Systemic cytokines/chemokines associated to radiographic abnormalities in pneumonia in children.

Community-acquired pneumonia (CAP) diagnosis remains a challenge in paediatrics. Chest radiography is considered gold standard for definition of pneumonia, however no previous study assessed the relationship between immune response and radiographic-confirmed-pneumonia. We assessed association between cytokines/chemokines levels and radiographic abnormalities in children with CAP. Children < 5-years-old hospitalized with CAP were investigated in a prospective study at the Federal University of Bahia Hospital, Brazil. On admission, clinical data and biological samples were collected to investigate 20 aetiological agents and determine serum cytokines/chemokines levels; chest radiographs were performed. Among 158 patients, radiographic diagnosis of pneumonia was confirmed in 126(79.7%) and 17(10.8%) had pleural effusion. Viral, bacterial and pneumococcal infection were detected in 80(50.6%), 78(49.4%) and 37(23.4%) cases. By comparing the median concentrations of serum cytokines/chemokines between children with or without pleural effusion, interleukin(IL)-6 was higher (26.6[18.6-103.7] vs 3.0[0.0-19.8]; p < 0.001) among those with pleural effusion; and between children with or without radiographic-confirmed-pneumonia, IL-6 was higher in the first subgroup (4.5[0.0-23.4] vs 0.0[0.0-3.6]; p = 0.02) after having excluded cases with pleural effusion. Stratified analyses according to aetiology showed IL-6 increase in the radiographic-confirmed-pneumonia subgroup inside the pneumococcal infection (28.2[5.9-64.1] vs 0.0[0.0-0.0]; p = 0.03) subgroup. By multivariable analysis, with IL-6 as dependent variable, pneumococcal infection and pleural effusion showed independent association with IL-6 elevation [respective OR: 5.071 (95%CI = 2.226-11.548; p < 0.001) and 13.604 (95%CI = 3.463-53.449; p = 0.0001)]. Considering the cases without pleural effusion, the area under the curve of IL-6 to predict pneumococcal infection was 0.76 (95%CI = 0.66-0.86; p < 0.001). IL-6 increase is a potential biomarker of pneumococcal infection among children with CAP without pleural effusion upon admission.

Evolution of cytokines/chemokines in cases with community-acquired pneumonia and distinct etiologies.

AIM: To compare the systemic cytokines/chemokines levels over time during the evolution of children hospitalized with community-acquired pneumonia (CAP) with and without pneumococcal infection. METHODS: Children less than 5-years-old hospitalized with CAP were prospectively investigated in Salvador, Brazil. Clinical data and biological samples were collected to investigate 20 etiological agents and to determine serum cytokines/chemokines levels on admission and 2 to 4 weeks later. Cases with pneumococcal infection received this diagnosis irrespective of also having other etiologies. RESULTS: A total of 277 patients were enrolled, however, serum sample was unavailable for cytokine measurement upon admission (n = 61) or upon follow-up visit (n = 36), etiology was undetected (n = 50) and one patient did not attend the follow-up visit. Therefore, this study group comprised of 129 cases with established etiology. The median (interquartile range) age and sampling interval was 18 (9-27) months and 18 (16-21) days, respectively. Established etiology was viral (52.0%), viral-bacterial (30.2%), and bacterial (17.8%). Pneumococcal infection was found in 31 (24.0%) patients. Overall, median interleukin-6 (IL-6; 10.6 [4.7-30.6] vs 21.0 [20.2-21.7]; P = .03), IL-10 (3.5 [3.1-4.5] vs 20.1 [19.8-20.4]; P < .001), and CCL2 (19.3 [12.4-23.2] vs 94.0 [67.2-117.8]; P < .001) were significantly higher in convalescent serum samples, whereas median CXCL10 (83.6 [36.4-182.9] vs 14.6 [0-116.6]; P < .001) was lower. Acute vs convalescent levels evolution of IL-10, CCL2, and CXCL10 did not differ among patients with or without pneumococcal infection. However, IL-6 decreased (27.8 [12.3-48.6] vs 20.8 [20.2-22.6]; P = .1) in patients with pneumococcal infection and increased (9.0 [4.2-22.6] vs 21.0 [20.2-21.7]; P = .001) in patients without it. CONCLUSION: The marked increase of IL-6 serum levels during the acute phase makes it a potential biomarker of pneumococcal infection among children with CAP.

Recovery from childhood community-acquired pneumonia in a developing country: Prognostic value of serum procalcitonin.

BACKGROUND: Childhood community-acquired pneumonia is a common and potentially life-threatening illness in developing countries. We assessed the prognostic value of serum procalcitonin level upon admission on clinical response to antibiotic treatment. METHODS: Out of 89 patients, the median (IQR) age was 19(12-29) months and 60% were boys. Viral (49.5%), typical bacterial (38%) and atypical bacterial (12.5%) infections as well as probable pneumococcal infections (26%) were diagnosed. RESULTS: Seventy-five (84%) children became afebrile ≤48h after treatment. In 14 children who remained febrile after 48h of treatment, median[IQR] serum procalcitonin (ng/ml) level on admission was higher than in those with rapid recovery (2.1[0.8-3.7] vs 0.6[0.1-2.2]; P=0.025). In the slow-responding children, pneumococcal infections were more common (71% vs 17%; P<0.001). Procalcitonin concentrations on admission were higher in children with pneumococcal pneumonia compared to children with non-pneumococcal pneumonia (2[0.7-4.2] vs 0.5[0.08-2.1]; P=0.002). The ROC curve found that <0.25ng/ml of serum procalcitonin had a high negative predictive value (93%[95%CI:80%-99%]) for pneumococcal infection. All children that remained febrile after 48h of treatment had procalcitonin >0.25ng/ml on admission. The majority of children with pneumonia in a developing country become afebrile within 48h after onset of antibiotic treatment. CONCLUSIONS: Serum procalcitonin <0.25ng/ml predicted rapid clinical response and non-pneumococcal etiology.

Systemic cytokines and chemokines on admission of children hospitalized with community-acquired pneumonia.

Community-acquired pneumonia (CAP) is the main cause of death in children under-5 years worldwide and Streptococcus pneumoniae is the most common bacterial agent. However, it is difficult to identify pneumococcal infection among children with CAP. We aimed to assess association between any cytokine/chemokine and pneumococcal infection in childhood CAP. Furthermore, we evaluated the diagnostic value of cytokine/chemokine for pneumococcal infection. This prospective study was conducted at an Emergency Room, in Salvador, Brazil. Children <5-years-old hospitalized with CAP in a 21-month period were evaluated. On admission, clinical and radiological data were collected along with biological samples to investigate 20 etiological agents and determine serum cytokines (interleukin (IL)-8, IL-6, IL-10, IL-1ß, IL-12, TNF-α, IL-2, IL-4, IL-5, γ-interferon), and chemokines (CCL2, CCL5, CXCL9, CXCL10) concentration. From 166 patients with etiology detected, pneumococcal infection was detected in 38 (22.9%) cases among which the median IL-6(pg/ml) was 31.2 (IQR: 12.4-54.1). The other 128 cases had other causative agents detected (Haemophilus influenzae, Moraxella catarrhalis, atypical bacteria and viruses) with the median IL-6 concentration being 9.0 (IQR: 4.1-22.0; p < 0.001). The area under the ROC curve for IL-6 to predict pneumococcal CAP was 0.74 (95%CI: 0.65-0.83; p < 0.001). By multivariate analysis, with pneumococcal CAP as dependent variable, IL-6 was an independent predictor for pneumococcal infection (OR = 5.56; 95%CI: 2.42-12.75, cut-off point = 12.5 pg/ml; p = 0.0001). The negative predictive value of IL-6 under 12.5 pg/ml for pneumococcal infection was 90% (95%CI: 82-95%). Independently significant difference was not found for any other cytokines/chemokines. Serum IL-6 concentration on admission is independently associated with pneumococcal infection among children under-5 years hospitalized with CAP.

Clinical and ultrasonographic criteria for using ventriculoperitoneal shunts in newborns with myelomeningocele.

Objective Hydrocephalus is one of the main complications associated with myelomeningocele (MM). This study aimed to identify clinical and ultrasonographic criteria for using ventriculoperitoneal (VP) shunts in this group of patients.Method A retrospective cohort study, based on established protocol for VP shunt implant in hydrocephalic children with MM. Parameters used to guide the indication of VP shunts included measurement of head circumference (HC), evaluation of fontanels, and measurement of lateral ventricular atrium (LVA) width by transcranial ultrasonography.Results 43 children were included in the analysis, of which 74% had hydrocephalus and required a VP shunt. These children had LVA width ≥ 15 mm, showed increased HC, or had bulging fontanels.Conclusion VP shunt is required in children with increased HC (≥ 2 standard deviation regarding age group), bulging fontanels, or LVA width of ≥ 15 mm after the closure of MM.

Clinical and ultrasonographic criteria for using ventriculoperitoneal shunts in newborns with myelomeningocele / Critérios clínicos e ultrassonográficos para a indicação de derivação ventrículo peritoneal em neonatos portadores de mielomeningocele

Objective Hydrocephalus is one of the main complications associated with myelomeningocele (MM). This study aimed to identify clinical and ultrasonographic criteria for using ventriculoperitoneal (VP) shunts in this group of patients.Method A retrospective cohort study, based on established protocol for VP shunt implant in hydrocephalic children with MM. Parameters used to guide the indication of VP shunts included measurement of head circumference (HC), evaluation of fontanels, and measurement of lateral ventricular atrium (LVA) width by transcranial ultrasonography.Results 43 children were included in the analysis, of which 74% had hydrocephalus and required a VP shunt. These children had LVA width ≥ 15 mm, showed increased HC, or had bulging fontanels.Conclusion VP shunt is required in children with increased HC (≥ 2 standard deviation regarding age group), bulging fontanels, or LVA width of ≥ 15 mm after the closure of MM.

Objetivo Identificar os critérios clínicos e ultrassonográficos para a recomendação do implante de derivações ventrículo peritoneais (DVP) em neonatos portadores de mielomeningocele (MM).Método Estudo de coorte retrospectivo, com base no protocolo estabelecido para o implante de DVP em crianças com hidrocefalia associada a MM. Parâmetros utilizados para orientar a indicação de DVP incluíram a medida da circunferência craniana (CC), a avaliação das fontanelas e a medida da largura lateral do átrio ventricular (LAV), avaliado por ultrassonografia transcraniana.Resultados 43 crianças foram incluídas na análise, dos quais 74% tinham hidrocefalia com recomendações para uso de DVP.Conclusão O aumento da CC e o abaulamento de fontanelas foram os principais critérios para a indicação de DVP. A DVP é necessária em crianças com aumento da CC (≥ 2 desvios padrões para a idade), fontanelas abauladas, ou LAV ≥ 15 mm após o fechamento cirúrgico da MM.

Congenital hydrocephalus in the northeast of Brazil: epidemiological aspects, prenatal diagnosis, and treatment.

PURPOSE: Congenital hydrocephalus (CH) has higher proportions in developing countries such as Brazil, reaching rates of 3.16:1,000 newborns. Early diagnosis is essential and can be done during the second trimester of pregnancy, highlighting the importance of regular prenatal care. Our objective is to describe the epidemiological profile of children with CH in the state of Bahia. METHODS: Consecutive medical records of patients with CH, aged less than 2 years and operated at a pediatric reference hospital between September 2009 and September 2012, were reviewed. RESULTS: One hundred twenty-one children underwent ventricular peritoneal shunt (VP shunt) due to CH. As for prenatal care, 38% of pregnant women did it regularly. Males predominated with 56% of cases with a median age of 3 months, and 68% were from the countryside area. The most frequent clinical manifestations were bulging fontanelle (37%) and increased head circumference (30%). There were 13 (11%) reports of complications associated with VP shunts. There were nine deaths (7%), and respiratory complications were the main cause. CONCLUSIONS: Public health measures are the key to increase mothers' knowledge about the importance of regular prenatal monitoring. There was a predominance of male children, with a median age of 3 months, with the majority coming from the countryside.

Oxacillin or cefalotin treatment of hospitalized children with cellulitis.

Cellulitis is an important cause of hospitalization in pediatrics. Because Staphylococcus aureus is the main pathogen of cellulitis, medicinal therapeutics should take the changing resistance profile of this organism into consideration. The aim of this study was to evaluate the progression and outcomes of children hospitalized for cellulitis and treated with oxacillin or cefalotin. This retrospective cohort study enrolled 218 children, hospitalized between 2001 and 2008 in Salvador, Northeast Brazil. All were diagnosed with cellulitis and treated with oxacillin or cefalotin (≥100 mg/kg/day). The median age was 2 years and 56.9% were males. Frequencies of signs and symptoms used in the clinical diagnoses were as follows: swelling (91.3%), redness (81.7%), warmth (47.2%), and tenderness (31.7%). All patients were discharged due to clinical recovery and the mean length of hospitalization was 7 ± 4 days. None of the patients died, needed intensive care, or had sequelae. By comparing the daily frequency of clinical findings during hospitalization, significant decreases were found in the frequencies of fever (admission day [42.2%], first day [20.8%], second day [12.9%], third day [8.3%], fourth day [6.1%]), toxemia, irritability, somnolence, vomiting, tachycardia, and need for intravenous hydration. In conclusion, oxacillin or cefalotin remain the drugs of choice for treating uncomplicated cellulitis in regions where community-acquired methicillin-resistant S. aureus is infrequent (<10%).

Risk of venous thromboembolism and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery.

BACKGROUND: Obesity is considered a highly prevalent risk factor for venous thromboembolism (VTE) in hospitalized patients. However, recommendations for VTE prophylaxis in obese patients are not clear. METHODS: To evaluate obesity as a risk factor for VTE in medical and bariatric patients and the efficacy of VTE prophylaxis, we performed a systematic review in MEDLINE, Cochrane Database of Systematic Reviews and LILACS from 1976 to 2006. Evidence was evaluated independently by 2 authors and presented descriptively. RESULTS: Of the 124 studies found, 87 were excluded based on predefined criteria. There is no consensus among studies, but prospective cohorts show that obesity is associated with a higher risk of VTE in medical patients. There is evidence that the risk of VTE exceeds that attributable to the surgical procedure alone in bariatric surgery. Only 6 studies evaluated prophylactic methods (unfractionated heparin, low molecular weight heparin and sequential compression devices) in obese patients. Although these studies have some methodological flaws, they suggest efficacy of VTE prophylaxis in medical and surgical obese patients. CONCLUSIONS: Obesity is a risk factor for VTE in obese medical patients and patients undergoing bariatric surgery. Obesity appears to play an adjuvant role for the development of VTE in hospitalized patients with other risk factors. The small number of prospective trials in this population prevents a definite conclusion about the most effective and safe VTE prophylactic method for obese patients. Thus, randomized clinical trials to compare VTE prophylactic methods in obese patients are still highly warranted.

Influência de implementos para o tornozelo nas respostas biomecânicas do salto e aterrissagem no basquete / Influence of ankle devices in the jump and landing biomechanical responses in basketball

FUNDAMENTOS E OBJETIVO: O segmento mais freqüentemente lesado no basquetebol é o tornozelo, sendo a entorse por inversão a lesão mais comum. Para evitá-la, é comum o uso de implementos. O objetivo deste estudo foi avaliar a força reação do solo (FRS) em jogadores de basquete durante execução do salto em três situações: uso de tênis, bandagem e tênis, e tênis e órtese tipo Aircast. MÉTODOS: Oito atletas foram analisados durante o salto, através de uma plataforma de força, nas três situações citadas, para análise das componentes vertical e horizontal médio-lateral da FRS. RESULTADOS E CONCLUSAO: Não houve diferença estatística significativa entre as três situações na componente vertical da FRS durante o salto, embora o uso de bandagem tenda a apresentar, na impulsão, maiores valores do pico de força vertical (3,10 ± 0,46PC; 3,01 ± 0,39PC; 3,03 ± 0,41PC) e do gradiente de crescimento (GC) (12,33 ± 12,21PC; 8,16 ± 3,89PC; 8,46 ± 3,85PC), e durante a aterrissagem, menores valores de pico de força vertical (5,18 ± 1,35PC; 5,56 ± 1,31PC; 5,49 ± 1,44PC) e do GC (88,83 ± 33,85PC; 95,63 ± 42,64PC; 94,53 ± 31,69PC). Durante a impulsão, a força medial do salto com Aircast foi significativamente menor que com tênis (p = 0,0249) e apresentou valor semelhante ao do uso da bandagem, enquanto a força lateral foi significativamente maior com a bandagem do que com tênis (p = 0,0485) e tendeu a ser maior do que o Aircast. Na aterrissagem o componente médio-lateral da FRS ficou inalterado nas três situações. Concluiu-se que a bandagem potencializou a força direcionada ao salto vertical durante a impulsão, porém não estabilizou tanto quanto o Aircast os movimentos de inversão e eversão do pé. Durante a aterrissagem, os implementos não foram efetivos para reduzir a força médio-lateral, mas com a bandagem, houve um tempo maior para absorção do impacto.