Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnourished patients were also evaluated in an attempt to identify those with a potential nutritional risk. METHODS: A total of 1077 patients were enrolled. Nutritional status was evaluated by Z-score (weight for age). We compared mortality, sepsis incidence, and length of hospital stay for nourished and malnourished patients. We had a subgroup of 15 patients with severe malnutrition (MN) and another with 14 well-nourished patients (WN). Cytokine IL-6 determinations were performed by enzyme-linked immunosorbent assay. RESULTS: 53% of patients were classified with moderate or severe malnutrition. Similar amounts of C- reactive protein (CRP) were observed in WN and MN patients. Both groups were able to increase IL-6 concentrations in response to inflammatory systemic response and the levels followed a similar evolution during the study. However, the mean values of serum IL-6 were significantly different between WN and MN patients across time, throughout the study (p = 0.043). DISCUSSION: a considerable proportion of malnourished patients need specialized nutritional therapy during an intensive care unit (ICU) stay. Malnutrition in children remains largely unrecognized by healthcare workers on admission. CONCLUSIONS: The incidence of malnutrition was very high. Malnourished patients maintain the capacity to release inflammatory markers such as CRP and IL-6, which can be considered favorable for combating infections On the other hand, this capacity might also have a significant impact on nutritional status during hospitalization.

OBJETIVOS: Analisar o efeito da exposição à fumaça do cigarro na gestação e lactação sobre a produção láctea de ratas, ganho ponderal e crescimento linear dos filhotes. MÉTODOS: Três grupos de ratas foram estudados na gestação e lactação: 15 ratas expostas à fumaça do cigarro mais fluxo de ar, 18 ratas manipuladas, isto é, expostas ao fluxo de ar comprimido e 18 ratas controle. Os filhotes foram medidos e pesados a cada 5 dias, do primeiro ao 15º dia. A produção láctea foi estimada pelos métodos de captação de leite em 1 hora e ganho ponderal dos filhotes. RESULTADOS: Os filhotes das ratas expostos à fumaça do cigarro apresentaram menor peso e comprimento ao nascer. Durante a lactação, os filhotes das ratas expostas à fumaça e das apenas manipuladas ganharam menos peso que o grupo controle. A produção láctea pelo método de captação de leite em 1 hora foi reduzida no grupo exposto à fumaça e, em menor proporção, nas ratas do grupo manipulado. Pelo método do ganho ponderal dos filhotes, a produção láctea reduziu-se igualmente nos grupos exposto à fumaça e manipulado, comparados ao grupo controle. CONCLUSÕES: A exposição à fumaça do cigarro comprometeu o peso e o comprimento ao nascer, mas, durante a lactação, também a manipulação comprometeu o ganho de peso dos filhotes. A manipulação e, mais acentuadamente, a exposição ao tabaco prejudicaram a produção de leite.

OBJECTIVES: To analyze the effects of exposure to cigarette smoke during gestation and lactation on the milk production of rats and on the weight gain and linear growth of their offspring. METHODS: Three groups of female rats were studied during gestation and lactation: 15 rats were exposed to cigarette smoke and air flow, 18 rats were handled, i.e., exposed to compressed air flow, and 18 rats were used as controls. Newborn rats were measured and weighed every 5 days, from the first to the 15th day. Milk production was estimated by 1-hour milk extraction and weight gained by litters. RESULTS: The offspring of rats exposed to cigarette smoke weighed less and were shorter at birth. During lactation, the offspring of rats exposed to smoke and also of rats that had merely been handled gained less weight than the control group. Milk production gauged by the 1-hour extraction method was reduced in the group exposed to smoke and, to a lesser extent, also in the group that had been handled. Milk production estimated according to the pups' weight gain was reduced equally in the groups exposed to smoke and merely handled, when compared to the control group. CONCLUSIONS: Exposure to cigarette smoke compromised the birth weight and birth length, but during lactation, handling also compromised weight gain of offspring. Handling and, to a greater extent, exposure to tobacco, were prejudicial to milk production.

OBJETIVO: Verificar a acurácia da interleucina 6 (IL-6) e da proteína C reativa (PCR) para o diagnóstico de sepse tardia no recém-nascido (RN). MÉTODOS: Trata-se de estudo de coorte prospectivo com 43 RNs internados com suspeita de sepse tardia na UTIN. Foram dosados no dia da suspeita diagnóstica (dia 0) e nos dias 1, 3 e 7 de evolução os níveis séricos da IL-6 e da PCR e calculado o melhor valor de coorte para o diagnóstico de sepse. Também foram calculados os índices de sensibilidade (S), especificidade (E), valor preditivo positivo e negativo (VPP, VPN) para cada um dos testes, assim como para a combinação entre eles. RESULTADOS: Os níveis séricos da IL-6 e da PCR estiveram acima do ponto de coorte nos RN com sepse e com sepse presumível com diferenças significantes entre ambos os grupos, nos quais a única diferença foi hemocultura positiva no primeiro. Foi possível afastar esse diagnóstico em seis RNs. Para o diagnóstico de sepse, a IL-6 obteve os melhores índices no dia da suspeita diagnóstica, dia 0 (S: 88,9%, E: 80%, VPP: 76,2%, VPN: 90,9%), seguida da proteína C reativa (S: 94%, E: 78,3%, VPP: 77,3%, VPN: 94,7%) 24 horas após. A combinação dos dois (IL 6/PCR) mostrou-se mais adequada para o diagnóstico precoce no dia 0 e até 24 horas de evolução com S e VPN de 100%. CONCLUSÃO: A combinação de IL6/PCR apresentou acurácia para o diagnóstico de sepse. A evolução destes testes ao longo dos dias refletiu a evolução clínica dos RN.

BACKGROUND: Verify the accuracy of interleukin 6 (IL-6) and C-reactive protein (CRP) for diagnosis of late onset sepsis in newborn (NB) infants. METHODS: a prospective cohort study with 43 NB infants hospitalized at the NICU with suspicion of late onset sepsis was carried out. Levels of IL-6 and of CRP were dosed with suspicion diagnoses; day (0) and sequentially on day 1, 3, and 7 of the evolution and the best cut-off values were calculated for the diagnoses. Indices of sensibility (S), specificity (SP), positive predictive value and negative predictive value (PPV, NPV) were calculated for each test as well as for the combination between them. RESULTS: Levels of IL-6 and CRP were above the established cut-off values in the NB infants with sepsis and with presumed sepsis. There was a significant difference between both groups, where the only difference was the positive blood culture for the first group. Diagnosis could be rejected in 6 NB infants. The IL-6 showed better indices on the day of suspicion diagnosis, day 0 (S: 88.9%, Sp: 80.0%, PPV: 76.2%, NPV: 90.9%), followed by the C-reactive protein (S: 94.0%, Sp: 78.3%, PPV: 77.3%, NPV: 94.7%) 24 hours later. The combination of IL-6 / CRP demonstrated to be adequate for early diagnosis of sepsis on day 0 and 24 hours later with S and NPV of 100%. CONCLUSION: for diagnosis of sepsis the combination interleukin 6 / CRP presented accuracy. During the following days their development reflected the clinical evolution of the NB infants.

INTRODUÇÃO: Foi realizada monitorização dos níveis séricos de vancomicina em recém-nascidos de termo com sepse ou suspeita de sepse Staphylococcus sp., através da cromatografia líquida de alta eficácia (HPLC) e imunoensaio por fluorescência polarizada (FPIA). OBJETIVO: Verificar a existência de correlação estatística entre os resultados obtidos pelas duas técnicas. MÉTODO E CASUÍSTICA: Foram obtidas dezoito e vinte concentrações séricas de vancomicina no pico e vale respectivamente, em recém-nascidos de termo, no período de outubro de 1995 a outubro de 1997. RESULTADO: O coeficiente de correlação linear para pico sérico foi de 0,27, p=0,110 e para vale sérico 0,26, p= 0,1045 não sendo estatisticamente significativo, não sendo estatisticamente significativo. CONCLUSÃO: Apesar da pequena casuística, não houve correlação estatisticamente significante entre os resultados obtidos pelos duas técnicas.

INTRODUCTION: Peak and trough serum concentrations of vancomycin were determined in term newborn infants with confirmed or suspected Staphylococcus sp sepsis by high performance liquid chromatography and flourescence polarization immunoassay. OBJECTIVE: To statistically compare the results of the high performance liquid chromatography and flourescence polarization immunoassay techniques for measuring serum vancomycin concentrations. METHODS: Eighteen peak and 20 trough serum samples were assayed for vancomycin concentrations using high performance liquid chromatography and flourescence polarization immunoassay from October 1995 to October 1997. RESULTS: The linear correlation coefficients for high performance liquid chromatography and flourescence polarization immunoassay were 0.27 (peak, P = 0.110) and 0.26 (trough, P = 0.1045) respectively, which were not statistically significant. CONCLUSION: There was wide variation in serum vancomycin concentrations determined by high performance liquid chromatography as compared with those determined by flourescence polarization immunoassay. There was no recognizable pattern in the variability; in an apparently random fashion, the high performance liquid chromatography measurement was sometimes substantially higher than the flourescence polarization immunoassay measurement, and at other times it was substantially lower.

Foi realizado um estudo prospectivo para verificar se as doses habituais de vancomicina determinam concentrações séricas adequadas em 25 recém - nascidos de termo com sepse. OBJETIVOS: Avaliou-se a resposta terapêutica da sepse neonatal por Staphylococcus sp., tratada com vancomicina, monitorizando além de sua concentração sérica, o poder bactericida do soro (PBS) e a concentração inibitória mínima (MIC). MÉTODO: Os níveis séricos do antibiótico foram obtidos através do imunoensaio por fluorescência polarizada, o MIC através de micro-difusão em ágar, e o PBS foi obtido por macro-diluição em caldo. RESULTADOS: Concentrações séricas no pico de vancomicina adequadas (20-40 mg/mL) ocorreram em 59,1% dos casos e um recém-nascido apresentou potencial risco de ototoxicidade (>40 mg/mL). Em 48% dos pacientes ocorreram vales séricos adequados (5-10 mg/mL) e 28% dos pacientes apresentaram potencial risco de nefrotoxicidade (>10mg/mL). Não houve concordância significante entre a normalidade determinada pelo pico e vale de vancomicina no método (prova de McNemar: p=0,7905). A concentração sérica no pico de vancomicina foi comparada com a evolução clínica dos recém-nascidos com sepse neonatal, não havendo diferença estatisticamente significante entre os picos séricos dos pacientes que apresentaram boa e má evolução (U=51,5; p=0,1947). Também não houve diferença estatisticamente significante entre os vales séricos dos pacientes que apresentaram boa e má evolução clínica ( U= 77,0; p=0,1710). Todos os MICs obtidos demonstraram sensibilidade à vancomicina. Metade dos pacientes que apresentou PBS no vale adequado (1/8), também tiveram concentração sérica de vancomicina adequada e boa evolução clínica. CONCLUSÕES: A recomendação de doses de vancomicina para recém-nascidos de termo deve ser baseada no peso e na idade pós-conceptual apenas para dar início à terapia antimicrobiana na sepse neonatal, não existindo um padrão de doses ideal. Logo, a dose deve ser individualizada. A utilização desses dados laboratoriais com a clínica favorecem a elucidação da provável causa da má evolução do paciente, facilitando o ajuste da droga e a menor chance de efeitos tóxicos ou sub-terapêuticos.

A prospective study was conducted to determine if standardized vancomycin doses could produce adequate serum concentrations in 25 term newborn infants with sepsis. Purpose: The therapeutic response of neonatal sepsis by Staphylococcus sp. treated with vancomycin was evaluated through serum concentrations of vancomycin, serum bactericidal titers (SBT), and minimum inhibitory concentration (MIC). METHOD: Vancomycin serum concentrations were determined by the fluorescence polarization immunoassay technique , SBT by the macro-broth dilution method, and MIC by diffusion test in agar . RESULTS: Thirteen newborn infants (59.1%) had adequate peak vancomycin serum concentrations (20--40 mg/mL) and one had peak concentration with potential ototoxicity risk (>40 µg/mL). Only 48% had adequate trough concentrations (5--10 mg/mL), and seven (28%) had a potential nephrotoxicity risk (>10 µg/mL). There was no significant agreement regarding normality for peak and trough vancomycin method (McNemar test : p = 0.7905). Peak serum vancomycin concentrations were compared with the clinical evaluation (good or bad clinical evolution) of the infants, with no significant difference found (U=51.5; p=0.1947). There was also no significant difference between the patients' trough concentrations and good or bad clinical evolution (U = 77.0; p=0.1710). All Staphylococcus isolates were sensitive to vancomycin according to the MIC. Half of the patients with adequate trough SBT (1/8), also had adequate trough vancomycin concentrations and satisfactory clinical evolution. CONCLUSIONS: Recommended vancomycin schedules for term newborn infants with neonatal sepsis should be based on the weight and postconceptual age only to start antimicrobial therapy. There is no ideal pattern of vancomycin dosing; vancomycin dosages must be individualized. SBT interpretation should be made in conjunction with the patient's clinical presentation and vancomycin serum concentrations. Those laboratory and clinical data favor elucidation of the probable cause of patient's bad evolution, which would facilitate drug adjustment and reduce the risk of toxicity or failing to achieve therapeutic doses.