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Increasing of its density on surface is directly related to the intensity of stimulation received by inflammatory cytokines&#46; It could be quantified by flow cytometry as mean fluorescence intensity &#40;MFI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The main objective of this preliminary study was to describe the CD64 expression in pediatric patients after appendectomy and pediatric critical care unit &#40;PICU&#41; admission&#46; For this purpose&#44; the percentage of CD64-positive cells and the degree of expression &#40;MFI&#41; of CD-64 on monocytes &#40;mCD64&#41; and granulocytes &#40;gCD64&#41; were determined&#46; Afterwards&#44; it was analyzed its association with common biomarkers&#44; the therapeutic care&#44; the hospitalization time and complications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study was prospectively conducted from November 2016 to January 2017&#46; Peripheral blood samples were extracted after parents or legal guardians consent at PICU admission&#46; The PICU admission was done by surgeon criteria and not protocoled&#46; Samples were collected at first 24<span class="elsevierStyleHsp" style=""></span>h after surgery in sterile EDTA at room temperature or refrigerated at 4<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; used for CD45&#43; cells marking and analyzed by flow cytometry in a time period shorter than 24<span class="elsevierStyleHsp" style=""></span>h&#46; Fifteen patients &#40;6 female and 9 male&#41; were recruited with a median age 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;2 years&#46; Median PICU stay was 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4 days with a median hospitalization of 5&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4 days&#46; The CD64 expression on neutrophils and monocytes were mCD64 median MFI of 16&#44;366<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6762 and gCD64 median MFI of 2071<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2791&#46;8 with a percentage of CD64&#43; 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and mCD64&#47;gCD64 ratio &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Also the hospitalization time showed correlation with mCD64&#47;gCD64 ratio &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; The use of nasogastric tube&#44; as an expression of bowel movement&#44; was correlated with gCD64 &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and &#37; gCD64&#43; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Finally&#44; Granulocytes of patients with parenteral nutrition necessity &#40;PNT&#41; showed greater positivity for CD64 &#40;&#37; gCD64&#43; &#8211; TPN 90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 vs not TPN 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;045&#41;&#46; Among the classical parameters&#44; none of them showed correlation or statistically significant association with the clinical data except for the C-reactive protein &#40;CRP&#41;&#46; At PICU admission leukocytes&#44; C reactive protein and procalcitonin were obtained and there was observed a positive correlation with no signification with CD64 expression&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This pilot work describes&#44; for the first time&#44; the CD64 expression on peripheral blood monocytes and granulocytes from pediatric patients after appendectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Also&#44; this is the first study that tries to correlate clinical and evolution data from acute appendicitis pediatric patients with CD64 values obtained by FC&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As said the FC interpretation may provide unique information letting know immunological changes in real-time&#46; These properties would help to substantiate diagnostic suspicion&#44; anticipate the evolution and modify therapeutic attitudes&#46; In this study&#44; CD64 expression in terms on granulocyte of MFI is lower&#44; as our group has previously seen&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> than in other inflammatory and infectious contexts&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> These results could have two explanation&#46; On the one hand&#44; the AA is&#44; with exceptions&#44; a localized infection in which the systemic expression through CD64 quantification on granulocytes and monocytes in peripheral blood&#44; may be underestimated&#46; In this process&#44; participating granulocytes would not be predominant in the bloodstream&#46; At the same time&#44; in this study&#44; determination by FC was performed after surgery&#44; so after having removed the inflammatory insult and having received&#44; at least&#44; one dose of antibiotic therapy&#46; It is well known that CD64 reduces its expression once received appropriate antibiotic therapy&#46; In the same way&#44; it is known that the half-life of a human granulocyte in peripheral blood is 6<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Thus&#44; in our experiment&#44; leukocyte populations studied might not be under the same inflammatory context than those present at the onset of AA underestimating the value of MFI&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In order to minimize the potential effect of this confusion factor&#44; CD64 expression ratio &#40;mCD64&#47;gCD64&#41; was studied knowing that the presence of CD64 on granulocytes should be null in case of no inflammation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Changes in this ratio could be used to quantify upregulation of this molecule in granulocytes&#46; Our study showed that mCD64&#47;gCD64 ratio inversely correlated with total hospital stay&#46; Also&#44; and with the same objective&#44; CD64&#43; granulocytes percentage was quantified&#46; Since baseline percentage of positive CD64 granulocytes must be zero&#44; any higher value would indicate activation&#46; In the studied population CD64 positivity existed in all cases&#44; being always superior to 45&#37; in granulocytes&#46; As said&#44; the percentage of CD64&#43; granulocytes was higher in patients with prolonged PICU stay&#44; days of hospital admission and need of PNT&#46; This correlation with the need of PNT&#44; is of great interest due to its novelty&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">This study presents limitations&#46; It was done in a single center&#44; with a small number of patients and without strictly defined PICU admission criteria&#46; At the same time&#44; it cannot be assumed that CD64 is the only responsible for the clinical course in the case of AA patients&#46; Their values should be compared with traditional biomarkers in larger samples&#46; This aspect could also be attenuated with the inclusion of other cell surface markers in further analysis&#46; Finally&#44; just a single blood sample was obtained after the surgery&#46; These values should be compared to previous surgery data and&#47;or later samples&#46; The study about CD64 dynamic variation should be included in future studies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As conclusion&#44; in our preliminary work&#44; the expression of CD64 on granulocytes at PICU admission correlated with the hospitalization time and need of nasogastric tube and non-enteral nutrition&#46; Based on these findings&#44; it seems of interest to continue the study of CD64 in order to provide dynamic and reliable information about the actual utility of the flow cytometry in these patients&#46;</p></span>"
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Scientific letter
CD64 expression on monocytes and granulocytes in pediatric acute appendicitis scenario: A pilot study in pediatric critical care
Expresión de CD64 en monocitos y granulocitos en apendicitis aguda: estudio piloto en cuidados intensivos pediátricos
A. García-Salidoa,
Autor para correspondencia
citopensis@yahoo.es

Corresponding author.
, M. De Lucio-Rodríguezb, J.L. Alonso Calderónb, G. De Lama Caro-Patóna, M. Ramírez-Orellanac,d, A. Serrano-Gonzáleza
a Pediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
b Pediatric Surgery Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
c Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
d Instituto de Investigaciones Sanitarias La Princesa, Madrid, Spain
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    "titulo" => "CD64 expression on monocytes and granulocytes in pediatric acute appendicitis scenario&#58; A pilot study in pediatric critical care"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spearman correlation between CD64 expression and days of PICU stay&#46; &#37;gCD64 is the percentage of CD64-positive cells&#44; gCD64 is the CD64 degree of expression in granulocytes by mean fluorescence intensity and mCD64 is the CD64 degree of expression in monocytes by mean fluorescence intensity&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute appendicitis &#40;AA&#41; is one of the most common childhood surgical entities&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Anamnesis&#44; physical examination&#44; blood tests and imaging provide an accurate diagnosis in 98&#37; of patients&#46; However&#44; there is a lack of reliable instruments to predict evolution and anticipate complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a> To this aim&#44; recent studies using flow cytometry &#40;FC&#41; have been done to evaluate expression profile in patients with acute abdomen&#46; The FC is a laboratory technique that allows to evaluate immune status or response of an individual based on marking leukocyte populations with monoclonal antibodies&#46; One of the biomarkers that have demonstrated clinical applicability is CD64&#46; Increasing of its density on surface is directly related to the intensity of stimulation received by inflammatory cytokines&#46; It could be quantified by flow cytometry as mean fluorescence intensity &#40;MFI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The main objective of this preliminary study was to describe the CD64 expression in pediatric patients after appendectomy and pediatric critical care unit &#40;PICU&#41; admission&#46; For this purpose&#44; the percentage of CD64-positive cells and the degree of expression &#40;MFI&#41; of CD-64 on monocytes &#40;mCD64&#41; and granulocytes &#40;gCD64&#41; were determined&#46; Afterwards&#44; it was analyzed its association with common biomarkers&#44; the therapeutic care&#44; the hospitalization time and complications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study was prospectively conducted from November 2016 to January 2017&#46; Peripheral blood samples were extracted after parents or legal guardians consent at PICU admission&#46; The PICU admission was done by surgeon criteria and not protocoled&#46; Samples were collected at first 24<span class="elsevierStyleHsp" style=""></span>h after surgery in sterile EDTA at room temperature or refrigerated at 4<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; used for CD45&#43; cells marking and analyzed by flow cytometry in a time period shorter than 24<span class="elsevierStyleHsp" style=""></span>h&#46; Fifteen patients &#40;6 female and 9 male&#41; were recruited with a median age 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;2 years&#46; Median PICU stay was 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4 days with a median hospitalization of 5&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;4 days&#46; The CD64 expression on neutrophils and monocytes were mCD64 median MFI of 16&#44;366<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6762 and gCD64 median MFI of 2071<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2791&#46;8 with a percentage of CD64&#43; granulocytes &#40;&#37;gCD64&#43;&#41; 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;4&#37; and a mCD64&#47;gCD64 ratio of 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&#46; Non-parametric test were applied&#46; Time of stay in the PICU correlated with gCD64 &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#44; &#37; gCD64&#43; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; and mCD64&#47;gCD64 ratio &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Also the hospitalization time showed correlation with mCD64&#47;gCD64 ratio &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; The use of nasogastric tube&#44; as an expression of bowel movement&#44; was correlated with gCD64 &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and &#37; gCD64&#43; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Finally&#44; Granulocytes of patients with parenteral nutrition necessity &#40;PNT&#41; showed greater positivity for CD64 &#40;&#37; gCD64&#43; &#8211; TPN 90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 vs not TPN 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;045&#41;&#46; Among the classical parameters&#44; none of them showed correlation or statistically significant association with the clinical data except for the C-reactive protein &#40;CRP&#41;&#46; At PICU admission leukocytes&#44; C reactive protein and procalcitonin were obtained and there was observed a positive correlation with no signification with CD64 expression&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This pilot work describes&#44; for the first time&#44; the CD64 expression on peripheral blood monocytes and granulocytes from pediatric patients after appendectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Also&#44; this is the first study that tries to correlate clinical and evolution data from acute appendicitis pediatric patients with CD64 values obtained by FC&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As said the FC interpretation may provide unique information letting know immunological changes in real-time&#46; These properties would help to substantiate diagnostic suspicion&#44; anticipate the evolution and modify therapeutic attitudes&#46; In this study&#44; CD64 expression in terms on granulocyte of MFI is lower&#44; as our group has previously seen&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> than in other inflammatory and infectious contexts&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> These results could have two explanation&#46; On the one hand&#44; the AA is&#44; with exceptions&#44; a localized infection in which the systemic expression through CD64 quantification on granulocytes and monocytes in peripheral blood&#44; may be underestimated&#46; In this process&#44; participating granulocytes would not be predominant in the bloodstream&#46; At the same time&#44; in this study&#44; determination by FC was performed after surgery&#44; so after having removed the inflammatory insult and having received&#44; at least&#44; one dose of antibiotic therapy&#46; It is well known that CD64 reduces its expression once received appropriate antibiotic therapy&#46; In the same way&#44; it is known that the half-life of a human granulocyte in peripheral blood is 6<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Thus&#44; in our experiment&#44; leukocyte populations studied might not be under the same inflammatory context than those present at the onset of AA underestimating the value of MFI&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In order to minimize the potential effect of this confusion factor&#44; CD64 expression ratio &#40;mCD64&#47;gCD64&#41; was studied knowing that the presence of CD64 on granulocytes should be null in case of no inflammation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Changes in this ratio could be used to quantify upregulation of this molecule in granulocytes&#46; Our study showed that mCD64&#47;gCD64 ratio inversely correlated with total hospital stay&#46; Also&#44; and with the same objective&#44; CD64&#43; granulocytes percentage was quantified&#46; Since baseline percentage of positive CD64 granulocytes must be zero&#44; any higher value would indicate activation&#46; In the studied population CD64 positivity existed in all cases&#44; being always superior to 45&#37; in granulocytes&#46; As said&#44; the percentage of CD64&#43; granulocytes was higher in patients with prolonged PICU stay&#44; days of hospital admission and need of PNT&#46; This correlation with the need of PNT&#44; is of great interest due to its novelty&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">This study presents limitations&#46; It was done in a single center&#44; with a small number of patients and without strictly defined PICU admission criteria&#46; At the same time&#44; it cannot be assumed that CD64 is the only responsible for the clinical course in the case of AA patients&#46; Their values should be compared with traditional biomarkers in larger samples&#46; This aspect could also be attenuated with the inclusion of other cell surface markers in further analysis&#46; Finally&#44; just a single blood sample was obtained after the surgery&#46; These values should be compared to previous surgery data and&#47;or later samples&#46; The study about CD64 dynamic variation should be included in future studies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As conclusion&#44; in our preliminary work&#44; the expression of CD64 on granulocytes at PICU admission correlated with the hospitalization time and need of nasogastric tube and non-enteral nutrition&#46; Based on these findings&#44; it seems of interest to continue the study of CD64 in order to provide dynamic and reliable information about the actual utility of the flow cytometry in these patients&#46;</p></span>"
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