CRP levels, the remaining less than half (40%) had normal CRP and leukocyte levels. While in the control group more than half (67%) had normal CRP and leukocyte levels and less than half (33%) had normal CRP and leukocyte levels. The results of data analysis showed p value 0.001 (&lt;0.005), which means there is a relationship between the CRP and leukocytes on the incidence of preeclampsia. Conclusion: Examination of CRP levels and leukocyte count proved effective for detecting the incidence of preeclampsia in pregnant women. It is expected that pregnant women carry out routine pregnancy checks and health workers are expected to routinely carry out early detection to prevent pregnancy complications such as preeclampsia

LRG1, a Novel Serum Biomarker for Idiopathic Multicentric Castleman Disease Activity

Objective: To investigate the relationship between serum Leucine-Rich α-2-Glycoprotein-1 (LRG1) and idiopathic multicentric Castleman disease (iMCD) activity, and to verify the effectiveness of LRG1 in monitoring treatment response. Methods: Clinical data and serum samples were collected from iMCD patients in flare and remission state diagnosed between August 2015 and April 2022 in Peking Union Medical College Hospital. Enzyme-linked Immunosorbent Assay was performed to quantify LRG1 concentration, which was further analyzed with patients' clinical data. Results: 81 patients were included, with 10 cases of iMCD-TAFRO and 40 cases of severe-disease, and 110 serum samples were acquired. The average LRG1 concentration was 113.5±14.27μg/mL in 76 samples of disease flare, 47.48±14.23μg/mL in 16 biochemical PR, and 14.4±1.18μg/mL in 18 biochemical CR samples. The difference is significant among different disease states (Flare vs PR, p = 0.0019; Flare vs CR, p < 0.0001; PR vs CR, p = 0.0349). Paired sample of 20 cases showed significant decrease of serum LRG1 from Flare to PR/CR (-35.36±5.94μg/mL, p < 0.0001) after treatment (figure 1A). Serum LRG1 level was also elevated in those iMCD-TAFRO cases with normal serum CRP level during disease flare. Baseline LRG1 level was significantly higher in patients with severe disease (142.6±23.2μg/mL vs 81.2±14.0μg/mL, p = 0.0271), which could be identified efficiently by baseline LRG1 over 57.75μg/mL (AUC = 0.655, p = 0.0203, sensitivity 70%, specificity 63.89%). Among 38 patients using thalidomide-cyclophosphamide-prednisone (TCP) regimen as first-line treatment, the median time to next treatment in patients with baseline LRG1 over 57.75μg/mL was significantly shorter than those under 57.75μg/mL (10 vs 30 months, HR: 2.254, 95% CI: 1.052-4.828, p = 0.0277) (figure 1B). Conclusion: Serum LRG1 level could mirror disease activity, and could be utilized to monitor the treatment response, especially in iMCD-TAFRO subtype. Serum LRG1 level over 57.75μg/mL could efficiently identify patients with severe iMCD, and had the potential to predict the efficacy of TCP regimen. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

POST COVID RECURRENT FEVER IN A CHILD WITH GENETIC SUSCEPTIBILITY TO FAMILIAL MEDITERRANEAN FEVER

<h3>Introduction</h3> Children and adults with post-acute sequelae of COVID (PASC) sometimes report recurrent fevers. We present the case of 13-year-old male with PASC recurrent fever who was found to have a heterozygous mutation in the gene associated with Familial Mediterranean fever (FMF). <h3>Case Description</h3> Our patient presented with recurrent fever 6 months after acute SARs-CoV-2 infection in January 2022. He endorsed prior episodes of unexplained fever and flushing prior but his recurrent fevers (39 C) post COVID had become more frequent occurring every few days. Laboratory analysis when he was afebrile demonstrated normal serum ESR, CRP, and CMP and normal cytokine levels. Genetic (In-Vitae) panel testing for autoinflammatory syndromes revealed a pathogenic heterozygous missense mutation in MEFV (p.A744S), the gene that controls pyrin production. A trial of colchicine was recommended, and he was referred to pediatric rheumatology. <h3>Discussion</h3> FMF is a genetic disorder that causes recurrent episodes of fever and almost always presents before age 20. Clinically significant FMF gene mutations lead to poorly functional pyrin; a protein that controls inflammation. Most children look and feel well between episodes but some children have such frequent episodes that they do not fully recover. In such cases, daily use of Colchicine should be considered as a safe and effective medication to control fever episodes. This report highlights the utility of genetic testing to identify potential causes of recurrent fever after COVID. Children with PASC related recurrent fevers should have genetic testing for susceptibility to FEF as this is a potentially treatable condition.

Ustekinumab trough levels predicting laboratory and endoscopic remission in patients with Crohn\u2019s disease

BackgroundsOptimal concentration of ustekinumab (UST) predicting endoscopic remission has not been fully investigated in Crohn’s disease (CD). We aimed to identify the optimal UST trough levels predicting clinical, laboratory and endoscopic remission in CD patients.MethodsTwenty-eight patients with CD were enrolled and investigated (27 patients by enteroscopy and 1 by colonoscopy). The endoscopic activity was assessed using the scoring system that applied the Rutgeerts score to observed intestine. Serum UST trough levels and anti-UST antibodies (AUAs) levels were determined by in-house immunoassays.ResultsEndoscopic activity was negatively correlated with serum UST trough levels (Spearman’s rank correlation coefficient (ρ) = − 0.66, P = 0.0001) and serum albumin levels (ρ = − 0.60, P = 0.0007). The endoscopic activity was positively and significantly correlated with CRP (ρ = 0.59, P = 0.0009) and ESR (ρ = 0.44, P = 0.033). There was no significant association between the endoscopic score and AUA levels and/or Crohn’s disease activity index (CDAI). Serum UST trough levels and albumin levels were significantly higher in the endoscopic remission group (scores of 0 and 1) than in the non-endoscopic remission group (UST trough, mean 3.3 vs. 1.8 μg/mL). No significant difference was observed in AUAs between the endoscopic remission and non-remission groups. Receiver operation curve (ROC) analysis revealed that the optimal cutoff value of UST trough levels predicting normal CRP and serum albumin levels was 1.7 μg/mL for each, and the optimal cutoff value predicting endoscopic remission was 2.0 μg/mL (AUC: 0.80, 95% CI 0.64–0.96).ConclusionAchievement of endoscopic remission requires higher UST trough levels than required for normalization of CRP and serum albumin levels.

Seroprevalence, clinical profile and knowledge, attitudes, and practices (KAPs) of brucellosis in North India in patients with pyrexia of unknown origin and chronic joint pain

Introduction: Brucellosis is a significant but lesser-known cause of pyrexia of unknown origin (PUO) in India. Studies documenting the prevalence of Brucellosis in different parts of India are sparse and few. Clinicians thus usually don’t consider it in their differential diagnosis. This study assesses its prevalence in two groups: febrile patients with unknown etiology and individuals presenting with arthritis and/or joint pains. Knowledge, Attitude, and Practices (KAP) among clinicians about the disease was evaluated.Materials and Methods: This is a prospective study conducted at a tertiary care center of North India catering to urban, semi-urban, and rural populace. Ninety-two patients with fever of unknown origin, arthralgia, or similar constitutional symptoms were recruited in this study. Detailed clinical history was elicited from all patients as per predesigned proforma and a rigorous physical examination was conducted. Following primary screening to rule out malaria, enteric fever, and leptospirosis, secondary screening for Brucellosis was done by Rapid Screen Test (PUO screen) and IgM and IgG ELISA. A predesigned survey was used for assessing KAP among clinicians about Brucellosis.Results: Brucella infection was diagnosed in 27 (29.3%) cases. The most common symptoms among the patients apart from fever were arthralgia (77.8%), fatigue (70.8%), pallor (66.1%), headache (59.2%), backache (53.8%) and cough (33.3%). PUO screen is a specific test for brucellosis but lacks sensitivity. It detects acute cases but misses chronic cases. IgM ELISA being more sensitive should be used for confirmation. Low ODs point to chronic brucellosis which was confirmed by IgG ELISA. Normal CRP levels in patients with PUO and chronic joint pains should point to brucellosis. KAP revealed that 25% to 50% of doctors considered Brucella in their differential diagnosis of acute and chronic fever respectively while 10% Orthopedics considered it in cases of arthralgia.Conclusion: Our results highlight the significance of Brucella as a cause of PUO and arthralgia. Brucellosis is an underrecognized but important cause of pyrexia of unknown origin and chronic joint pain. It should be actively suspected, diagnosed, and treated.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 80-88

Association of Serum C- Reactive Protein with Severity of Acute Ischemic Stroke Patients

Introduction: Stroke is a leading cause of death and long-term disability worldwide. Of the total number of prevalent strokes, more than 80% are ischemic. Atherosclerosis being an inflammatory condition is associated with raised serum level of CRP. Hence the possible role of serum CRP in pathogenesis of AIS is being studied. Many studies support that serum CRP is a marker of stroke severity and prognosis. Materials and Methods: The observational and prospective study was carried out at Department of Neurology, Sheikh Sayera Khatun Medical College, Gopalganj, Bangladesh from January to December-2020.The present study ‘Serum C-reactive protein in Acute Ischemic stroke and its impact on stroke severity and prognosis. Total 51 neuroimaging confirmed cases of AIS were selected randomly for this non- interventional prospective study. Serum CRP was measured in all patients and NIHSSS was used for assessing stroke severity. Results: The mean CRP level was 21.93±3.60 mg/l and only 18% of cases were having normal CRP level. 60% of cases were having serum CRP level in the range of 3-30mg/L and 18% were having even the higher level. Age of the patient significantly correlated with the CRP level (r=0.294 at p-0.05) but the sex didn’t affect the rise in CRP (p= 0.490). Serum CRP level was affecting the stroke severity significantly (r=0.643, p-0.000).The mean CRP level in discharged patients was 10.51 ± 13.21 mg/l whereas it was 44.11 ± 29.7 mg/l in those who died in the hospital. Thus CRP level affected mortality of acute ischemic stroke significantly. (p-0.00). Conclusion: CRP is raised in most of the patients of acute ischemic stroke and its elevation reveals the underlying inflammation causing atherosclerosis as well as CRP as a marker of brain injury. Serum C-reactive protein elevation is associated with more severe stroke and poor prognosis.

May Mutation of SNP rs1800947 Affects Length of Stay Outcome of COVID-19 suspects?

Coronavirus disease 2019 (COVID-19) is a new type of respiratory infection that first emerged in December 2019 in Wuhan, Hubei, China. COVID-19 is caused by a new type of virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aims to determine the association of SNP CRP rs1800947 gene in suspected COVID-19 patients to length of stay at Al Ihsan Hospital, and Banten Hospital in June-November 2020. This study used data from 60 patients, all patients were suspect COVID-19. The subject was 29 COVID-19 people were confirmed, whereas 31 people were not. A statistics analysis due to pearson correlation and linear multi regretion. This study found a significant assosiation between the subject. The results of this study were the relationship between SNP rs1800947 and outcome, a fairly strong association level relationship was found in the SNP rs1800947 (p-value= 0.045, association= 0.537). The association between length of stay and CRP levels has a low level of association (p-value=0.015, association=0.378). The SNP genotype rs1800947 G had a longer treatment duration of 0.14778 days compared to the SNPrs1800947 C genotype. CRP levels showed that higher CRP levels increased the length of treatment compared to normal CRP levels. Where high CRP levels are at risk of 0.6330 days longer than normal CRP while very high CRP is at risk of 2.9561 days longer than Normal CRP levels. In general, the gene SNP rs1800947 and CRP levels, together affect the outcome of patients with suspected COVID-19.

Positive frozen section during reimplantation increases the risk of treatment failure in two-stage exchange arthroplasty even in patients with normal ESR and CRP.

It can be extremely challenging to determine whether to perform reimplantation in patients who have contradictory serum inflammatory markers and frozen section results. We investigated whether patients with a positive frozen section at reimplantation were at a higher risk of reinfection despite normal ESR and CRP. We retrospectively reviewed 163 consecutive patients with periprosthetic joint infections (PJIs) who had normal ESR and CRP results pre-reimplantation in our hospital from 2014 to 2018. Of these patients, 26 had positive frozen sections at reimplantation. The minimum follow-up time was two years unless reinfection occurred within this period. Univariable and multivariable logistic regression analyses were performed to identify the association between positive frozen sections and treatment failure. Treatment failure occurred in eight (30.77%) of the 26 PJI patients with positive frozen sections at reimplantation, compared with 13 (9.49%) of 137 patients with negative results. In the multivariate analysis, positive frozen section increased the risk of failure (odds ratio 4.70; 95% confidence interval (CI) 1.64 to 13.45). The mean number of months to reinfection was lower in the positive frozen section group than in the control group (p = 0.041). While there were nine (34.62%) patients with positive frozen section and 25 (18.25%) patients with negative frozen section who had prolonged antibiotic use (p = 0.042), the mean duration of antibiotic use was comparable in two groups. Synovial white blood cell count (p = 0.137) and polymorphonuclear leucocyte percentage (p = 0.454) were not associated with treatment failure in logistic regression model. Positive frozen section at reimplantation was independently associated with subsequent failure and earlier reinfection, despite normal ESR and CRP levels pre-reimplantation. Surgeons should be aware of the risk of treatment failure in patients with positive frozen sections and carefully consider benefits of reimplantation. Cite this article: Bone Joint J2021;103-B(5):916-922.

Normal inflammatory markers and acute appendicitis: a national multicentre prospective cohort analysis

PurposeFor the diagnosis of acute appendicitis, the combination of clinical and laboratory variables achieves high diagnostic accuracy. Nevertheless, appendicitis can present with normal laboratory tests of inflammation. The aim of this study was to investigate the incidence of normal inflammatory markers in patients operated for acute appendicitis.MethodsThis is an analysis of data from a prospective, multicentre SNAPSHOT cohort study of patients with suspected acute appendicitis. Only patients with histopathologically proven acute appendicitis were included. Adult patients with acute appendicitis and normal preoperative inflammatory markers were explored further in terms of abdominal complaints, preoperative imaging results and intraoperative assessment of the degree of inflammation and compared to those with elevated inflammatory markers.ResultsBetween June and July 2014, 1303 adult patients with histopathologically proven acute appendicitis were included. In only 23 of 1303 patients (1.8%) with proven appendicitis, both preoperative white blood cell count and C-reactive protein levels were normal. Migration of pain was reported less frequently in patients with normal inflammatory markers compared to those with elevated inflammatory marker levels (17.4% versus 43.0%, p = 0.01). Characteristics like fever, duration of symptoms and localized peritonitis were comparable. Only 4 patients with normal inflammatory markers (0.3% overall) had complicated appendicitis at histopathological evaluation.ConclusionCombined normal WBC and CRP levels are seen in about 2 per 100 patients with confirmed acute appendicitis and can, although rarely, be found in patients with complicated appendicitis.

Correlation between Expulsion of Distal Ureteric Calculus with CRP Level, WBC Count and Neutrophil Percentage among the Patients attending on Manipal Teaching Hospital, Pokhara (Retrospective Study)

Introduction: Urolithiasis is a common medical diagnosis that doctor encounters in the outpatients and emergency departments. The prevalence of renal stone disease has increased steadily over the past decades. There are different modalities of treatment of ureteric calculus. However, most of the distal ureteric calculus passes spontaneously thus the application of invasive procedure at the early stage can be considered overtreatment.Methods: The 68 patients of the surgical department, Manipal teaching hospital, Pokhara, with distal ureteric calculus of ≤ 8mm, who were under the treatment Tamsulosin Hydrochloride 0.4mg once daily for 2 weeks or till the expulsion of stone from 1st October 2017 to 30th September 2018 (one year period) were retrospectively evaluated for the spontaneous stone expulsion rate and its association with serum CRP level, WBC count and Neutrophil percentage. The patients were divided into 2 groups i.e. spontaneously ureteric stone expelled group and non expelled group. Furthermore, for statistical analysis, each group were subdivided according to normal and elevated serum CRP level, white blood cell count and neutrophil percentage. The associations between these factors and ureteral stone passage were then examined.Results: Most of the cases were in the age group of 21-40 years with the mean age of 40.09 ± 16.11, where 57.4% of patients were male. Among all mean duration of symptoms was 6 days. The ratio of left to right stone was 1.26:1. Out of 68 patients, 80.9% of the patient’s distal ureteric stone was passed out spontaneously with medical expulsion therapy. There were statistically significant (p&lt;0.001) association between normal serum CRP level, White cell counts and neutrophil percentage with the expulsion of distal ureteric calculus with size ≤ 8mm.Conclusion: There is a higher expulsion rate of distal ureteric calculus of size ≤ 8mm with the patient of the normal level of serum CRP level, White cell counts and neutrophil percentage than that of abnormal level.

Time to Start Delivering Iron Chelation Therapy in Newly Diagnosed Severe β-Thalassemia.

Background Iron overload is still a major complication of severe β-thalassemia. Indication to start iron chelation therapy is based on serum ferritin (SF) or transferrin saturation (TS) level or the amount of transfusion. The goal of this study is to analyse the pattern of iron status, the amount of transfusion regarding the time to start iron chelator, and serum hepcidin levels in newly diagnosed severe β-thalassemia. Methods A prospective cohort study was performed at Hasan Sadikin General Hospital on newly diagnosed severe β-thalassemia patients. Subjects had not received any blood transfusion with normal liver function test, CRP, and IL-6 levels who consumed normal diet according to age. The SF and TS levels indicate iron status, while hepcidin level indicates iron regulator status. Main indicator to start iron chelation therapy when SF level ≥1.000 ng/mL, TS level ≥70%, or after receiving transfusion at least 10 times. Statistical analysis used Mann–Whitney and Spearman. Results Forty-two newly severe β-thalassemia, 30 (71.4%), were diagnosed before 1 year old, mean 9.9 ± 6.4 months, range 2–24 months. Range amount of transfusion until SF level reached ≥1,000 ng/mL were 4-12 times, mean 7 ± 2 times. Mean SF and TS level at diagnosis were 365.6 ± 194.9 ng/mL and 67.3 ± 22.5%, while hepcidin level was normal, mean 242.6 ± 58 ng/mL. 36/42 patients have reached SF >1000 ng/mL with amount of transfusion less than 10 times. There was no significant difference of SF, TS, and hepcidin levels when SF >1000 ng/mL in the group with amount of transfusion 7–12 and less than 7 (p = 0.454, p = 0.084, p = 0.765), respectively. A significant positive correlation between SF and amount of transfusion was observed (p < 0.001; r = 0.781). Conclusion Iron overload in severe β-thalassemia patients might occur earlier even before they received 10 times transfusion. Hepcidin serum level tends to increase when iron overload just started.

P204 Re-established CRP cut-off in UC; it may be a better predictor of mucosal remission

Abstract Background Although faecal calprotectin can predict mucosal remission in ulcerative colitis, the CRP level in this context is insufficient and frequently stay under the current cut off level. While some patients with active mucosal disease have normal CRP levels most patients in mucosal remission have much lower CRP levels. The aim of this study is to define CRP cut off levels in the prediction of mucosal remission, considering both extensiveness and severity, in ulcerative colitis. Methods We retrospectively reviewed colonoscopy reports of ulcerative colitis patients (who are not on any steroid treatment at that time) which were performed between December 2016 and March 2019 and also their CRP levels which were obtained at the same week of the colonoscopy examination. We excluded the data of patients with any other possible cause of inflammation or infection at the time of laboratory assessment. Degree of mucosal disease at colonoscopy was evaluated according to endoscopic Mayo score. Mucosal remission was defined as endoscopic Mayo score 0 or 1. The extent of mucosal inflammation was classified according to Montreal classification. The CRP level with optimal sensitivity and specificity for mucosal remission prediction was assessed by ROC curve analysis and positive and negative predictive values were also calculated. Results A total of 331 colonoscopy reports of 260 patients (122 m, 138 f) were involved in this study. There were no significant differences between ages of patients when compared with ex, and Montreal classification and we did not find any correlation between age and CRP levels. Sensitivity, specificity, positive predictive value and negative predictive values for 5 mg/l, 3 mg /l and 2 mg/l are summarised in Table 1. CRP levels which predict Mayo 0 disease, mucosal remission (Mayo 0–1) and Mayo 3 disease are shown in Table 2. At the ROC curve analysis, we found that CRP level of approximately 2.9 mg/l can predict mucosal remission with a 77% sensitivity and % 80 specificity in all examinations without grouping into a separate segmental disease. For subgroups with Montreal E1, E2 and E3 ROC curve analysis suggested 1,8 mg/l (sn. 84%, sp. 90%), 2,7 mg/l (sn. 75%, sp. 75%) and 3 mg/l (sn. 80%, sp. 80%) CRP levels can be used for prediction of mucosal remission respectively (Table 3). It is important to emphasise that 30% of all patients with Mayo 3 colonoscopy and further 23% of patients with Montreal E3–Mayo 3 activity have CRP levels below the regular cut-off value of 5 mg/l. Conclusion CRP cut-off level of approximately 2.9 mg/l can predict mucosal remission in ulcerative colitis better than standard cut-off of 5 mg/l which has a low positive predictive value and specificity even at extended and active mucosal disease.