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Objectives To evaluate the extent to which internationally agreed treat-to-target recommendations were applied in clinical practice in patients with axial spondyloarthritis. Methods Data were used from a web-based patient registry for monitoring SpA in daily practice in the Netherlands. The extent to which treat-to-target was applied was evaluated through four indicators: the proportion of patients (i) with ≥1 Ankylosing Spondylitis Disease Activity Score (ASDAS) assessed during a 1-year period, (ii) having inactive disease/low disease activity (i.e. ASDAS Results In 185 out of 219 patients (84%), disease activity was monitored with ≥1 ASDAS during a 1-year period, of whom 71 (38%) patients had a score below the target (ASDAS Conclusions Treat-to-target was applied to a limited extent in clinical practice in patients with axial spondyloarthritis. Available disease activity scores seemed not to be used for determining the frequency of re-evaluation nor treatment adaptation.

This follow-up study of the CORIMUNO-TOCI-1 randomized clinical trial examines the association between survival and C-reactive protein levels in patients hospitalized with COVID-19 who were treated with tocilizumab.

Background and Aims Renal cyst infection (CI) is a major complication of autosomal dominant polycystic kidney disease (ADPKD), associated with frequent hospitalization, worsening of kidney function and significant mortality. Data regarding treatment are scarce and recommendations only expert-based, with low level of evidence. Prolonged treatment duration and use of lipid-soluble antibiotics may increase antibiotic concentration in infected kidney cysts. However, benefits of this strategy have never been investigated in clinical practice. Method We undertook a monocentric retrospective study of CI in ADPKD patients from 2000 to 2018. CI were classified as “definite” (microbiologically proven), “probable” (clinical/biological and radiological signs) or possible (clinical/biological signs). Determinants of treatment failure and recurrences were studied. Results 139 CI (11 “definite”, 74 “probable”, 54 “possible”) were compiled among 90 patients. Median age was 53 years. 28/90 (31%) were kidney transplant recipients. Escherichia coli was identified in 89/106 (84%) episodes. Treatment failure was reported in 22/139 (16%), and found associated with cyst diameter >5cm (80% vs 36%, P Conclusion Treatment of kidney CI should last ≥28 days and include when possible lipid soluble antibiotics.

Funding Acknowledgements Type of funding sources: None. BACKGROUND Cardiac magnetic resonance imaging (MRI) represents the gold standard for the diagnosis of acute myocarditis. However, several institutions are not able to perform such imaging test, especially in the early phase of the disease, with possible missing or delaying in diagnosis. On the other hand, the penetration of the trans-thoracic echocardiographic (TTE) assessment of global longitudinal strain (GLS) by speckle tracking echocardiography (STE) is rapidly growing. An impairment in GLS may occur in the early phase of acute myocarditis, with the degree of such impairment being related to the amount of oedema. Few studies have been published on the role of STE in the diagnosis of acute myocarditis and current evidence on the topic is limited. We present here a multicentre, retrospective study on the diagnostic accuracy of a non-invasive model including GLS for acute myocarditis. PURPOSE Aim of the study was the evaluation of the accuracy of 3-layer left ventricular (LV) GLS data (epicardial, midwall and endocardial) coupled with clinical and laboratory assessment for the diagnosis of acute myocarditis, using cardiac MRI as reference diagnostic tool. METHODS A total of 70 patients with clinical suspect of acute myocarditis were identified. Clinical parameters, results of laboratory tests and data from both TTE and STE on admission were recorded. Cardiac MRI was performed in all patients. GLS assessment was reported as absolute value. A total of 13 patients were excluded because of poor acoustic window, unconfirmed diagnosis or missing data. RESULTS 57 patients with MRI-confirmed acute myocarditis were included in the final analysis (age 38.8 ± 15.6 years, 49 males). Twenty-one patients (37.5%) had fever on admission. Mean white blood cell (WBC) count was 10.92/10^3 ± 1.7 and C-reactive protein levels were 4.9 ± 5.2 mg/dL. At TTE, a mild reduction of LV systolic function was overall observed (LV ejection fraction 50.1% ±11.2), without impairment of the diastolic function (E/A Ratio 1.31 ± 0.55, E/e’ average ratio 7.59 ± 3.4). Mean epicardial GLS of the LV was 14.5 ± 4.3%, midwall GLS was 16.5 ± 4.7% and endocardial GLS 18.6 ± 5%. The best localization agreement between regional strain decrease and late gadolinium enhancement at cardiac MRI was found for an epicardial GLS 37.5°) and laboratory findings (WBC >10/10^3) was able to identify all patients (100%) with MRI-diagnosed acute myocarditis (Figure 1). CONCLUSION STE of the LV, especially for epicardial GLS, presents a high agreement with cardiac MRI to detect acute myocarditis. The integration of GLS assessment, body temperature and WBC on admission is highly sensitive for an early diagnosis of acute myocarditis. This model could be more extensively tested in those settings where cardiac MRI is not immediately available. Abstract Figure 1

Background Diagnosis of COVID-19 relies upon RT-PCR assays for SARS-CoV-2 from a nasopharyngeal swab (NPS). However, results depend upon duration of illness at the time of testing and operator performance. False negatives occur 10–30% of the time. In our center we formulated & applied a clinical prediction tool for diagnosis of COVID-19 infection. Patients who satisfied criteria were designated as having COVID-19 regardless of NPS results. Herein, we describe the set of patients who fulfilled full and strict clinical criteria (VHCL) (Table 1) and had at least 2 negative NPSs on hospital admission. Table 1: Clinical criteria for Very High Clinical Likelihood of COVID-19 Infection (VHCL COVID-19) Methods A retrospective descriptive study was conducted from March 4th to April 11th, 2020. We evaluated patients with ≥ 2 consecutive negative NPS COVID-19 results admitted to our hospital. Of these, we identified patients fitting all 5 criteria for Very High Clinical Likelihood (VHCL) of COVID-19 infection (Table 1). We analyzed symptoms & lab data (including results of repeat NPS testing if performed) in those patients. Results 1855 patients were diagnosed with COVID-19 in the study period. Of these, 23 had ≥ 2 negative COVID-19 NPS results but met criteria for VHCL (Table 2). Of these 23, 7 had a subsequent 3rd NPS that was positive-proving infection. Similar to other reports, patients had low lymphocytes and elevated procalcitonin, ferritin, C-reactive protein levels. And consistent with proven cases, our cohort presented after a median of 5 days of symptoms (Table 3). Table 2: Clinical and laboratory characteristics of VHCL COVID-19 patients [Rows Bolded include those patients who had a 3rd NPS swab that was positive]. Table 3: Demographic and Median Lab Data of VHCL COVID-19 patients Conclusion It is critical to be mindful of the imperfection of laboratory testing & to integrate clinical criteria to diagnostic algorithms. This is especially true in the COVID-19 pandemic, which is marked by high morbidity & mortality. In our study, we demonstrated how a set of clinical parameters (which we termed VHCL) can aid in widening the net of patients diagnosed with COVID-19 despite negative laboratory tests. While 16 patients in our cohort did not have a confirmatory result, the strict criteria for VHCL & the close match of other study variables with those of proven cases supports the value of VHCL designation. Applying VHCL can optimize infection control, identify patients for emerging therapeutics & aid in contact tracing to reduce nosocomial & community transmission of COVID-19. Disclosures All Authors: No reported disclosures

Introduction Air pollution has been a well-described environmental factor contributing significantly to the global disease burden. Purpose To examine the association of gaseous air pollutants with atherosclerosis, especially in subjects with coronary artery disease (CAD). Methods 2053 individuals enrolled in the Corinthia study underwent clinical and biochemical assessment followed by carotid ultrasonography to evaluate carotid intima-media thickness (cIMT) and plaque burden. Inflammation was estimated via measurement of C-Reactive protein (CRP). Air pollutants concentration analysis was performed in prespecified regions with respect to their proximity to heavy industries, highways and shipyards. Results A higher concentration of gaseous air pollutants was observed in Region 4 when compared to other regions (Table). Mean cIMT, maximum cIMT and carotid plaque burden were significantly increased in individuals of Region 4 (Table, Figure A and B), a result which remained unaffected after adjustment for cardiovascular confounders (Figure C). In parallel, inhabitants of Region 4 had higher levels of CRP (Region 1: 4.60±5.01mg/l; Region 2: 3.08±3.26mg/l; Region 3: 4.37±4.70mg/l, Region 4: 6.78±9.77mg/l, p Conclusion Air pollution may significantly contribute to atherosclerosis progression, potentially via the induction of inflammation. A more pronounced effect was noted in CAD individuals exposed to high air pollution. Funding Acknowledgement Type of funding source: None

Low C-reactive protein in acute bacterial infections could convey the erroneous impression of a mild infection. We focussed on gram-negative bacteraemia, a phenomenon frequently seen at the emergency room.Of 2200 patients with gram-negative bacteraemia, 460 patients with first C-reactive protein30 mg/L and 460 patients with C-reactive protein187 mg/L were reviewed. Following exclusions, we finally investigated 229 and 289 patients with low and high C-reactive protein concentrations, respectively.The cohort was divided into low and high C-reactive protein groups. Median first C-reactive protein was 13.6 and 219.9 mg/L, respectively (interquartile range 6.4-21.6 and 195-270.1). Compared to patients with first high C-reactive protein, patients with first low C-reactive protein concentrations had a significant five-fold higher C-reactive protein level with their second test.Patients with gram-negative bacteraemia can present with C-reactive protein within the range of apparently healthy individuals. A second C-reactive protein might help to avoid an erroneous decision regarding the severity of the infection.

Background Screening Crohn’s disease (CD) patients with high risk of early-onset surgery is crucial in launching therapeutic strategies. We have already identified disease behavior, smoking, body mass index, C-reactive protein level at diagnosis, previous perianal or intestinal surgery, maximum bowel wall thickness, use of biologics, and exclusive enteral nutrition as independent significant factors associated with 1-year surgery surgeries risk and further established a prognostic model (Fig.1,World J Gastroenterol. 2020;26(5):524–534). We aimed to validate this model using external cohort. Methods This retrospective study was conducted from Jan, 1, 2017, to Dec, 31, 2019 in three tertiary referral centers including Sixth Affiliated Hospital of Sun Yat-Sen University, Second Affiliated Hospital of Zhejiang University, and Second Affiliated Hospital of Military Medical University. Data of patients with a confirmed diagnosis of CD were collected through hospital electronic system. The published model was validated with calibration using the Hosmer-Lemeshow goodness-of-fit test, and discrimination was assessed using areas under the curve (AUC). Results A total of 756 patients were enrolled in our study with 101 (13.4%) excluded for the sake of incomplete data and loss of follow-up. Of the enrolled patients, 74.8% were male (n = 490) at the mean age of 28.4 ± 11.0 years, with the mean follow-up period of 21.8 ± 8.1 months. An ideal predictive ability of this model was confirmed by receiver operating characteristic curves and AUC as high as 94.5%. Besides, acceptable sensitivity of 69.5% and excellent specificity of 97.0% supported further clinical promotion and application of this model. Conclusion This model owns ideal ability to predict 1-year surgery risk in CD patients, which definitely help clinical decision-making and acid therapeutic strategies launching.

Introduction Hospital associated deconditioning is a well-established phenomenon. Whilst mechanisms are not well understood, one is thought to be skeletal muscle wasting and/or loss of muscle strength. The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. We also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength. Methods This was a prospective repeated-measures cohort study. Measurements of muscle strength and functional mobility were taken at recruitment, on day 7 of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first 7 days of admission, daily measurements of muscle strength were taken. Results We recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of 6 days whilst in hospital, on average participants were ‘active’ for less than 4% of the day. Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post-hospitalisation. A repeated-measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients' sedentary time decreased on days 2 to 7 of the study. Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant. Conclusion Our findings provide an important link in understanding the mechanisms and relative contributions of risk factors to hospital associated deconditioning. Further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post-hospitalisation.

Studies have shown that postoperative serum C-reactive protein (CRP) measurement may be useful in predicting the type of complication, infective or otherwise, following surgery for colorectal cancer. It may be that the magnitude of the postoperative CRP is also associated with the severity of the complication. The aim of the present study was to examine the relationship between daily postoperative CRP concentrations and Clavien-Dindo complication grade. Data was recorded prospectively for patients undergoing elective, potentially curative, surgery for colorectal cancer in two hospitals between January 2011 and January 2013, n = 241. All patients had daily CRP measurement following surgery for the first four postoperative days. Complications were retrospectively classified by Clavien-Dindo grade. Of the 241 patients, the majority were male (59 %) and were over 65 years old (69 %). The majority had colonic (86 %) and node negative (65 %) disease. One hundred nineteen patients (49 %) developed a complication, and 28 (12 %) of these were Clavien-Dindo grade 3, 4 or 5. Median and established threshold CRP concentrations on postoperative days 2 (>190 mg/L), 3 (>170 mg/L) and 4 (>125 mg/L) were directly associated with an increase in the Clavien-Dindo grade (all p

Background ERM-DA474/IFCC has been used as a reference material for C-reactive protein (CRP) since 2012. However, the commutabilities and the capacity for harmonizing CRP results of the material and its dilutions have not yet been reported. In this study, we aimed to evaluate the harmonization of CRP results using commutable ERM-DA474/IFCC. Methods Twenty-one serum samples were collected and split into five vials. The samples were then analyzed using five popular assays (Siemens BN II, Beckman Immage 800, Roche, Diasys, and Leadman). ERM-DA474/IFCC and four dilutions of healthy human serum containing low levels of CRP were also analyzed using the five assays described above. Commutability was assessed using the Roche, Diasys, and Leadman assays. Clinical sample results from assays were recalibrated based on ERM-DA474/IFCC and its dilutions. Results There were significant variations among the five assays for CRP measurement. The slopes ranged from 0.60 to 1.60, and the BN II and Leadman assays showed significant negative and positive systemic biases, respectively. ERM-DA474/IFCC and its dilutions exhibited commutability among the three assays. After recalibration, the slope was reduced to 0.76 - 1.27. Conclusions Harmonization was not ideal for CRP measurement. ERM-DA474/IFCC may play a role in improving harmonization for CRP measurement.

Background The aim of this study to assess the efficacy and safety of adalimumab (ADA), a monoclonal antibody against tumour necrosis factor α (TNF-α), and to explore predictors of response in Korean patients with ulcerative colitis (UC). Methods We conducted a prospective observational multicenter study over 56 weeks in adult patients with moderately to severely active UC. Clinical response and remission were assessed by Mayo score. Mucosal healing was defined as Mayo subscore 0 or 1. Faecal calprotectin (FC) were assessed at baseline, week 8 and 56. Adalimumab drug levels were checked at week 8 and at loss of response. Missing or incomplete data were handled using the nonresponder imputation method. Results A total of 146 patients were enrolled and included in the analysis. Clinical response rates were 52.1% (76/146) and 37.7% (55/146) at week 8 and 56, respectively. Clinical remission was achieved in 24.0% (35/146) and 21.9% (32/146) of patients at week 8 and 56. Steroid-free remission rates were 21.2% (31/146) at week 56. Mucosal healing rates were 39.0% (57/146) and 30.1% (44/146) at week 8 and 56. Prior use of anti-TNF-α did not affect the clinical and endoscopic responses. Treatment persistence was achieved in 57.5% (84/146) of patients at week 56. Adalimumab drug level was significantly higher in patients with clinical response (10.8 vs. 8.0, p = 0.004), clinical remission (11.7 vs. 8.8, p = 0.007) and mucosal healing (11.0 vs. 8.5, p = 0.010) at week 8. Adalimumab dose was escalated to 40 mg weekly in 25 (17.1%) patients, and clinical response and remission were achieved in 40% and 20% of patients at week 56, respectively. Mean faecal calprotectin levels were significantly more decreased in clinical responders compared with non-responders at week 8 (336.3 mg/kg vs. 628.8 mg/kg, p < 0.001). The Fecal calprotectin levels are well correlated with endoscopic severity, and the best cut-off value to predict mucosal healing was 274 mg/kg. The lower endoscopic severity, higher body mass index and higher serum albumin level at baseline were associated with a clinical response at week 8. The lower Mayo score, lower C-reactive protein level, clinical response (74.5% vs. 38.5%, p < 0.001) and mucosal healing (52.7% vs. 30.8%, p = 0.008) at week 8 were associated with clinical response at week 56. Serious adverse drug reactions were identified in 2.7% (4/146) of patients including 1 case of pulmonary tuberculosis. Conclusion Adalimumab is safe and effective for induction and maintenance in Korean patients with UC, regardless of prior anti-TNF therapy. Adalimumab drug level is associated with the efficacy of induction therapy. A better response to induction therapy can predict a better long-term response.

Background Brucellosis is a zoonotic infectious disease caused by Brucella spp. that affects multiple body systems and may lead to several complications. Saudi Arabia is one of the countries where brucellosis is endemic. The purpose of this study was to describe the epidemiological characteristics of brucellosis as well as assessing outcomes of different antibiotic regimens. Methods A retrospective cohort study was conducted in a Saudi tertiary academic medical center. Eligible patients were adults with confirmed brucellosis (via culture, antibody test, or both) seen between January 2008 and March 2018 who received antibiotic therapy. Endpoints included clinical cure, all-cause mortality, and length of stay (LOS). Data were analyzed using ANOVA and chi-square. A P-value of < 0.05 was considered statistically significant. Results Out of 580 patients screened, 79 met the criteria and were included in the study. Based on the most common regimens prescribed, patients were divided into three groups, doxycycline–rifampin–aminoglycoside (DRA) with 39 patients, doxycycline–rifampin (DR) with 28 patients, and other regimens with 12 patients. All groups did not differ in their baseline characteristics except for the location (mostly outpatients or inpatients and very few in the intensive care unit), duration of therapy, and the presence of co-infection (most patients did not have co-infections). The most common risk factor was consumption of raw dairy products and most patients had both B. melitensis and B abortus in their culture and/or antibody test. There was no significant difference between the groups in terms of clinical cure, all-cause mortality, LOS, and end of therapy temperature, white blood cells counts, C-reactive protein levels, and erythrocyte sedimentation rates. Conclusion Due to lack of differences in clinical outcomes, all-cause mortality, LOS, and end of therapy parameters between the three groups, a regimen comprising two, rather than three, agents (namely doxycycline and rifampin) can be sufficient. Such finding complies with previous studies although replacing rifampin with an aminoglycoside might be superior per the World Health Organization guidelines for the treatment of brucellosis. Further studies with a larger sample size are warranted to confirm these findings. Disclosures All authors: No reported disclosures.

This study presents a new microfluidic chip integrated with pneumatic micropumps, normally close microvalves and vortex-type micromixers for C-reactive protein (CRP) measurement. CRP is a protein produced during the inflammation process. It has been reported that CRP in serum can be used for risk assessment of cardiovascular diseases. In this study, CRP measurements were performed by using the integrated microfluidic chip incorporated with magnetic beads. The magnetic beads coated with CRP-specific DNA aptamers were used to recognize, purify and enrich the target CRP. The entire process including sample pre-treatment, and the interaction between the target CRP and anti-CRP antibody was automatically performed on a single chip. The chemiluminescence signal was measured using a luminometer to detect the concentration of CRP afterwards. The entire reaction time is less then 25 min, which is only about 20% of the time required when compared to using traditional bench-top machines (150 min). More importantly, the detection limit has been improved from 0.125 to 0.0125 mg/L with only half the amount of reagent consumption. The development of this microfluidic system is promising for fast, accurate, and sensitive detection of CRP.

Background The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgical treatment and increased mortality. The 2007 and 2013 Tokyo Guidelines for AC proposed to use C-reactive protein (CRP) as an additional bench mark of AC. The aim of this study was to evaluate whether CRP measurement influences management of patients with AC. Methods For more than a period of 5 y (May 2004 to June 2009), 1959 patients were identified from the audit of cholecystectomies in North Shore, Waitakere and Southern Cross hospitals at Waitemata District Health Board, Auckland, New Zealand. The exclusion criteria were elective and private patients, patients without AC on histologic examination of gallbladders, and patients with acute acalculous cholecystitis. Results A total of 414 patients met eligibility criteria. Compared with the non-CRP group, patients who had CRP measured had a longer time to operation theater and a greater proportion of acute gangrenous cholecystitis on histologic examination of excised gallbladders, but similar postoperative complication rate, index, and total hospital stay. Time to operation theater was not associated with development of acute gangrenous cholecystitis (odds ratio, 1.0; 95% confidence interval, 0.996–1.01; P = 0.797), but correlated with the index hospital admission length (correlation coefficient, 0.6092; P Conclusions CRP measurement does not influence management of patients with AC. To improve quality of care and to minimize health care provider costs physiologically fit patients with more advanced forms of AC and higher values of CRP should have their operation performed earlier than patients with mild AC and a lower concentration of CRP.

Objective: The aim of this study was to determine the validity of pleural fluid C-reactive protein (CRP) concentrations and/or pleural fluid to serum CRP ratio for differentiating tuberculous pleuritis (TBP) from malignant pleural effusion (MPE) in patients presenting with lymphocytic exudative pleural effusions. Methodology: A cross-sectional study was conducted on 161 patients with pleural effusion who underwent diagnostic evaluation at Siriraj Hospital, Bangkok, Thailand, between April 2001 and March 2002. The complete biochemical analysis of pleural fluid, cultures of pleural fluid, and pathological examinations of pleural fluid and pleural tissue were performed. The CRP concentrations were then measured in stored sera and pleural fluid samples from patients with a lymphocytic exudative pleural effusion and with a definite diagnosis. Results: Among the 148 patients with lymphocytic exudative pleural effusions, 55 were diagnosed with TBP, 60 with MPE, and 33 with non-specific pleuritis. Pleural fluid and serum CRP levels were significantly higher in the TBP group than in the MPE group (54.58 ± 4.50 mg/L and 106.93 ± 9.54 mg/L vs 12.66 ± 3.52 mg/L and 49.66 ± 8.84 mg/L, respectively, P

Rapid and accurate diagnosis of C-reactive protein (CRP) is crucial for preventing cardiovascular diseases because it is a well-known biomarker for evaluating risks of cardiovascular diseases. Our previous work has shown that a microfluidic system equipped with a field-effect-transistor (FET)-based biosensor could detect CRP in 0.1X PBS and provided a limit of detection (LOD) of 26 pM CRP without gate bias. To improve the LOD, a new microfluidic device with a new methodology for measuring FET-based biosensors is presented in this study. Not only can the proposed system work in a solution with a physiological salt concentration but it also detects CRP with ultra-high sensitivity in an automatic fashion. This is the first time that a FET-based biosensor can effectively and automatically detect CRP in a physiological salt concentration without decreasing the sensitivity. The LOD of CRP using aptamer-immobilized AlGaN/GaN high-electron-mobility transistors (HEMTs) was experimentally found to be 1fM, demonstrating the superior performance of this new technique. It may be used as a point-of-care device for CRP detection in the near future.

To evaluate the usefulness of a single C-Reactive Protein (CRP) measurement at 18 h of age to identify neonates where antibiotics started for possible early onset sepsis (EOS) could safely be discontinued.In a prospective cohort of 647 preterm (35 weeks) and 555 late preterm (35-36 weeks) or term newborns with maternal and/or neonatal risk factors for EOS, CRP levels were measured between 15 and 21 h of age.There were 16, 107 and 1079 neonates with proven EOS, possible EOS and no EOS, respectively. Among the 645 neonates with a CRP10 mg/L, 1 had proven EOS, 43 had possible EOS and 601 (93.2%) were not infected. All with possible or proven EOS were either less than 35 weeks' gestation, symptomatic at the time of CRP assessment or remained on antibiotics because of maternal bacteraemia: they would therefore not be considered for discharge. There were 557 neonates with a 18-h CRP ≥ 10 mg/L. Of these, 15 had proven EOS, 64 had possible EOS, and 478 (85.8%) were not infected. Sensitivity and specificity of 18-h CRP for proven or possible EOS were 64% (95% CI 56 to 73) and 56% (95% CI 53 to 59), respectively. The negative predictive value was 93% (95% CI 91 to 95), and the positive predictive value was 14% (95% CI 11 to 17).The duration of antibiotic treatment in neonates born beyond 34 weeks' gestation and asymptomatic at the time of CRP assessment could be potentially reduced with a diagnostic algorithm that includes a point-of-care 18-h CRP measurement. An elevated 18-h CRP in isolation should not be used as a reason to prolong antibiotics.

Recent advances in laboratory technology have enabled us to measure C-reactive protein with a higher sensitivity in a short period using a minimal amount of blood. Thus C-reactive protein can be measured easily several times a day. In this study, serial changes in C-reactive protein values were evaluated in 108 term and 240 preterm newborn infants with suspicion of infection, and the changing patterns of C-reactive protein values were compared with clinical outcome. For a diagnosis of infection, the negative predictive values in term and preterm infants were 99.0% and 97.8%, respectively, although the sensitivities were 61.5% and 75.0%, respectively. Antibiotic therapy was started at birth and discontinued when the changing pattern of C-reactive protein and clinical findings did not suggest infection. As a result, mean durations of administration of antibiotics in the term and preterm infants were 3 and 4 days, respectively. Recognition of the changing pattern of C-reactive protein was very useful in excluding infection and minimizing unnecessary antibiotic therapy in managing neonatal infection.

Since 1973, assessment of serum concentrations of C-reactive protein (CRP) has been advocated as a objective measure of disease activity in rheumatoid arthritis (RA). Our review of clinical experience with CRP measurement suggests it has at least two important roles to play in the management of RA. First, persistently elevated CRP levels have prognostic value. In general, such elevated levels are found in those patients who are at greater risk for continuing joint deterioration and therefore may need more aggressive treatment and supportive care. Second, in general, improvement in CRP levels is an objective indication that a drug has produced a beneficial effect and thus may be useful to the physician for monitoring effects of therapy. Since CRP may be elevated in a number of conditions besides RA, a diagnosis of RA must be made before using CRP as a prognostic factor.

Acute appendicitis is a common condition that can lead to peritonitis and, rarely, death.1,2 While traditionally a clinical diagnosis, inflammatory markers are often now used to aid diagnosis.3 The paper published in the Annals by Sengupta et al reviewed 98 patients with lower abdominal pain and concluded that patients with a normal white cell count (WCC) and C-reactive protein (CRP) levels are unlikely to have appendicitis and can be safely sent home. We believe, however, that appendicitis can occur in the presence of normal inflammatory markers. To demonstrate this, we reviewed 200 consecutive cases of appendicitis at our institution. 162 patients had histologically confirmed appendicitis. Appendicitis in the presence of normal CRP, WCC or neutrophil counts occurred in 47, 47 and 36 patients respectively, while appendicitis in the presence of normal CRP, WCC and neutrophil counts occurred in 13 patients. Furthermore, 3 patients with histologically proven gangrenous appendicitis had presented with normal inflammatory markers. We therefore recommend that clinicians be wary of normal inflammatory markers in patients with a high clinical suspicion of appendicitis and that further investigations or treatment should not be delayed where this is the case.

We examined whether serum C-reactive protein (CRP) measurements used in conjunction with leucocyte counts help in the diagnosis of perinatally acquired and nosocomial infections in very preterm newborn infants. One hundred and twenty-five infants born at a gestational age between 23 and 31 weeks with respiratory distress were studied at birth. A similar group of 85 infants beyond 3 days of age were also studied on 100 occasions for suspected infection. The diagnosis of proven or probable infection was correlated with abnormal haematology (leucopenia less than 5000/mm3, leucocytosis greater than 20,000/mm3 or ratio of immature forms to total neutrophils of greater than 0.2) and an elevated CRP (greater than 10 mg/L) singly or in combination. The sensitivity of an elevated CRP was relatively higher than abnormal haematology in both early and late infections and the sensitivity was highest when either test was abnormal. Similarly, the specificity, positive and negative predictive values and efficiency of an elevated CRP was relatively higher than abnormal haematology. The performance of the tests in 45 infants born at 23-28 weeks gestation was similar to that in 80 infants born at 29-31 weeks gestation. It was concluded that both CRP and leucocyte counts should be determined as they provide valuable information in the diagnosis of neonatal bacterial infection.

C-reactive protein (CRP) is becoming more frequently measured in patients with vascular disease. Awareness of why CRP levels are measured, knowledge of normal versus elevated levels, ability to obtain accuracy in measurement, and teaching appropriate for patients with vascular disease may enhance the care given by vascular nurses. The purpose of this article is to provide a guide for vascular nurses in understanding the role of the serum marker CRP for patients with vascular disease.

An established time-resolved immunofluorometric assay designed for measurement of C-reactive protein (CRP) in canine blood was evaluated and validated for use in canine saliva. C-reactive protein was measured in saliva specimens from 5 healthy dogs before and after the injection of casein and in 37 dogs with different disease conditions. The analytical and functional limits of detection were 0.000053 μg/ml and 0.0091 μg/ml, respectively, and intra- and interassay coefficients of variation ranged between 6.7–9.9% and 8.5–16.5%, respectively. A recovery experiment showed no significant disagreement between detected values and expected ones, and saliva CRP concentration was measured in a linear and proportional manner. A positive correlation was found between CRP levels obtained in saliva and serum samples in the experimental ( R2 = 0.76) and clinical studies ( R2 = 0.70). The assay was able to detect significant differences between salivary CRP levels in healthy dogs and dogs with inflammatory processes. These results suggest that saliva can be used for CRP measurement in dogs. The use of saliva presents the advantage of an easier and less stressful sampling method for the animals, which might be performed outside of hospital environments.

High-sensitivity C-reactive protein (hs-CRP) adds prognostic information beyond that provided by the Framingham risk score. The clinical utility of hs-CRP evaluation per guidelines was investigated by determining how it changed the cardiovascular risk stratification of 100 patients deemed at intermediate risk. Screening guidelines defined the cardiovascular risk due to hs-CRP as low (1.0 mg/L), intermediate (1.0 to 3.0 mg/L), or high (3.0 mg/L). After hs-CRP evaluation, risk was adjusted in 66% of the patients. Because hs-CRP evaluation significantly altered the cardiovascular risk strata of most intermediate-risk patients, it may therefore be a useful test during primary cardiovascular disease prevention.

In 1930, Tillet and Francis observed a substance in the sera of individuals infected with pneumococcal pneumonia that formed a precipitate when mixed with the C-polysaccharide fraction of Streptococcus pneumoniae (1). They noted that this “C-reactive” activity was absent from the sera of healthy individuals. MacLeod and Avery subsequently characterized this substance as a protein that required calcium ions for its reaction with C-polysaccharide and introduced the term “acute phase” to describe the sera of patients with various acute infections (2). Despite its name, the acute phase response was subsequently identified by Lofstrom to be present in both acute and chronic inflammatory conditions; consequently, C-reactive protein (CRP) became recognized as a nonspecific acute phase protein (3).

We read with interest the article from Messrs Al-Jabi and El-Shawarby entitled “Value of C-reactive protein after neurosurgery: a prospective study” suggesting that C-reactive protein (CRP) is a re...