Salivary C-reactive protein, mean platelet volume and neutrophil lymphocyte ratio as diagnostic markers for neonatal sepsis

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(A) Comparison of mean blood pressure during the intra-operative period (a, b, c, d: p<0.05). (B) Comparison of mean blood pressure within the first post-operative 24h. 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Mohammad, Amina Abdelwahab" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ahmed" "apellidos" => "Omran" "email" => array:1 [ 0 => "agomran1@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Abdallah" "apellidos" => "Maaroof" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Mai H.S." "apellidos" => "Mohammad" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Amina" "apellidos" => "Abdelwahab" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Suez Canal University, Faculty of Medicine, Departments of Pediatrics & Neonatology, Ismailia, Egypt" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Suez Canal University, Faculty of Medicine, Department of Clinical Pathology, Ismailia, Egypt" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Proteína C reativa salivar, volume médio de plaquetas e proporção de neutrófilos/linfócitos como marcadores de diagnóstico de sepse neonatal" ] ] "textoCompleto" => "IntroductionSepsis is a serious life-threatening condition and a leading cause of morbidity and mortality in full and pre-term infants, especially in the developing countries. It is broadly defined as a systemic inflammatory response occurring in the first 28 days of life as a result of a suspected or proven infection.<a class="elsevierStyleCrossRef" href="#bib0155">1</a>There is an urgent call for detecting reliable biomarkers to differentiate between infected and non-infected neonates. Blood culture has been considered as the gold standard for diagnosis, but this analysis is still slow and limited by false negative results.C-reactive protein (CRP), a major acute phase protein, is a member of the pentraxin family and plays a central role in innate and adaptive immunity.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> Despite the development of new biomarkers, to date CRP is one of the most studied and most used laboratory tests for diagnosis of neonatal sepsis.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> CRP takes 10–12h to significantly rise after the onset of infection.<a class="elsevierStyleCrossRef" href="#bib0170">4</a> As CRP shows an increase in several conditions, it is preferably used in combination with other biomarkers.<a class="elsevierStyleCrossRef" href="#bib0165">3</a>A relevant problem in the current clinical approach for sick neonates is the limited availability of simple, safe, noninvasive diagnostic tools with high diagnostic accuracy. Neonatal saliva overcomes many of the hurdles associated with neonatal research and offers investigators a new, exciting, and non-invasive sample source for exploring neonatal biology. CRP is detectable in neonatal saliva and can predict abnormal serum CRP thresholds.<a class="elsevierStyleCrossRef" href="#bib0175">5</a>Recently, certain parameters of complete blood count (CBC) were used as markers of inflammation and infections. Mean platelet volume (MPV) has been used in diagnosis, follow-up, and prediction of neonatal sepsis severity in term and preterm neonates.<a class="elsevierStyleCrossRefs" href="#bib0180">6–8</a> The neutrophil–lymphocyte ratio (NLR) is a simple biomarker of inflammation.<a class="elsevierStyleCrossRef" href="#bib0195">9</a> In addition, platelet lymphocyte ratio (PLR) is also a useful marker of systemic inflammation.<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a>The present study aimed to assess the applicability of salivary CRP, MPV, NLR, and PLR as diagnostic markers in full-term neonates with neonatal sepsis.MethodsThe present study was conducted at the neonatal intensive care unit (NICU) of the Suez Canal University Hospital, Ismailia, Egypt between January 2016 and June 2016. During these six months, 320 neonates were admitted to the unit. Thirty-five neonates with either early or late onset neonatal sepsis and 35 healthy control neonates were enrolled.Full term infants of both genders from birth to the 28th day of life who were admitted to the Suez Canal University NICU with clinical features of either early- or late-onset neonatal sepsis were enrolled in this study. The diagnosis of clinical sepsis was made by history, clinical findings, laboratory findings, and blood culture. The clinical findings included the presence of three or more of the following: (1) temperature instability (hypothermia, hyperthermia); (2) respiratory alterations (grunting, intercostal retractions, apnea, tachypnea, cyanosis); (3) cardiovascular alterations (bradycardia, tachycardia, poor perfusion, hypotension); (4) neurologic alterations (hypotonia, lethargy, seizures); and (5) gastrointestinal alterations (feeding intolerance, abdominal distension). CRP values >10mg/L were considered to be positive.<a class="elsevierStyleCrossRefs" href="#bib0165">3,11</a>Preterm neonates and neonates with confirmed pneumonia or other inflammatory conditions, CNS malformations, metabolic disorders, chromosomal abnormalities, intrauterine growth restriction, or birth asphyxia were excluded from the study.Thirty-five healthy neonates with no symptoms, signs, or risk factors for infections who had been hospitalized for physiological jaundice in the neonatal unit, and all neonates without infectious risk factors admitted to outpatient clinics of the hospital were prospectively enrolled as controls. Serum CRP level for neonates in this group was negative (CRP<10mg/L).Samples were collected from septic neonates within 4–12h of clinically indicated serum CRP levels measurement and before starting antibiotic treatment.For CBC measurement, peripheral blood was collected into an EDTA Vacutainer tube and analyzed by an automated blood cell counter (Cell-Dyn 3700, Abbott Laboratories, IL, USA). The NLR and PLR were calculated as the ratio of neutrophils to lymphocytes and platelets to lymphocytes respectively. Their levels were obtained from the same blood samples. For accurate MPV calculation, samples were analyzed within 60minutes after collection to avoid platelet swelling and false increase of MPV value.For determination of serum CRP level, the fully automated auto-analyzer Cobas c501 (Roche Diagnostics, Manheim, Germany) was used. For salivary CRP, samples were collected nearly 1h before feeding to avoid milk contamination. Saliva was collected by tilting the head forward to pool saliva in the floor of the mouth. Samples were then obtained by using a 1-mL syringe attached to low wall suction (<20mm Hg), ensuring that the saliva remained in the syringe and did not enter into the tubing or suction trap. Saliva was suctioned from under the neonates’ tongues and in their gingival crevices. Suctioning was maintained for approximately 10–15s, collecting around 0.5mL. The syringe was then detached from suction and the plunger was placed back into the syringe.After collection, samples were put in polypropylene tubes to avoid contamination and analytic retention faults. Samples were stored at −20°C until use. Salivary CRP was measured by ELISA. Blood cultures were performed for the septic group.This study was approved by the local institutional ethics committee and an informed consent was obtained from the parents of all the neonates throughout the study.Statistical analysesStatistical analyses were performed using SPSS for Windows statistical package, version 20 (SPSS, Chicago, IL, USA). The differences between groups regarding non-parametric quantitative data were assessed by Mann–Whitney's U-test. The chi-squared test was used for testing significant differences of qualitative variables. The sensitivity, specificity, and optimal salivary CRP cut-point were determined using the receiver operating characteristic (ROC) curve. For all statistical analysis, the level of statistical significance was set at p<0.05.ResultsDemographic and prenatal dataStatistical differences were observed between the two groups regarding age, history of maternal urinary tract infection (UTI), and mode of delivery. Late-onset sepsis (LOS) was diagnosed in 74.3% of the septic neonates, while early onset sepsis (EOS) was diagnosed in only 25.7% of them (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Clinical presentation, CBC, and blood culture results in septic groupAt time of presentation of septic neonates, 19 (54.3%) of them presented with poor activity and refusal of feeding, while nine (25.7%) presented with fever and poor activity, and seven (20%) presented with refusal of feeding in addition to respiratory distress. There were significant differences between the two groups in CBC indices. Anemia was observed in 12 (34.3%) septic neonates and in four (11.4%) controls. A difference was observed in white blood cell count between septic and control infants; leucocytosis was observed in 11 (31.4%) septic neonates and in one (2.9%) control. Thrombocytopenia was found in nine (25.7%) septic neonates and in one (2.9%) control.In the septic group, blood culture was positive in 25 (71.5%). Coagulase-negative staphylococci were the most frequent isolated pathogens, followed by E. coli, Klebsiella pneumonia, and Serratia marcescens.Serum CRP, salivary CRP, MPV, NLR, and PLR valuesThere were significant differences between both groups in serum CRP, salivary CRP, MPV, and NLR. Serum CRP values showed significant differences between both groups (mean 27.3±13.3mg/L vs. 4.9±2.8mg/L, respectively). The mean serum CRP for neonates with EOS was 23.2±11.3, while its mean in neonates with LOS was 29.4±13. Salivary CRP also showed a significant difference between both groups (mean 12.0±4.6ng/L vs.2.8±1.2ng/L, respectively). MPV showed a significant difference between both groups (mean 10.2±1.2fL vs.8.0±0.5fL, respectively). NLR also showed a significant difference between both groups (mean 2.9±1.7, vs.1.6±0.4, respectively). The difference in PLR between both groups was not significant (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Correlation between salivary CRP and each of serum CRP, MPV, NLR, and PLRThere were statistically significant correlations between salivary CRP and serum CRP (0.66, p<0.001), MPV (r=0.45, p<0.001), and NLR (r=0.408, p<0.001). The correlation between salivary CRP and PLR was not statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Comparison of ROC curves of serum CRP, salivary CRP, MPV, NLR, and PLR as markers of neonatal sepsisThe analysis of the ROC curves showed that serum CRP, at a cut-off value of 10mg/L, had sensitivity of 83.1% and specificity of 85.9%. Salivary CRP, at a cut-off value of 3.48ng/L, had sensitivity of 94.3% and specificity of 80%. MPV showed 80% sensitivity and 80% specificity at a cut-off value of 10.2fL. NLR, at a cut-off value of 2.7, had sensitivity of 80% and specificity of 57.1%. PLR showed low sensitivity and specificity in predicting neonatal sepsis (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Salivary CRP at a cut-off value of 3.4ng/L showed sensitivity of 94% and specificity of 91.3% in predicting serum CRP ≥10mg/L in septic neonates.DiscussionNeonatal sepsis is a major cause of morbidity and mortality in neonatal intensive care units.<a class="elsevierStyleCrossRef" href="#bib0210">12</a> Furthermore, it has long-term morbidities.<a class="elsevierStyleCrossRefs" href="#bib0215">13,14</a> In turn, simple practices, such as the use of hand sanitizer and training in hand hygiene could reduce LOS.<a class="elsevierStyleCrossRef" href="#bib0225">15</a>Worldwide, infections account for two-thirds of the 6 million annual deaths in children younger than 5 years. The neonatal period has the highest lifetime risk of serious infections, with an estimated 400,000 newborn deaths annually.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> In Egypt, rates of sepsis exceed 50% in neonatal intensive care units.<a class="elsevierStyleCrossRef" href="#bib0235">17</a>Recently, analysis of saliva for clinical monitoring and biomarker detection in neonates holds great promise for improving the healthcare of this fragile population. Saliva represents an ideal and easily accessible bio-fluid for non-invasive screening of common neonatal morbidities, such as prematurity, infections, and brain insults.<a class="elsevierStyleCrossRefs" href="#bib0240">18–20</a>To date, CRP is the most extensively studied acute-phase reactant; despite the detection of new markers of infection, its wide availability and its fast, simple, and cost-effective determination makes it one of the preferred indices in many NICUs.The literature, serum CRP showed different kinetics and cut-off values ranging from 1.5 to 20mg/L, with wide-ranging sensitivities and specificities (from 74% to 98% and from 71% to 94%, respectively) for either serial CRP determinations or a single measurement at least 12h after the onset of neonatal sepsis symptoms.<a class="elsevierStyleCrossRefs" href="#bib0165">3,11,21–23</a>These differences in cut-off values can be explained by different gestational ages, birth weights, and the physiologic kinetics of CRP after birth in the studied neonates.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> There is a debate about the cut-off point for CRP in cases of EOS and LOS, with some agreement about the use of 10mg/L as a reliable cut-off, especially in EOS.<a class="elsevierStyleCrossRefs" href="#bib0165">3,11</a> In the present study, the mean serum CRP was 27.3±13.3mg/L in septic neonates, with 83.1% sensitivity and 85.9% specificity at a cut off-value of 10mg/L.Serial measurements of CRP level may also be useful for identification of neonates with bacterial infection, monitoring the response to treatment in infected neonates and determining the duration of antibiotic therapy.<a class="elsevierStyleCrossRefs" href="#bib0255">21,24</a> Nonetheless, serial CRP monitoring in the neonatal population puts these patients in medical risks from frequent sampling.Salivary CRP detection is a new method for diagnosis in neonatal population. In 2014, Iyengar et al. published the first article about detection and utility of salivary CRP in neonates, which was considered the first study to detect, quantify, and demonstrate that salivary CRP is a good index for clinically relevant serum CRP thresholds.<a class="elsevierStyleCrossRef" href="#bib0175">5</a>To the best of the authors’ knowledge, this was the first study to investigate the role of salivary CRP as non-invasive diagnostic marker in septic neonates. The difference in mean salivary CRP between septic neonates and controls was statistically significant, with mean of 12.0±4.6ng/L in septic neonates versus 2.8±1.2ng/L in controls. At a cut-off point of 3.48ng/L, salivary CRP showed high sensitivity (94.3%) and specificity (80.0%). In the present study, salivary CRP showed good accuracy in predicting high serum CRP levels. It was observed that salivary CRP, at a cut-off point of 3.4ng/L, had a corresponding sensitivity (94%) and specificity (91.3%) in accurately predicting a serum CRP level of ≥10mg/L.Iyengar et al. showed that raw salivary CRP concentration of 4.84ng/L had a sensitivity and specificity of 64% and 94%, respectively, for accurately predicting a serum CRP level of 5mg/L, and a sensitivity and specificity of 54% and 95%, respectively, for accurately predicting a serum CRP of 10mg/L.<a class="elsevierStyleCrossRef" href="#bib0175">5</a> This discrepancy could return to the nature of disease under investigation.CBC is a simple and routine workup to determine infection in neonates. Low white blood cell count, absolute neutrophil count, and high immature-to-total neutrophil ratio were the most commonly used indices for detection of infection in neonates.<a class="elsevierStyleCrossRef" href="#bib0275">25</a>Recently, other CBC indices, such as MPV, NLR, and PLR, have been used as markers of systemic inflammation in children and adults. In neonates, very limited data are available about the usage of NLR and PLR for diagnosis of neonatal infection or other inflammatory conditions.In the present study, MPV values showed a significant difference between septic neonates and controls, with a mean of 9.5±1.2fL and 8.0±0.5fL, respectively, and showed a significant correlation with serum and salivary CRP. Oncel et al. also reported a higher mean MPV in septic neonates when compared with controls(8.82±0.8fL and 8.44±0.5fL, respectively).<a class="elsevierStyleCrossRef" href="#bib0180">6</a>MPV was able to predict diseased neonates and demonstrated diagnostic accuracy with 80% sensitivity and specificity at a cut-off point of 10.2fL. Aydın et al. reported that the diagnostic cut-off value for MPV in neonates with sepsis, 10.4fL, presented sensitivity of 54% and specificity of 82%.<a class="elsevierStyleCrossRef" href="#bib0280">26</a> Recently, Yao et al. found that optimal cut-off point of MPV for the diagnosis of sepsis was 11.4fL, with sensitivity of 40.5% and specificity of 88.4%.<a class="elsevierStyleCrossRef" href="#bib0285">27</a>NLR, which was recently considered as a new indicative marker of systemic inflammation, is simple and easy to calculate using routine laboratory data without an additional technique or cost.To the best of the authors’ knowledge, this study was the first report of a statistically significant difference in mean NLR between septic neonates and controls (2.9±1.7 vs. 1.6±0.4, respectively) that also showed a good statistical significance in predicting and differentiating between septic neonates and controls with 80% sensitivity and 57.1% specificity at a cut-off point of 2.7. With regard to infections, NLR has been reported as a predictor of the severity and clinical outcome in patients with community- acquired pneumonia<a class="elsevierStyleCrossRef" href="#bib0290">28</a> and bacteremia,<a class="elsevierStyleCrossRef" href="#bib0295">29</a> being able to differentiate between bacterial and viral meningitis.<a class="elsevierStyleCrossRef" href="#bib0300">30</a>PLR is a blood ratio that is largely used in chronic diseases and malignancies in adults. In the present study, PLR showed no significant accuracy in predicting septic neonates with low sensitivity (50%) and specificity (46.7%) at a cut-off point of 73.1.The main limitations of the present study are the relatively small number of septic neonates, the small percentage of neonates with EOS, and the use of the same cut-off value for serum CRP in neonates with EOS and LOS.In conclusion, this study provides initial evidence for the usefulness of salivary CPR, MPV, and NLR to be combined with other markers in the diagnosis of neonatal sepsis. However, these findings still need to be confirmed by other future studies aiming to examine larger numbers of neonates and different categories of infections using rigorous methods, in order to fully establish the role of salivary CRP and other tested markers in diagnosis of neonatal sepsis.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1402842" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1284290" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1402843" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1284289" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analyses" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Demographic and prenatal data" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical presentation, CBC, and blood culture results in septic group" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Serum CRP, salivary CRP, MPV, NLR, and PLR values" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Correlation between salivary CRP and each of serum CRP, MPV, NLR, and PLR" ] ] ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Comparison of ROC curves of serum CRP, salivary CRP, MPV, NLR, and PLR as markers of neonatal sepsis" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-16" "fechaAceptado" => "2017-02-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1284290" "palabras" => array:5 [ 0 => "Neonatal sepsis" 1 => "Salivary CRP" 2 => "Mean platelet volume" 3 => "Neutrophil/lymphocyte ratio" 4 => "Platelets/lymphocytes ratio" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1284289" "palabras" => array:5 [ 0 => "Sepse neonatal" 1 => "PCR salivar" 2 => "Volume médio de plaquetas" 3 => "Proporção de neutrófilos/linfócitos" 4 => "Proporção de plaquetas/linfócitos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo assess the applicability of salivary C-reactive protein, mean platelet volume, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio in the diagnosis of neonatal sepsis. MethodsProspective case-control study of 70 full-term neonates, 35 with sepsis (20 with proven sepsis and 15 with clinical sepsis) and 35 healthy controls. Serum and salivary C-reactive protein concentrations were measured by enzyme-linked immunosorbent assay while mean platelet volume, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio were measured by automated blood cell counter. ResultsThis study showed statistically signiﬁcant difference of mean salivary C-reactive protein between septic neonates and controls (12.0±4.6ng/L vs. 2.8±1.2ng/L) respectively. At a cut-off point of 3.48ng/L, salivary C-reactive protein showed 94.3% sensitivity and 80% speciﬁcity. Salivary C-reactive protein also showed good predictive accuracy for predicting elevated serum C-reactive protein values in septic neonates. Mean platelet volume and neutrophil-lymphocyte ratio showed signiﬁcant difference between septic neonates and controls (10.2±1.2fL vs.8.0±0.5fL; 2.9±1.7 vs. 1.6±0.4, respectively). At a cut-off point of 10.2fL, mean platelet volume presented 80% sensitivity and speciﬁcity. At a cut-off point of 2.7, neutrophil-lymphocyte ratio presented 80% sensitivity and 57.1% speciﬁcity. ConclusionThis study provides support for further studies on the usefulness of salivary C-reactive protein, mean platelet volume, and neutrophil-lymphocyte ratio as diagnostic markers for neonatal sepsis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoAvaliar a aplicabilidade da proteína C reativa (PCR) salivar, do volume médio de plaquetas (VMP), a proporção de neutrófilos-linfócitos (PNL) e a proporção de plaquetas/linfócitos (PPL) no diagnóstico de sepse neonatal. MétodosEstudo caso-controle prospectivo de 70 neonatos a termo, 35 com sepse (20 com sepse comprovada e 15 com sepse clínica) e 35 controles saudáveis. As concentrações de PCR no soro e salivar foram medidas por ensaio imunossorvente ligado a enzima (ELISA), ao passo que o VMP, PNL e PPL foram medidos por contador de células sanguíneas automatizado. ResultadosEste estudo mostrou uma diferença estatisticamente significativa da média de PCR salivar entre os neonatos com sepse e os controles (12,0±4,6ng/L em comparação a 2,8±1,2ng/L), respectivamente. Um ponto de corte 3,48ng/L na PCR salivar mostrou sensibilidade de 94,3% e especificidade de 80%. A PCR salivar mostrou, ainda, boa precisão preditiva para prever altos valores de PCR no soro em neonatos com sepse. O VMP e a PNL mostraram diferença significativa entre os neonatos com sepse e os controles (10,2±1,2fL em comparação a 8,0±0,5fL), (2,9±1,7 em comparação a 1,6±0,4), respectivamente. O VMP no ponto de corte 10,2fL apresentou 80% de sensibilidade e especificidade. A PNL no ponto de corte 2,7fL apresentou 80% de sensibilidade e 57,1% de especificidade. ConclusãoEste estudo fornece uma base para outros estudos na utilidade da PCR salivar, VMP e PNL como marcadores de diagnóstico de sepse neonatal." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Omran A, Maaroof A, Mohammad MH, Abdelwahab A. Salivary C-reactive protein, mean platelet volume and neutrophil lymphocyte ratio as diagnostic markers for neonatal sepsis. J Pediatr (Rio J). 2018;94:82–7." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "PROM, premature rupture of membrane; UTI, urinary tract infection; CS, cesarean section; NVD, normal vaginal delivery." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Septic (35)No. (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Controls (35)No. (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Basic characteristics</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (62.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (48.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.229 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (37.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (51.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age in days</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (25.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (48.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.048a \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (74.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (51.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gestational age</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full term \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (100.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (100.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prenatal data</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of PROM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (34.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (37.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.621 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of UTI during pregnancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (68.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001a \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mode of delivery</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 (85.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (28.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NVD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (14.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25(71.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2405950.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Demographic and prenatal data for each group." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "CRP, C-reactive protein; NLR, neutrophil–lymphocyte ratio; PLR, platelet lymphocyte ratio; MPV, mean platelet volume." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Septic (35)Mean±SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Controls (35)Mean±SD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRP</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.3±13.3mg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9±2.8mg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Salivary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.0±4.6ng/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8±1.2ng/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.2±1.2fL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.0±0.5fL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.9±1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.6±7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.4±32.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.350 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2405948.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Serum CRP, salivary CRP, NLR, PLR, and MPV values." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "CRP, C-reactive protein; MPV, mean platelet volume; NLR, neutrophil–lymphocyte ratio; PLR, platelet lymphocyte ratio." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Salivary CRP</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pearson's correlation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serum CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.45<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.408<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.489 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2405951.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Correlation between salivary CRP and serum CRP, MPV, NLR, and PLR in the septic group." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "ROC, receiver operating characteristic; CRP, C-reactive protein; MPV, mean platelet volume; NLR, neutrophil–lymphocyte ratio; PLR, platelet lymphocyte ratio; SE, standard error." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Parameter \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Area under curve \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">SE \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% confidence interval</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Cut-off value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Sensitivity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Specificity \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower bound \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper bound \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serum CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.837 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.035 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.868 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10mg/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Salivary CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.886 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.043 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.801 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.970 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.48ng/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.873 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.046 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.783 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.952 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.2fL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.791 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.057 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.680 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.903 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.460 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.070 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.569 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.323 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.597 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2405949.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "ROC curves results for serum CRP, salivary CRP, MPV, NLR, and PLR." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neonatal sepsis: a difficult diagnostic challenge" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. 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Proteína C reativa salivar, volume médio de plaquetas e proporção de neutrófilos/linfócitos como marcadores de diagnóstico de sepse neonatal

Ahmed Omrana,

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agomran1@yahoo.com

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, Abdallah Maaroofa, Mai H.S. Mohammadb, Amina Abdelwahaba

a Suez Canal University, Faculty of Medicine, Departments of Pediatrics & Neonatology, Ismailia, Egypt

b Suez Canal University, Faculty of Medicine, Department of Clinical Pathology, Ismailia, Egypt

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        "titulo" => "Prote&#237;na C reativa salivar&#44; volume m&#233;dio de plaquetas e propor&#231;&#227;o de neutr&#243;filos&#47;linf&#243;citos como marcadores de diagn&#243;stico de sepse neonatal"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sepsis is a serious life-threatening condition and a leading cause of morbidity and mortality in full and pre-term infants&#44; especially in the developing countries&#46; It is broadly defined as a systemic inflammatory response occurring in the first 28 days of life as a result of a suspected or proven infection&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There is an urgent call for detecting reliable biomarkers to differentiate between infected and non-infected neonates&#46; Blood culture has been considered as the gold standard for diagnosis&#44; but this analysis is still slow and limited by false negative results&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">C-reactive protein &#40;CRP&#41;&#44; a major acute phase protein&#44; is a member of the pentraxin family and plays a central role in innate and adaptive immunity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Despite the development of new biomarkers&#44; to date CRP is one of the most studied and most used laboratory tests for diagnosis of neonatal sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> CRP takes 10&#8211;12<span class="elsevierStyleHsp" style=""></span>h to significantly rise after the onset of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> As CRP shows an increase in several conditions&#44; it is preferably used in combination with other biomarkers&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A relevant problem in the current clinical approach for sick neonates is the limited availability of simple&#44; safe&#44; noninvasive diagnostic tools with high diagnostic accuracy&#46; Neonatal saliva overcomes many of the hurdles associated with neonatal research and offers investigators a new&#44; exciting&#44; and non-invasive sample source for exploring neonatal biology&#46; CRP is detectable in neonatal saliva and can predict abnormal serum CRP thresholds&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Recently&#44; certain parameters of complete blood count &#40;CBC&#41; were used as markers of inflammation and infections&#46; Mean platelet volume &#40;MPV&#41; has been used in diagnosis&#44; follow-up&#44; and prediction of neonatal sepsis severity in term and preterm neonates&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;8</span></a> The neutrophil&#8211;lymphocyte ratio &#40;NLR&#41; is a simple biomarker of inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> In addition&#44; platelet lymphocyte ratio &#40;PLR&#41; is also a useful marker of systemic inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The present study aimed to assess the applicability of salivary CRP&#44; MPV&#44; NLR&#44; and PLR as diagnostic markers in full-term neonates with neonatal sepsis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The present study was conducted at the neonatal intensive care unit &#40;NICU&#41; of the Suez Canal University Hospital&#44; Ismailia&#44; Egypt between January 2016 and June 2016&#46; During these six months&#44; 320 neonates were admitted to the unit&#46; Thirty-five neonates with either early or late onset neonatal sepsis and 35 healthy control neonates were enrolled&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Full term infants of both genders from birth to the 28th day of life who were admitted to the Suez Canal University NICU with clinical features of either early- or late-onset neonatal sepsis were enrolled in this study&#46; The diagnosis of clinical sepsis was made by history&#44; clinical findings&#44; laboratory findings&#44; and blood culture&#46; The clinical findings included the presence of three or more of the following&#58; &#40;1&#41; temperature instability &#40;hypothermia&#44; hyperthermia&#41;&#59; &#40;2&#41; respiratory alterations &#40;grunting&#44; intercostal retractions&#44; apnea&#44; tachypnea&#44; cyanosis&#41;&#59; &#40;3&#41; cardiovascular alterations &#40;bradycardia&#44; tachycardia&#44; poor perfusion&#44; hypotension&#41;&#59; &#40;4&#41; neurologic alterations &#40;hypotonia&#44; lethargy&#44; seizures&#41;&#59; and &#40;5&#41; gastrointestinal alterations &#40;feeding intolerance&#44; abdominal distension&#41;&#46; CRP values &#62;10<span class="elsevierStyleHsp" style=""></span>mg&#47;L were considered to be positive&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Preterm neonates and neonates with confirmed pneumonia or other inflammatory conditions&#44; CNS malformations&#44; metabolic disorders&#44; chromosomal abnormalities&#44; intrauterine growth restriction&#44; or birth asphyxia were excluded from the study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Thirty-five healthy neonates with no symptoms&#44; signs&#44; or risk factors for infections who had been hospitalized for physiological jaundice in the neonatal unit&#44; and all neonates without infectious risk factors admitted to outpatient clinics of the hospital were prospectively enrolled as controls&#46; Serum CRP level for neonates in this group was negative &#40;CRP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Samples were collected from septic neonates within 4&#8211;12<span class="elsevierStyleHsp" style=""></span>h of clinically indicated serum CRP levels measurement and before starting antibiotic treatment&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">For CBC measurement&#44; peripheral blood was collected into an EDTA Vacutainer tube and analyzed by an automated blood cell counter &#40;Cell-Dyn 3700&#44; Abbott Laboratories&#44; IL&#44; USA&#41;&#46; The NLR and PLR were calculated as the ratio of neutrophils to lymphocytes and platelets to lymphocytes respectively&#46; Their levels were obtained from the same blood samples&#46; For accurate MPV calculation&#44; samples were analyzed within 60<span class="elsevierStyleHsp" style=""></span>minutes after collection to avoid platelet swelling and false increase of MPV value&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">For determination of serum CRP level&#44; the fully automated auto-analyzer Cobas c501 &#40;Roche Diagnostics&#44; Manheim&#44; Germany&#41; was used&#46; For salivary CRP&#44; samples were collected nearly 1<span class="elsevierStyleHsp" style=""></span>h before feeding to avoid milk contamination&#46; Saliva was collected by tilting the head forward to pool saliva in the floor of the mouth&#46; Samples were then obtained by using a 1-mL syringe attached to low wall suction &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>mm Hg&#41;&#44; ensuring that the saliva remained in the syringe and did not enter into the tubing or suction trap&#46; Saliva was suctioned from under the neonates&#8217; tongues and in their gingival crevices&#46; Suctioning was maintained for approximately 10&#8211;15<span class="elsevierStyleHsp" style=""></span>s&#44; collecting around 0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#46; The syringe was then detached from suction and the plunger was placed back into the syringe&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">After collection&#44; samples were put in polypropylene tubes to avoid contamination and analytic retention faults&#46; Samples were stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C until use&#46; Salivary CRP was measured by ELISA&#46; Blood cultures were performed for the septic group&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">This study was approved by the local institutional ethics committee and an informed consent was obtained from the parents of all the neonates throughout the study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analyses</span><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analyses were performed using SPSS for Windows statistical package&#44; version 20 &#40;SPSS&#44; Chicago&#44; IL&#44; USA&#41;&#46; The differences between groups regarding non-parametric quantitative data were assessed by Mann&#8211;Whitney&#39;s <span class="elsevierStyleItalic">U</span>-test&#46; The chi-squared test was used for testing significant differences of qualitative variables&#46; The sensitivity&#44; specificity&#44; and optimal salivary CRP cut-point were determined using the receiver operating characteristic &#40;ROC&#41; curve&#46; For all statistical analysis&#44; the level of statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Demographic and prenatal data</span><p id="par0085" class="elsevierStylePara elsevierViewall">Statistical differences were observed between the two groups regarding age&#44; history of maternal urinary tract infection &#40;UTI&#41;&#44; and mode of delivery&#46; Late-onset sepsis &#40;LOS&#41; was diagnosed in 74&#46;3&#37; of the septic neonates&#44; while early onset sepsis &#40;EOS&#41; was diagnosed in only 25&#46;7&#37; of them &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical presentation&#44; CBC&#44; and blood culture results in septic group</span><p id="par0090" class="elsevierStylePara elsevierViewall">At time of presentation of septic neonates&#44; 19 &#40;54&#46;3&#37;&#41; of them presented with poor activity and refusal of feeding&#44; while nine &#40;25&#46;7&#37;&#41; presented with fever and poor activity&#44; and seven &#40;20&#37;&#41; presented with refusal of feeding in addition to respiratory distress&#46; There were significant differences between the two groups in CBC indices&#46; Anemia was observed in 12 &#40;34&#46;3&#37;&#41; septic neonates and in four &#40;11&#46;4&#37;&#41; controls&#46; A difference was observed in white blood cell count between septic and control infants&#59; leucocytosis was observed in 11 &#40;31&#46;4&#37;&#41; septic neonates and in one &#40;2&#46;9&#37;&#41; control&#46; Thrombocytopenia was found in nine &#40;25&#46;7&#37;&#41; septic neonates and in one &#40;2&#46;9&#37;&#41; control&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the septic group&#44; blood culture was positive in 25 &#40;71&#46;5&#37;&#41;&#46; Coagulase-negative staphylococci were the most frequent isolated pathogens&#44; followed by <span class="elsevierStyleItalic">E&#46; coli</span>&#44; <span class="elsevierStyleItalic">Klebsiella pneumonia</span>&#44; and <span class="elsevierStyleItalic">Serratia marcescens&#46;</span></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Serum CRP&#44; salivary CRP&#44; MPV&#44; NLR&#44; and PLR values</span><p id="par0100" class="elsevierStylePara elsevierViewall">There were significant differences between both groups in serum CRP&#44; salivary CRP&#44; MPV&#44; and NLR&#46; Serum CRP values showed significant differences between both groups &#40;mean 27&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;L <span class="elsevierStyleItalic">vs</span>&#46; 4&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; respectively&#41;&#46; The mean serum CRP for neonates with EOS was 23&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;3&#44; while its mean in neonates with LOS was 29&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46; Salivary CRP also showed a significant difference between both groups &#40;mean 12&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6<span class="elsevierStyleHsp" style=""></span>ng&#47;L <span class="elsevierStyleItalic">vs</span>&#46;2&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#44; respectively&#41;&#46; MPV showed a significant difference between both groups &#40;mean 10&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>fL <span class="elsevierStyleItalic">vs</span>&#46;8&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>fL&#44; respectively&#41;&#46; NLR also showed a significant difference between both groups &#40;mean 2&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&#44; <span class="elsevierStyleItalic">vs</span>&#46;1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; respectively&#41;&#46; The difference in PLR between both groups was not significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Correlation between salivary CRP and each of serum CRP&#44; MPV&#44; NLR&#44; and PLR</span><p id="par0105" class="elsevierStylePara elsevierViewall">There were statistically significant correlations between salivary CRP and serum CRP &#40;0&#46;66&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; MPV &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;45&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and NLR &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;408&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The correlation between salivary CRP and PLR was not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparison of ROC curves of serum CRP&#44; salivary CRP&#44; MPV&#44; NLR&#44; and PLR as markers of neonatal sepsis</span><p id="par0110" class="elsevierStylePara elsevierViewall">The analysis of the ROC curves showed that serum CRP&#44; at a cut-off value of 10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; had sensitivity of 83&#46;1&#37; and specificity of 85&#46;9&#37;&#46; Salivary CRP&#44; at a cut-off value of 3&#46;48<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#44; had sensitivity of 94&#46;3&#37; and specificity of 80&#37;&#46; MPV showed 80&#37; sensitivity and 80&#37; specificity at a cut-off value of 10&#46;2<span class="elsevierStyleHsp" style=""></span>fL&#46; NLR&#44; at a cut-off value of 2&#46;7&#44; had sensitivity of 80&#37; and specificity of 57&#46;1&#37;&#46; PLR showed low sensitivity and specificity in predicting neonatal sepsis &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Salivary CRP at a cut-off value of 3&#46;4<span class="elsevierStyleHsp" style=""></span>ng&#47;L showed sensitivity of 94&#37; and specificity of 91&#46;3&#37; in predicting serum CRP &#8805;10<span class="elsevierStyleHsp" style=""></span>mg&#47;L in septic neonates&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Neonatal sepsis is a major cause of morbidity and mortality in neonatal intensive care units&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; it has long-term morbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a> In turn&#44; simple practices&#44; such as the use of hand sanitizer and training in hand hygiene could reduce LOS&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Worldwide&#44; infections account for two-thirds of the 6 million annual deaths in children younger than 5 years&#46; The neonatal period has the highest lifetime risk of serious infections&#44; with an estimated 400&#44;000 newborn deaths annually&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In Egypt&#44; rates of sepsis exceed 50&#37; in neonatal intensive care units&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Recently&#44; analysis of saliva for clinical monitoring and biomarker detection in neonates holds great promise for improving the healthcare of this fragile population&#46; Saliva represents an ideal and easily accessible bio-fluid for non-invasive screening of common neonatal morbidities&#44; such as prematurity&#44; infections&#44; and brain insults&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#8211;20</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">To date&#44; CRP is the most extensively studied acute-phase reactant&#59; despite the detection of new markers of infection&#44; its wide availability and its fast&#44; simple&#44; and cost-effective determination makes it one of the preferred indices in many NICUs&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The literature&#44; serum CRP showed different kinetics and cut-off values ranging from 1&#46;5 to 20<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; with wide-ranging sensitivities and specificities &#40;from 74&#37; to 98&#37; and from 71&#37; to 94&#37;&#44; respectively&#41; for either serial CRP determinations or a single measurement at least 12<span class="elsevierStyleHsp" style=""></span>h after the onset of neonatal sepsis symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;11&#44;21&#8211;23</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">These differences in cut-off values can be explained by different gestational ages&#44; birth weights&#44; and the physiologic kinetics of CRP after birth in the studied neonates&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> There is a debate about the cut-off point for CRP in cases of EOS and LOS&#44; with some agreement about the use of 10<span class="elsevierStyleHsp" style=""></span>mg&#47;L as a reliable cut-off&#44; especially in EOS&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;11</span></a> In the present study&#44; the mean serum CRP was 27&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;L in septic neonates&#44; with 83&#46;1&#37; sensitivity and 85&#46;9&#37; specificity at a cut off-value of 10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Serial measurements of CRP level may also be useful for identification of neonates with bacterial infection&#44; monitoring the response to treatment in infected neonates and determining the duration of antibiotic therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21&#44;24</span></a> Nonetheless&#44; serial CRP monitoring in the neonatal population puts these patients in medical risks from frequent sampling&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Salivary CRP detection is a new method for diagnosis in neonatal population&#46; In 2014&#44; Iyengar et al&#46; published the first article about detection and utility of salivary CRP in neonates&#44; which was considered the first study to detect&#44; quantify&#44; and demonstrate that salivary CRP is a good index for clinically relevant serum CRP thresholds&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">To the best of the authors&#8217; knowledge&#44; this was the first study to investigate the role of salivary CRP as non-invasive diagnostic marker in septic neonates&#46; The difference in mean salivary CRP between septic neonates and controls was statistically significant&#44; with mean of 12&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6<span class="elsevierStyleHsp" style=""></span>ng&#47;L in septic neonates <span class="elsevierStyleItalic">versus</span> 2&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;L in controls&#46; At a cut-off point of 3&#46;48<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#44; salivary CRP showed high sensitivity &#40;94&#46;3&#37;&#41; and specificity &#40;80&#46;0&#37;&#41;&#46; In the present study&#44; salivary CRP showed good accuracy in predicting high serum CRP levels&#46; It was observed that salivary CRP&#44; at a cut-off point of 3&#46;4<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#44; had a corresponding sensitivity &#40;94&#37;&#41; and specificity &#40;91&#46;3&#37;&#41; in accurately predicting a serum CRP level of &#8805;10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Iyengar et al&#46; showed that raw salivary CRP concentration of 4&#46;84<span class="elsevierStyleHsp" style=""></span>ng&#47;L had a sensitivity and specificity of 64&#37; and 94&#37;&#44; respectively&#44; for accurately predicting a serum CRP level of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; and a sensitivity and specificity of 54&#37; and 95&#37;&#44; respectively&#44; for accurately predicting a serum CRP of 10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> This discrepancy could return to the nature of disease under investigation&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">CBC is a simple and routine workup to determine infection in neonates&#46; Low white blood cell count&#44; absolute neutrophil count&#44; and high immature-to-total neutrophil ratio were the most commonly used indices for detection of infection in neonates&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Recently&#44; other CBC indices&#44; such as MPV&#44; NLR&#44; and PLR&#44; have been used as markers of systemic inflammation in children and adults&#46; In neonates&#44; very limited data are available about the usage of NLR and PLR for diagnosis of neonatal infection or other inflammatory conditions&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In the present study&#44; MPV values showed a significant difference between septic neonates and controls&#44; with a mean of 9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>fL and 8&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>fL&#44; respectively&#44; and showed a significant correlation with serum and salivary CRP&#46; Oncel et al&#46; also reported a higher mean MPV in septic neonates when compared with controls&#40;8&#46;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>fL and 8&#46;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>fL&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">MPV was able to predict diseased neonates and demonstrated diagnostic accuracy with 80&#37; sensitivity and specificity at a cut-off point of 10&#46;2<span class="elsevierStyleHsp" style=""></span>fL&#46; Ayd&#305;n et al&#46; reported that the diagnostic cut-off value for MPV in neonates with sepsis&#44; 10&#46;4<span class="elsevierStyleHsp" style=""></span>fL&#44; presented sensitivity of 54&#37; and specificity of 82&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> Recently&#44; Yao et al&#46; found that optimal cut-off point of MPV for the diagnosis of sepsis was 11&#46;4<span class="elsevierStyleHsp" style=""></span>fL&#44; with sensitivity of 40&#46;5&#37; and specificity of 88&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">NLR&#44; which was recently considered as a new indicative marker of systemic inflammation&#44; is simple and easy to calculate using routine laboratory data without an additional technique or cost&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">To the best of the authors&#8217; knowledge&#44; this study was the first report of a statistically significant difference in mean NLR between septic neonates and controls &#40;2&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7 <span class="elsevierStyleItalic">vs&#46;</span> 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; respectively&#41; that also showed a good statistical significance in predicting and differentiating between septic neonates and controls with 80&#37; sensitivity and 57&#46;1&#37; specificity at a cut-off point of 2&#46;7&#46; With regard to infections&#44; NLR has been reported as a predictor of the severity and clinical outcome in patients with community- acquired pneumonia<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> and bacteremia&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> being able to differentiate between bacterial and viral meningitis&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">PLR is a blood ratio that is largely used in chronic diseases and malignancies in adults&#46; In the present study&#44; PLR showed no significant accuracy in predicting septic neonates with low sensitivity &#40;50&#37;&#41; and specificity &#40;46&#46;7&#37;&#41; at a cut-off point of 73&#46;1&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The main limitations of the present study are the relatively small number of septic neonates&#44; the small percentage of neonates with EOS&#44; and the use of the same cut-off value for serum CRP in neonates with EOS and LOS&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In conclusion&#44; this study provides initial evidence for the usefulness of salivary CPR&#44; MPV&#44; and NLR to be combined with other markers in the diagnosis of neonatal sepsis&#46; However&#44; these findings still need to be confirmed by other future studies aiming to examine larger numbers of neonates and different categories of infections using rigorous methods&#44; in order to fully establish the role of salivary CRP and other tested markers in diagnosis of neonatal sepsis&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Comparison of ROC curves of serum CRP&#44; salivary CRP&#44; MPV&#44; NLR&#44; and PLR as markers of neonatal sepsis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the applicability of salivary C-reactive protein&#44; mean platelet volume&#44; neutrophil-lymphocyte ratio&#44; and platelet lymphocyte ratio in the diagnosis of neonatal sepsis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective case-control study of 70 full-term neonates&#44; 35 with sepsis &#40;20 with proven sepsis and 15 with clinical sepsis&#41; and 35 healthy controls&#46; Serum and salivary C-reactive protein concentrations were measured by enzyme-linked immunosorbent assay while mean platelet volume&#44; neutrophil-lymphocyte ratio&#44; and platelet lymphocyte ratio were measured by automated blood cell counter&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This study showed statistically signi&#64257;cant difference of mean salivary C-reactive protein between septic neonates and controls &#40;12&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6<span class="elsevierStyleHsp" style=""></span>ng&#47;L vs&#46; 2&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#41; respectively&#46; At a cut-off point of 3&#46;48<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#44; salivary C-reactive protein showed 94&#46;3&#37; sensitivity and 80&#37; speci&#64257;city&#46; Salivary C-reactive protein also showed good predictive accuracy for predicting elevated serum C-reactive protein values in septic neonates&#46; Mean platelet volume and neutrophil-lymphocyte ratio showed signi&#64257;cant difference between septic neonates and controls &#40;10&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>fL vs&#46;8&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>fL&#59; 2&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7 vs&#46; 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#44; respectively&#41;&#46; At a cut-off point of 10&#46;2<span class="elsevierStyleHsp" style=""></span>fL&#44; mean platelet volume presented 80&#37; sensitivity and speci&#64257;city&#46; At a cut-off point of 2&#46;7&#44; neutrophil-lymphocyte ratio presented 80&#37; sensitivity and 57&#46;1&#37; speci&#64257;city&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study provides support for further studies on the usefulness of salivary C-reactive protein&#44; mean platelet volume&#44; and neutrophil-lymphocyte ratio as diagnostic markers for neonatal sepsis&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a aplicabilidade da prote&#237;na C reativa &#40;PCR&#41; salivar&#44; do volume m&#233;dio de plaquetas &#40;VMP&#41;&#44; a propor&#231;&#227;o de neutr&#243;filos-linf&#243;citos &#40;PNL&#41; e a propor&#231;&#227;o de plaquetas&#47;linf&#243;citos &#40;PPL&#41; no diagn&#243;stico de sepse neonatal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo caso-controle prospectivo de 70 neonatos a termo&#44; 35 com sepse &#40;20 com sepse comprovada e 15 com sepse cl&#237;nica&#41; e 35 controles saud&#225;veis&#46; As concentra&#231;&#245;es de PCR no soro e salivar foram medidas por ensaio imunossorvente ligado a enzima &#40;ELISA&#41;&#44; ao passo que o VMP&#44; PNL e PPL foram medidos por contador de c&#233;lulas sangu&#237;neas automatizado&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Este estudo mostrou uma diferen&#231;a estatisticamente significativa da m&#233;dia de PCR salivar entre os neonatos com sepse e os controles &#40;12&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;6<span class="elsevierStyleHsp" style=""></span>ng&#47;L em compara&#231;&#227;o a 2&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#41;&#44; respectivamente&#46; Um ponto de corte 3&#44;48<span class="elsevierStyleHsp" style=""></span>ng&#47;L na PCR salivar mostrou sensibilidade de 94&#44;3&#37; e especificidade de 80&#37;&#46; A PCR salivar mostrou&#44; ainda&#44; boa precis&#227;o preditiva para prever altos valores de PCR no soro em neonatos com sepse&#46; O VMP e a PNL mostraram diferen&#231;a significativa entre os neonatos com sepse e os controles &#40;10&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>fL em compara&#231;&#227;o a 8&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>fL&#41;&#44; &#40;2&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;7 em compara&#231;&#227;o a 1&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;4&#41;&#44; respectivamente&#46; O VMP no ponto de corte 10&#44;2<span class="elsevierStyleHsp" style=""></span>fL apresentou 80&#37; de sensibilidade e especificidade&#46; A PNL no ponto de corte 2&#44;7<span class="elsevierStyleHsp" style=""></span>fL apresentou 80&#37; de sensibilidade e 57&#44;1&#37; de especificidade&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Este estudo fornece uma base para outros estudos na utilidade da PCR salivar&#44; VMP e PNL como marcadores de diagn&#243;stico de sepse neonatal&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Omran A&#44; Maaroof A&#44; Mohammad MH&#44; Abdelwahab A&#46; Salivary C-reactive protein&#44; mean platelet volume and neutrophil lymphocyte ratio as diagnostic markers for neonatal sepsis&#46; J Pediatr &#40;Rio J&#41;&#46; 2018&#59;94&#58;82&#8211;7&#46;</p>"
      ]
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PROM&#44; premature rupture of membrane&#59; UTI&#44; urinary tract infection&#59; CS&#44; cesarean section&#59; NVD&#44; normal vaginal delivery&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Area under curve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">SE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Cut-off value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Sensitivity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Specificity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower bound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper bound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serum CRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;868&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10<span class="elsevierStyleHsp" style=""></span>mg&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Salivary CRP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">46&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  """
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                            0 => "F&#46; Raimondi"
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Article information

ISSN: 00217557
Original language: English

DOI:10.1016/j.jped.2017.03.006

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Year/Month	Html	Pdf	Total

2024 November	5	2	7
2024 October	62	32	94
2024 September	71	34	105
2024 August	88	52	140
2024 July	38	35	73
2024 June	26	24	50
2024 May	26	16	42
2024 April	24	28	52
2024 March	25	21	46
2024 February	22	17	39
2024 January	23	23	46
2023 December	13	24	37
2023 November	28	29	57
2023 October	35	40	75
2023 September	30	31	61
2023 August	19	14	33
2023 July	22	8	30
2023 June	16	5	21
2023 May	26	16	42
2023 April	15	5	20
2023 March	39	15	54
2023 February	21	12	33
2023 January	15	13	28
2022 December	46	38	84
2022 November	26	31	57
2022 October	32	37	69
2022 September	23	50	73
2022 August	24	36	60
2022 July	29	35	64
2022 June	21	28	49
2022 May	38	29	67
2022 April	44	39	83
2022 March	32	42	74
2022 February	18	38	56
2022 January	36	28	64
2021 December	19	18	37
2021 November	12	15	27
2021 October	14	28	42
2021 September	15	10	25
2021 August	10	6	16
2021 July	10	7	17
2021 June	11	4	15
2021 May	31	12	43
2021 April	34	7	41
2021 March	31	18	49
2021 February	17	6	23
2021 January	10	12	22
2020 December	28	11	39
2020 November	16	11	27
2020 October	10	9	19
2020 September	24	22	46
2020 August	11	1	12
2020 July	12	3	15
2020 June	15	9	24
2020 May	20	7	27
2020 April	9	11	20
2020 March	9	4	13
2020 February	20	13	33
2020 January	15	12	27
2019 December	8	5	13
2019 November	15	5	20
2019 October	14	10	24
2019 September	21	14	35
2019 August	15	5	20
2019 July	39	13	52
2019 June	32	16	48
2019 May	28	16	44
2019 April	25	12	37
2019 March	22	10	32
2019 February	8	5	13
2019 January	3	7	10
2018 December	11	5	16
2018 November	20	8	28
2018 October	84	13	97
2018 September	25	12	37
2018 August	8	8	16
2018 July	9	7	16
2018 June	13	8	21
2018 May	47	13	60
2018 April	13	3	16
2018 March	49	16	65
2018 February	36	18	54
2018 January	23	15	38
2017 December	1	4	5
2017 November	1	0	1
2017 October	3	7	10
2017 September	0	4	4
2017 August	0	8	8

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