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Background Rapid and accurate detection of pathogens is needed in community-acquired pneumonia (CAP) to enable appropriate antibiotics and to slow the development of antibiotic resistance. We aimed to compare the effect of point-of-care (POC) polymerase chain reaction (PCR) detection of respiratory pathogens added to standard care with standard care only (SCO) on antibiotic prescriptions after acute hospital admission. Methods and findings We performed a superiority, parallel-group, open-label, multicentre, randomised controlled trial (RCT) in 3 Danish medical emergency departments (EDs) from March 2021 to February 2022. Adults acutely admitted with suspected CAP during the daytime on weekdays were included and randomly assigned (1:1) to POC-PCR (The Biofire FilmArray Pneumonia Panel plus added to standard care) or SCO (routine culture and, if requested by the attending physician, target-specific PCR) analysis of respiratory samples. We randomly assigned 294 patients with successfully collected samples (tracheal secretion 78.4% or expectorated sputum 21.6%) to POC-PCR (n = 148, 50.4%) or SCO (146, 49.6%). Patients and investigators owning the data were blinded to the allocation and test results. Outcome adjudicators and clinical staff at the ED were not blinded to allocation and test results but were together with the statistician, blinded to data management and analysis. Laboratory staff performing standard care analyses was blinded to allocation. The study coordinator was not blinded. Intention-to-treat and per protocol analysis were performed using logistic regression with Huber-White clustered standard errors for the prescription of antibiotic treatment. Loss to follow-up comprises 3 patients in the POC-PCR (2%) and none in the SCO group. Intention-to-treat analysis showed no difference in the primary outcome of prescriptions of no or narrow-spectrum antibiotics at 4 h after admission for the POC-PCR (n = 91, 62.8%) odds ratio (OR) 1.13; (95% confidence interval (CI) [0.96, 1.34] p = 0.134) and SCO (n = 87, 59.6%). Secondary outcomes showed that prescriptions were significantly more targeted at 4-h OR 5.68; (95% CI [2.49, 12.94] p < 0.001) and 48-h OR 4.20; (95% CI [1.87, 9.40] p < 0.001) and more adequate at 48-h OR 2.11; (95% CI [1.23, 3.61] p = 0.006) and on day 5 in the POC-PCR group OR 1.40; (95% CI [1.18, 1.66] p < 0.001). There was no difference between the groups in relation to intensive care unit (ICU) admissions OR 0.54; (95% CI [0.10, 2.91] p = 0.475), readmission within 30 days OR 0.90; (95% CI [0.43, 1.86] p = 0.787), length of stay (LOS) IRR 0.82; (95% CI [0.63, 1.07] p = 0.164), 30 days mortality OR 1.24; (95% CI [0.32, 4.82] p = 0.749), and in-hospital mortality OR 0.98; (95% CI [0.19, 5.06] p = 0.986). Conclusions In a setting with an already restrictive use of antibiotics, adding POC-PCR to the diagnostic setup did not increase the number of patients treated with narrow-spectrum or without antibiotics. POC-PCR may result in a more targeted and adequate use of antibiotics. A significant study limitation was the concurrent Coronavirus Disease 2019 (COVID-19) pandemic resulting in an unusually low transmission of respiratory virus. Trial registration ClinicalTrials.gov (NCT04651712)., Author(s): Mariana Bichuette Cartuliares 1,2,*, Flemming Schønning Rosenvinge 3,4, Christian Backer Mogensen 1,2, Thor Aage Skovsted 5, Steen Lomborg Andersen 6, Claus Østergaard 7, Andreas Kristian Pedersen 8, Helene Skjøt-arkil [...]

Simple Summary: The ringed seal is part of the daily diet for local Inuits in Greenland, and therefore, the contents of trace elements are being monitored bi-annually under the AMAP CORE Programme. In this study Hg, Cd and Se concentrations were measured in ringed seal livers, along with pathological changes in both the liver and the kidneys of the seals. The oldest seals had the highest concentrations of the three trace elements, while the content was the same in both sexes. In more than half of the livers, we found mononuclear cell infiltration (94.7%) and portal cell infiltration (68.4%), while glomerular mesangial deposits (54.1%) were the predominant finding in the kidney. Ringed seals are consumed in Greenland and are therefore included as a key biomonitoring species with the focus on pollution exposure and health effects. Ringed seals in Central West Greenland (Qeqertarsuaq) and in North West Greenland (Qaanaaq) were analyzed for metal concentrations in the liver and histological changes in the liver and kidney. The mean liver concentration of mercury in Qaanaaq was 3.73 ± 5.01 µg/g ww (range: 0.28–23.29 µg/g ww), and the mean cadmium concentration was 7.80 ± 8.95 µg/g ww (range: 0.013–38.79 µg/g ww). For Qeqertarsuaq, the liver concentration of mercury was 1.78 ± 1.70 µg/g ww (range: 0.45–8.00 µg/g ww) and the mean cadmium concentration was 11.58 ± 6.32 µg/g ww (range: 0.11–25.45 µg/g ww). Age had a positive effect on the liver concentrations of metals, while no effect was found for sex or histological changes. The prevalence of histological changes in liver tissue decreased in the following order: random pattern mononuclear cell infiltration (92.1%), portal cell infiltration (68.4%), hepatic intracellular fat (18.4%), portal fibrosis (7.9%), focal hepatic fibrosis (7.9%), bile duct hyperplasia/fibrosis (7.9%) and lipid granuloma (2.6%). For kidney tissue, the prevalence of histological changes decreased in the following order: glomerular mesangial deposits (54.1%) > glomerular basement membrane thickening (45.9%) > THD (40%) > tubular hyaline casts (14.0%) > glomerular atrophy (13.5%) > dilated tubules (13.5%) > glomerular hyper-cellularity (10.8%) > mononuclear cell infiltrations (8.1%). [ABSTRACT FROM AUTHOR]

Identification of the bacterial etiology of lower respiratory tract infections (LRTI) is crucial to ensure a narrow-spectrum, targeted antibiotic treatment. However, Gram stain and culture results are often difficult to interpret as they depend strongly on sputum sample quality. We aimed to investigate the diagnostic yield of Gram stain and culture from respiratory samples collected by tracheal suction and expiratory technique from adults admitted with suspected community-acquired LRTI (CA-LRTI). In this secondary analysis of a randomized controlled trial, 177 (62%) samples were collected by tracheal suction, and 108 (38%) by expiratory technique. We detected few pathogenic microorganisms, and regardless of sputum quality, there were no significant differences between the sample types. Common pathogens of CA-LRTI were identified by culture in 19 (7%) samples, with a significant difference between patients with or without prior antibiotic treatment (p = 0.007). The clinical value of sputum Gram stain and culture in CA-LRTI is therefore questionable, especially in patients treated with antibiotics. [ABSTRACT FROM AUTHOR]

Microbiological diagnostics of good-quality sputum samples are fundamental for infection control and targeted treatment of lower respiratory tract infections (LRTI). This study aims to compare the expiratory technique and tracheal suction on the quality of sputa from adults acutely hospitalized with suspected LRTI. We performed an open-label, randomized controlled trial. Patients were randomized to sputum sampling by tracheal suction (standard care) or the expiratory technique. The primary outcome was quality of sputum evaluated by microscopy and was analysed in the intention-to-treat population. The secondary outcomes were adverse events and patients experience. In total, 280 patients were assigned to tracheal suction (n = 141, 50.4%) or the expiratory technique (n = 139, 49.6%). Sputum samples were collected from 122 (86.5%) patients with tracheal suction and 67 (48.2%) patients with expiratory technique. Good-quality sputa were obtained more often with tracheal suction than with expiratory technique (odds ratio 1.83 [95% CI 1.05 to 3.19]; p = 0.035). There was no statistical difference in adverse events (IRR 1.21 [95% CI, 0.94 to 1.66]; p = 0.136), but patient experience was better in the expiratory technique group (p < 0.0001). In conclusion, tracheal suction should be considered a routine procedure in emergency departments for patients with suspected LRTI. [ABSTRACT FROM AUTHOR]

Background: Azole resistance complicates treatment of patients with invasive aspergillosis with an increased mortality. Azole resistance in Aspergillus fumigatus is a growing problem and associated with human and environmental azole use. Denmark has a considerable and highly efficient agricultural sector. Following reports on environmental azole resistance in A. fumigatus from Danish patients, the ministry of health requested a prospective national surveillance of azole‐resistant A. fumigatus and particularly that of environmental origin. Objectives: To present the data from the first 2 years of the surveillance programme. Methods: Unique isolates regarded as clinically relevant and any A. fumigatus isolated on a preferred weekday (background samples) were included. EUCAST susceptibility testing was performed and azole‐resistant isolates underwent cyp51A gene sequencing. Results: The azole resistance prevalence was 6.1% (66/1083) at patient level. The TR34/L98H prevalence was 3.6% (39/1083) and included the variants TR34/L98H, TR343/L98H and TR34/L98H/S297T/F495I. Resistance caused by other Cyp51A variants accounted for 1.3% (14/1083) and included G54R, P216S, F219L, G54W, M220I, M220K, M220R, G432S, G448S and Y121F alterations. Non‐Cyp51A‐mediated resistance accounted for 1.2% (13/1083). Proportionally, TR34/L98H, other Cyp51A variants and non‐Cyp51A‐mediated resistance accounted for 59.1% (39/66), 21.2% (14/66) and 19.7% (13/66), respectively, of all resistance. Azole resistance was detected in all five regions in Denmark, and TR34/L98H specifically, in four of five regions during the surveillance period. Conclusion: The azole resistance prevalence does not lead to a change in the initial treatment of aspergillosis at this point, but causes concern and leads to therapeutic challenges in the affected patients. [ABSTRACT FROM AUTHOR]

The antihypertensive drug Avapro can slow the progression of kidney disease in people with type 2 diabetes and high blood pressure, according to a study of 590 patients. Avapro belongs to a new class of drugs called angiotensin II-receptor blockers.

Objective: To investigate the association between treatment-induced change in continuous glucose monitoring (CGM) time in range (TIR) and albuminuria in persons with type 1 diabetes (T1D) treated with sensor-augmented insulin pumps (SAP).Research Design and Methods: Twenty-six out of 55 participants with albuminuria and multiple daily injection therapy (25% females; median 51 [interquartile range 46-63] years of age; glycated hemoglobin A1c (HbA1c) 75 [68-88] mmol/mol [9.0% (8.4-10.4%)]; and urinary albumin-to-creatinine ratio (UACR) 89 [37-250] mg/g) were in a randomized controlled trial assigned to SAP therapy for 1 year. Anthropometrics, CGM data, and blood and urine samples were collected every 3 months.Results: Mean change (95% CI) in percentage of TIR (%TIR) was 13.2% (6.2; 20.2), in HbA1c was -14.4 (-17.4; -10.5) mmol/mol (-1.3% [-1.6; -1.0]), and in UACR was -15% (-38; 17) (all P < 0.05). UACR decreased by 19% (10; 28) per 10% increase in %TIR (P = 0.04), 18% (1; 30) per 10 mmol/mol decrease in HbA1c (P = 0.07), and 31% per 10-mmHg decrease in mean arterial pressure (P < 0.001).Conclusions: In this longitudinal study, treatment-induced increase in %TIR was significantly associated with decrease in albuminuria in T1D. [ABSTRACT FROM AUTHOR]

For the first time in > 30 years of routine sampling under the Arctic Monitoring and Assessment Program, a parasite was found in the liver of ringed seals (Phoca hispida) collected near Qaanaaq (Thule), Northwest Greenland, in 2008 and 2014. Concerns regarding changes to parasite occurrence, possibly related to climate change and bioaccumulation of immunomodulating anthropogenic pollutants, spurred further investigations into parasite characterization, and implications for wildlife health and seal hunters. Microscopic, molecular, and morphometric analyses are presented herein. Of 40 seals, 6 (15%) were infected, and 5 of 6 of these seals had severe infections. The parasite was identified morphologically as Orthosplanchnus arcticus Odhner, 1905 (Trematoda; Digenea: Brachycladiidae). Macro- and microscopic pathologic study indicated mild-to-severe biliary hyperplasia associated, stasis associated, and fibrosis associated with trematode infections. Molecular analysis of the trematode confirmed its classification within the Brachycladiidae using sequencing and comparing Internal Transcribed Spacer-1, mitochondrial-NADH Dehydrogenase 3, 18S ribosomal DNA, and Cyclooxygenase-1 regions. This is the first ever report of O. arcticus in ringed seals from Qaanaaq and is one of the most northern records of this parasite. We found significant liver pathology in severely infected seals, but its effects on health of seals in this population are unknown. Host-specificity and the lifecycle of O. arcticus are unknown, but transmission may involve subsistence and commercially harvested Arctic fish species. Further work is needed to answer these questions. Surveying parasites in Arctic wildlife is important in order to assess potential effects on wildlife and human health (i.e., zoonoses). [ABSTRACT FROM AUTHOR]

Background: Individual patients show a large variability in albuminuria response to angiotensin receptor blockers (ARB). Identifying novel biomarkers that predict ARB response may help tailor therapy. We aimed to discover and validate a serum metabolite classifier that predicts albuminuria response to ARBs in patients with diabetes mellitus and micro- or macroalbuminuria.Methods: Liquid chromatography-tandem mass spectrometry metabolomics was performed on serum samples. Data from patients with type 2 diabetes and microalbuminuria (n = 49) treated with irbesartan 300 mg/day were used for discovery. LASSO and ridge regression were performed to develop the classifier. Improvement in albuminuria response prediction was assessed by calculating differences in R(2) between a reference model of clinical parameters and a model with clinical parameters and the classifier. The classifier was externally validated in patients with type 1 diabetes and macroalbuminuria (n = 50) treated with losartan 100 mg/day. Molecular process analysis was performed to link metabolites to molecular mechanisms contributing to ARB response.Results: In discovery, median change in urinary albumin excretion (UAE) was -42 % [Q1-Q3: -69 to -8]. The classifier, consisting of 21 metabolites, was significantly associated with UAE response to irbesartan (p < 0.001) and improved prediction of UAE response on top of the clinical reference model (R(2) increase from 0.10 to 0.70; p < 0.001). In external validation, median change in UAE was -43 % [Q1-Q35: -63 to -23]. The classifier improved prediction of UAE response to losartan (R(2) increase from 0.20 to 0.59; p < 0.001). Specifically ADMA impacting eNOS activity appears to be a relevant factor in ARB response.Conclusions: A serum metabolite classifier was discovered and externally validated to significantly improve prediction of albuminuria response to ARBs in diabetes mellitus. [ABSTRACT FROM AUTHOR]

Abstract: Der königliche Komplex in Jelling mit seinen monumentalen Verweisen auf königliche Macht und Christianisierung ist als bedeutender Schlüsselort für die archäologische wie historische Deutung des politischen und religiösen Wandels im skandinavischen Raum am Ende der Wikingerzeit zu verstehen. In den letzten Jahren erfolgte eine Neubewertung der Denkmäler und ihrer Umgebung auf Basis neuer umfangreicher Ausgrabungen und damit auch der in einem Zeitraum von gut zweihundert Jahren akkumulierten Forschungsergebnisse. Diese jüngsten Untersuchungen erlaubten abweichende Deutungen zum bislang bekannten Charakter des Fundplatzes, konnten doch hochinteressante neue strukturelle Elemente erkannt werden, darunter ein von Palisaden umgrenztes Areal mit einer Fläche von 12,5 ha sowie Gebäuden des Trelleborg-Typs, vergleichbar mit den Hauptgebäuden der Ringburgen König Harald Blauzahns. Jene Neuentdeckungen ließen die Historie des Platzes in einem neuen Licht erscheinen, führten aber auch zu veränderten Deutungen der im 10. Jahrhundert nachweisbaren Umwandlungsprozesse im südlichen Skandinavien sowie der Rolle, die Jelling und die hiesigen Könige dabei spielten. Abstract: Le complexe royal de Jelling, avec ses références au pouvoir royal et à la christianisation, forme un site clé dans l'explication archéologique et historique des transformations politiques et religieuses du monde scandinave à la fin de l'époque des Vikings. Ces dernières années, les monuments et leurs alentours ont fait l'objet de nouvelles fouilles extensives, et les données existantes, recueillies au long de deux siècles de recherche sur ce site, ont été réévaluées. Ces investigations ont profondément modifié nos connaissances du caractère de ce complexe, car elles révèlent de nouveaux éléments architecturaux tels qu'une palissade de 12,5 ha et des bâtiments de type Trelleborg comparables aux forteresses circulaires du roi Harald Blaatand («Dent bleue»). Ces découvertes incitent à réinterpréter le développement du site, ce qui a des implications sur la discussion des processus de transformation qui eurent lieu au 10e siècle dans le sud de la Scandinavie et du rôle qu'y jouèrent les rois de Jelling. Abstract: The royal complex at Jelling with its monumental references to royal power and Christianization stands as a key site in the archaeological and historical explanation of the political and religious transformations of the Scandinavian world at the end of the Viking Age. In recent years, the monuments and their surroundings have been subject to renewed, extensive excavations and the existing data from the two-centuries-long research history of the site have been re-evaluated. These investigations have significantly altered our knowledge of the character of the monument complex as they present new structural elements including a 12.5 ha palisade enclosure and buildings of Trelleborg-type comparable to the main buildings of King Harald Bluetooth's ring fortresses. Such findings incite reinterpretations of the development of the site which have implications for the discussion of the transformation processes that took place in 10th-century South Scandinavia and the role which Jelling and the Jelling kings played therein. [ABSTRACT FROM AUTHOR]

Recent studies have shown that both glomerular and tubulointerstitial damage are important factors in the pathophysiology and progression of diabetic nephropathy. To examine whether markers of tubular damage are useful in monitoring the progression of disease, we measured urinary levels of neutrophil gelatinase-associated lipocalin (NGAL), liver-fatty acid-binding protein (LFABP), and kidney injury molecule-1 (KIM-1) in a 3-year intervention study of 63 type 1 diabetic patients with kidney disease. The baseline mean glomerular filtration rate (GFR) was 87 ml/min per 1.73 m2 and urinary albumin excretion 1141 mg/24 h. Patients with the highest compared with the lowest quartile of urinary NGAL at baseline had higher urinary KIM-1 levels and a significant decrease in their GFR each year. Using linear regression analysis, we found that elevated urinary NGAL and KIM-1 concentrations were associated with a faster decline in GFR, but not after adjustment for known promoters of progression. Urinary LFABP was not related to decline in GFR. Losartan treatment (100 mg/day) reduced urinary KIM-1 by 43% over a 12-month period. Thus, urine biomarker measurements in patients with type 1 diabetic nephropathy did not provide additional prognostic information to that of known progression promoters. [ABSTRACT FROM AUTHOR]