Diagnostic properties of C-reactive protein for detecting pneumonia in children

SummaryBackgroundThe diagnostic value of C-reactive protein (CRP) level for pneumonia in children is unknown. As a first step in the assessment of the value of CRP, a diagnostic study was performed in children at an emergency department (ED).MethodsIn this cross-sectional study, data were retrospectively collected from children presenting with suspected pneumonia at the ED of Antonius Hospital Nieuwegein in The Netherlands between January 2007 and January 2012. Diagnostic outcome was pneumonia yes/no according to independent radiologist. (Un)adjusted association between CRP level and pneumonia and diagnostic value of CRP were calculated.ResultsOf 687 presenting children, 286 underwent both CRP measurement and chest radiography. 148 had pneumonia (52%). The proportion of pneumonia increased with CRP level. Negative predictive values declined, but positive predictive values increased with higher CRP thresholds. Univariable odds ratio for the association between CRP level and pneumonia was 1.2 (95% CI 1.11–1.21) per 10 mg/L increase. After adjustment for baseline characteristics CRP level remained associated with pneumonia.ConclusionsCRP level has independent diagnostic value for pneumonia in children presenting at the ED with suspected pneumonia, but low levels do not exclude pneumonia in this setting. These results prompt evaluation of CRP in primary care children with LRTI

Medication Complications in Extracorporeal Membrane Oxygenation.

The need for extracorporeal membrane oxygenation (ECMO) therapy is a marker of disease severity for which multiple medications are required. The therapy causes physiologic changes that impact drug pharmacokinetics. These changes can lead to exposure-driven decreases in efficacy or increased incidence of side effects. The pharmacokinetic changes are drug specific and largely undefined for most drugs. We review available drug dosing data and provide guidance for use in the ECMO patient population

Prediabetes Is Associated With Structural Brain Abnormalities:The Maastricht Study

OBJECTIVE Structural brain abnormalities are key risk factors for brain diseases, such as dementia, stroke, and depression, in type 2 diabetes. It is unknown whether structural brain abnormalities already occur in prediabetes. Therefore, we investigated whether both prediabetes and type 2 diabetes are associated with lacunar infarcts (LIs), white matter hyperintensities (WMHs), cerebral microbleeds (CMBs), and brain atrophy. RESEARCH DESIGN and METHODS We used data from 2,228 participants (1,373 with normal glucose metabolism [NGM], 347 with prediabetes, and 508 with type 2 diabetes (oversampled); mean age 59.2 6 8.2 years; 48.3% women) of the Maastricht Study, a population-based cohort study. Diabetes status was determined with an oral glucose tolerance test. Brain imaging was performed with 3 Tesla MRI. Results were analyzed with multivariable logistic and linear regression analyses. RESULTS Prediabetes and type 2 diabetes were associated with the presence of LIs (odds ratio 1.61 [95% CI 0.98-2.63] and 1.67 [1.04-2.68], respectively; P trend = 0.027), larger WMH (b 0.07 log10-transformed mL [log-mL] [95% CI 0.00-0.15] and 0.21 log-mL [0.14-0.28], respectively; P trend <0.001), and smaller white matter volumes (b 24.0 mL [27.3 to 20.6] and 27.2 mL [210.4 to 24.0], respectively; P trend <0.001) compared with NGM. Prediabetes was not associated with gray matter volumes or the presence of CMBs. CONCLUSIONS Prediabetes is associated with structural brain abnormalities, with further deterioration in type 2 diabetes. These results indicate that, in middle-aged populations, structural brain abnormalities already occur in prediabetes, which may suggest that the treatment of early dysglycemia may contribute to the prevention of brain diseases

Reactive Infiltration of MORB-Eclogite-Derived Carbonated Silicate Melt into Fertile Peridotite at 3GPa and Genesis of Alkalic Magmas

We performed experiments between two different carbonated eclogite-derived melts and lherzolite at 1375°C and 3 GPa by varying the reacting melt fraction from 8 to 50 wt %. The two starting melt compositions were (1) alkalic basalt with 11·7 wt % dissolved CO2 (ABC), (2) basaltic andesite with 2·6 wt % dissolved CO2 (BAC). The starting melts were mixed homogeneously with peridotite to simulate porous reactive infiltration of melt in the Earth’s mantle. All the experiments produced an assemblage of melt + orthopyroxene + clinopyroxene + garnet ± olivine; olivine was absent for a reacting melt fraction of 50 wt % for ABC and 40 wt % for BAC. Basanitic ABC evolved to melilitites (on a CO2-free basis, SiO2 ∼27–39 wt %, TiO2 ∼2·8–6·3 wt %, Al2O3 ∼4·1–9·1 wt %, FeO* ∼11–16 wt %, MgO ∼17–21 wt %, CaO ∼13–21 wt %, Na2O ∼4–7 wt %, CO2 ∼10–25 wt %) upon melt–rock reaction and the degree of alkalinity of the reacted melts is positively correlated with melt–rock ratio. On the other hand, reacted melts derived from BAC (on a CO2-free basis SiO2 ∼42–53 wt %, TiO2 ∼6·4–8·7 wt %, Al2O3 ∼10·5–12·3 wt %, FeO* ∼6·5–10·5 wt %, MgO ∼7·9–15·4 wt %, CaO ∼7·3–10·3 wt %, Na2O ∼3·4–4 wt %, CO2 ∼6·2–11·7 wt %) increase in alkalinity with decreasing melt–rock ratio. We demonstrate that owing to the presence of only 0·65 wt % of CO2 in the bulk melt–rock mixture (corresponding to 25 wt % BAC + lherzolite mixture), nephelinitic-basanite melts can be generated by partial reactive crystallization of basaltic andesite as opposed to basanites produced in volatile-free conditions. Post 20% olivine fractionation, the reacted melts derived from ABC at low to intermediate melt–rock ratios match with 20–40% of the population of natural nephelinites and melilitites in terms of SiO2 and CaO/Al2O3, 60–80% in terms of TiO2, Al2O3 and FeO, and <20% in terms of CaO and Na2O. The reacted melts from BAC, at intermediate melt–rock ratios, are excellent matches for some of the Mg-rich (MgO >15 wt %) natural nephelinites in terms of SiO2, Al2O3, FeO*, CaO, Na2O and CaO/Al2O3. Not only can these reacted melts erupt by themselves, they can also act as metasomatizing agents in the Earth’s mantle. Our study suggests that a combination of subducted, silica-saturated crust–peridotite interaction and the presence of CO2 in the mantle source region are sufficient to produce a large range of primitive alkalic basalts. Also, mantle potential temperatures of 1330–1350°C appear sufficient to produce high-MgO, primitive basanite–nephelinite if carbonated eclogite melt and peridotite interaction is taken into account

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p&nbsp;&lt;.001. Over 24&nbsp;months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10&nbsp;ml/min/1.73&nbsp;m2 decrease), that was most notable in patients with eGFR &lt;30&nbsp;ml/min/1.73&nbsp;m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90&nbsp;ml/min/1.73&nbsp;m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF