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Satoshi Hayashida

and 9 more

BACKGROUND Although low voltage zones (LVZs) in the left atrium (LA) are seen as arrhythmogenic substrate in some patients with atrial fibrillation (AF), pathophysiologic factors responsible for LVZ formation remain unclear. OBJECTIVE To elucidate the anatomical relation between the LA and ascending aorta responsible for remodeling of the anterior LA wall. METHODS We assessed the relation between existence of LVZs on the anterior LA wall and measurements taken on 3-dimensional computed tomography images obtained from 102 patients who underwent AF ablation. RESULTS Twenty-nine patients (28%) had LVZs >1.0 cm2 on the LA wall at the LA-ascending aorta contact area (LVZ Group); no LVZs were seen in the other 73 patients (No LVZ Group). In the LVZ Group (vs. No LVZ Group), the aorta-LA angle was smaller (21.0±7.7° vs. 24.9±7.1°, P = 0.015), the aorta-left ventricle (LV) angle was greater (131.3±8.8° vs. 126.0±7.9°; P = 0.005), non-coronary cusp (NCC) diameter was greater (20.4±2.2 mm vs. 19.3±2.5 mm; P = 0.036), and the NCC was closer to the anterior LA wall (2.29±0.68 mm vs. 2.76±0.79 mm; P = 0.006). The aorta-LA angle correlated positively with patients’ body mass index (BMI) and negatively with body weight and BMI. CONCLUSION Deviation of the ascending aorta course and distention of the NCC appear to be related to the development of LA anterior wall LVZs at the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with limited thoracic space may contribute to the development of LVZs associated with AF.

Venkatesh Ravi

and 1 more

Title: Making the Cut for Generator ReplacementsAuthors: Venkatesh Ravi, MD1; Jeremiah Wasserlauf, MD, MS1;1: Section of electrophysiology, Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, USACorresponding author:Jeremiah Wasserlauf, MD, MSAssistant Professor of Medicine,Cardiac Electrophysiology, Department of Internal Medicine/Division of Cardiology,Rush University Medical Center.1717 W. Congress Parkway, Suite 345, Chicago, IL 60612Email: Jeremiah_wasserlauf@rush.eduFunding: NoneDisclosure: Dr. Jeremiah Wasserlauf has received consulting fees from Stryker. No other conflicts of interest to disclose.EditorialCardiac implantable electronic devices (CIED) have become a common treatment modality for cardiac arrhythmia with over 300,000 new implants every year in the United States. A growing number of patients will require device replacement procedures throughout their lifetime.1 In a registry of 1744 patients undergoing CIED replacement procedures, lead damage or dislodgement requiring revision was found to occur in 1% of patients without previously planned addition of leads.2 The resulting lead addition and extraction procedures give rise to added procedural time, risk of complications, prolonged hospitalization, and increased health care costs.2 Polyurethane and copolymer insulation materials are more susceptible to thermal damage when compared to silicone.3,4 Avoidance of lead damage during CIED replacement procedures has been a topic of increasing investigation, with studies evaluating differences between electrosurgical modes, power settings, blade orientation, and equipment manufacturers. Operators have the option to choose between standard electrocautery with non-insulated blades, and cautery with insulated blades (PEAK PlasmaBlade, Medtronic Inc., Minneapolis, MN, or Photonblade, Stryker, Kalamazoo, MI).Electrocautery operates by generating a high current density which results in resistive heating and thereby cuts or coagulates tissue. PlasmaBlade uses a proprietary power output waveform to deliver energy along the exposed edge of a thin, insulated electrode powered by a proprietary electrosurgical generator. Photonblade is an alternative insulated electrocautery blade that is compatible with a standard electrosurgical generator. In a retrospective study by Kypta et al, PlasmaBlade was associated with a lesser risk of lead damage and shorter procedure duration and hospital stay when compared with electrocautery and scissors.3 In an ex vivo animal tissue model using Photonblade, coagulation mode during cautery was associated with more damage than cut, and this effect was greatest when contact occurred using the active edge as opposed to the insulated flat side of the cautery blade, and when the lead insulation consisted of polyurethane or copolymer. Visible lead damage was found to be more common with PlasmaBlade when compared to Photonblade. 4In this edition of the Journal of Cardiovascular Electrophysiology , Ananwattanasuk et al performed a retrospective analysis of traditional electrocautery vs PlasmaBlade on lead parameters and complications following CIED generator replacement procedures.5 The study included 410 consecutive patients (840 leads) who underwent CIED replacement using conventional electrocautery (EC group) and 410 patients (824 leads) who underwent CIED replacement using PlasmaBlade (PK group). The power settings for the PK group were 6 in CUT mode and 8 in COAG mode. In the EC group, power output was set to 40 Watts for both CUT and COAG mode. CUT mode was used for tissue dissection and COAG was only used for hemostasis. The two groups had similar device systems and baseline characteristics. In comparison to the PK group, the EC group had a slightly lower proportion of silicone leads (78% vs 83%, p < 0.01) and a slightly higher proportion of polyurethane leads (19% vs 13%, p < 0.01). The study found no statistically significant difference in lead damage requiring lead revision between the EC group and PK group (0.6% vs 0.4%, p=0.5). There was no difference in procedural complications between the two groups (2.2% vs 1.2%, p = 0.28). There was no difference in lead sensing. There was a higher number of patients with a decrease in lead impedance in the PK group compared to the EC group (61.5% vs 52.1%, p < 0.01), and perhaps unexpectedly, more patients with an increase in lead impedance in the EC group compared to the PK group (46.8% vs 34.2%, p<0.01).On average, the change in pacing impedance changed less than 10% in both groups. A majority of leads in both groups were comprised of silicone which may have been a primary contributor to the low rate of lead damage observed. These findings contrast with the older retrospective study that found a lower risk of lead damage with PlasmaBlade compared to a historical control group where titanium scissors were used with conventional electrocautery for hemostasis. The difference observed in the prior study between groups, and the overall higher rates of lead damage in that study may have been related to the use of scissors or perhaps a greater proportion of leads with non-silicone insulation (lead insulation material was not reported). The present study by Ananwattanasuk et al contributes to the literature with a larger cohort of patients and contemporary operative technique.It is never too late to scrutinize the benefit of tools that have added costs as our procedural techniques evolve. The authors should be commended for rigorously collecting not only clinical outcomes but also electrical device parameters to assess for subclinical lead damage. Although generator replacements are short and less complex when compared to other EP procedures, the total cost of generator replacement procedures is estimated at several billion dollars yearly in the US alone.6 Leadless pacemakers and the evolution of modular systems are attractive and may solve some problems related to lead damage during generator replacements, or perhaps one day eliminate generator replacements altogether. However, with the current number of CIEDs in operation and the aging population, a growing number of patients will continue to require generator replacement procedures over the next several decades. The overall safety of generator replacement procedures has improved though advances such as avoidance of routine capsulectomy, antibiotic-impregnated pouches for appropriate candidates, and prolonged replacement intervals due to improved battery longevity. Through an unremitting focus on safety and cost-effectiveness, we will stay on the cutting edge of straightforward and complex procedures in the EP lab.References1. Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol. 2011;58:1001-1006.2. Poole JE, Gleva MJ, Mela T, et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry.Circulation. 2010;122:1553-1561.3. Kypta A, Blessberger H, Saleh K, et al. An electrical plasma surgery tool for device replacement–retrospective evaluation of complications and economic evaluation of costs and resource use. Pacing Clin Electrophysiol. 2015;38:28-34.4. Wasserlauf J, Esheim T, Jarett NM, et al. Avoiding damage to transvenous leads-A comparison of electrocautery techniques and two insulated electrocautery blades. Pacing Clin Electrophysiol.2018;41:1593-1599.5. Ananwattanasuk T, Jame S, Bogun F, et al. Journal of Cardiovascular Electrophysiology. 2021.6. Hauser RG. The growing mismatch between patient longevity and the service life of implantable cardioverter-defibrillators. J Am Coll Cardiol. 2005;45:2022-2025.

Samantha Hauser

and 2 more

1. IntroductionTropical mountainous ecosystems are recognized as providers of valuable ecological and hydrological services (Viviroli et al, 2007). In Central America, the Páramo, a high‐elevation tropical grassland ecosystem, extends over ~ 200 km2 in Costa Rica and Panama, with ~50% of this area located within the Chirripó National Park between 3,100 and 3,820 m asl (-83.49°, 9.46°). Vegetation mostly consists of 0.5 to 2.5 m tall bamboo dominated (Chusquea subtessellata ) grasslands, covering up to 60% of the total Páramo area in Costa Rica (Fig.1a). The climate is controlled by the northeast trade winds, the latitudinal migration of the Intertropical Convergence Zone (ITCZ), cold continental outbreaks (i.e., northerly winds), and the seasonal influence of Caribbean cyclones. These circulation patterns produce two rainfall maxima on the Pacific slope, one in June and one in September, which are interrupted by a relative minimum between July-August, known as the Mid-Summer Drought, due to intensification of trade winds over the Caribbean Sea (Magaña et al., 1999; Waylen, 1996). The wettest season extends from May to November (contributing up to 89% of the annual precipitation), whereas the driest season is from December to April (Fig. 2a; Esquivel-Hernández et al., 2018). The surface water system of Chirripó is characterized by a lake district which comprises approximately 30 lakes of glacial origin and streams flowing down the Caribbean and Pacific slopes (Fig 1b). Lake catchments are characterized by steep slopes that promote rapid hydrological responses such as fast water‐level changes. Input of water to these glacial lakes is mostly controlled by the seasonal inputs of rainfall, which mix up with stream and subsurface waters. In April 2015, the Chirripó Hydrological Research Site (CHRS) was installed with the goal of advancing the understanding of the hydrological functioning in the Central American Páramo using environmental tracers (i.e., water stable isotopes) in combination with hydrometric data. A detailed map of CHRS is available in Esquivel-Hernández et al. (2019).

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Fabio Ramponi

and 6 more

Coronary artery and cerebrovascular disease represent a major cause of cardiovascular morbidity and mortality worldwide. Despite technological advancements in percutaneous interventions, surgical revascularization remains the preferred strategy in patients with left main or multivessel disease and in those with complex lesions with high SYNTAX score. As a result, an increasing number of older patients with diffuse atherosclerotic extracoronary disease are referred for coronary artery bypass grafting (CABG). Cerebrovascular complications after isolated coronary surgery occurs in 1-5% of patients; the magnitude of injury ranges from overt neurologic lesions with varying degree of permanent disability to “asymptomatic” cerebral events detected by dedicated neuro-imaging, nevertheless associated with significant long term cognitive and functional decline. Thromboembolic events due to manipulation of an atherosclerotic aorta are universally recognized as the leading etiology of early postoperative stroke following CABG. Coronary bypass surgery performed on an arrested heart relies on considerable aortic instrumentation associated with significant atheroembolic risk especially in older patients presenting with diffuse aortic calcifications. Surgical techniques to deal with a calcified ascending aorta during isolated coronary surgery have evolved over the last forty years. Moving away from aggressive aortic debridement or replacement, surgeons have developed strategies aimed to minimize aortic manipulation: from pump-assisted beating heart surgery with the use of composite grafts to complete avoidance of aortic manipulation with “anaortic” off-pump coronary artery bypass grafting, a safe and effective approach in significantly reducing the risk of intraoperative stroke.

Oktay Ucer

and 3 more

Semih Ak

and 1 more

Background: Hookah is a tobacco product of Middle Eastern origin; however, its popularity increases in Europe and the US. Despite its frequent use, hookah’s potentially detrimental effects are underestimated due to the scarcity of the relevant research. Since septoplasty is one of the most commonly performed procedures of otolaryngology practice, we aimed to investigate the impact of hookah consumption on recovery after septoplasty. Methods: Patients who underwent septoplasty in Sanliurfa Training and Research Hospital Department of Otolaryngology between January 2017 and December 2019 were divided into four groups based on their history of hookah and cigarette smoking. The patients’ prospectively collected data, including demographic features, healing time, and presence or absence of septal perforation during follow-up, were compared between these four groups. Results: The entire cohort included 270 patients. The mean patient age was 29.2±5.8 years. One hundred and thirty-two (48.9%) patients were non-smokers, 96 (35.5%) were cigarette smokers, 27 (10%) were hookah smokers, and 15 (5.6%) consumed both tobacco products regularly. Mean healing time was 10 days, and septal perforation was encountered in 10 patients (3.7%). A comparison of the groups revealed that cigarette smoking did not impact septal perforation rates (p=0.326) but prolonged the healing time. However, hookah smoking with or without cigarette smoking significantly influenced septal perforation rates and healing times. Conclusion: Patients should be questioned about hookah smoking in addition to cigarette smoking before the septoplasty procedure. Patients with a positive history of hookah smoking should be followed closely in terms of delayed healing and increased septal perforation rates.

George Angelidis

and 3 more

COVID-19 and nuclear cardiology: Introducing the ‘’forward” virtual visit Angelidis G, Valotassiou V, Psimadas D, Georgoulias PNuclear Medicine Laboratory, University of Thessaly, Larissa, GreeceWe read with great interest the recent review article by Kaushik A, et al. concerning the potential role of digital health applications in the present pandemic situation [1]. As the authors noted, alternative tools are needed for the optimal management of cardiovascular patients, avoiding unnecessary visits to health care facilities. The severe acute respiratory syndrome – coronavirus – 2 (SARS-CoV-2) can invade the cardiovascular cells, potentially causing life-threatening cardiac impairment [2]. In particular, patients with pre-existing cardiovascular diseases are characterized by a higher risk of adverse cardiovascular events. Therefore, most of those referred for nuclear cardiology techniques are expected to be at higher risk of developing serious coronavirus disease 2019 (COVID-19) complications. However, the performance of the individually required diagnostic and follow-up procedures is important [3].Telemedicine applications have been used in public health emergencies, leading to several advantages in terms of safety and efficacy. In the field of nuclear cardiology, the initial evaluation of patients’ history and clinical features can take place remotely (‘’forward” virtual visit). This approach seems to be patient-centred (permitting an adequate case assessment) and conducive to self-quarantine (protecting patients, healthcare professionals, and the community from viral exposure). Importantly, possible clinical presentations of COVID-19 may be evaluated during the ‘’forward” virtual visit, as well as information regarding travel and exposure histories. Moreover, local epidemiological information may be used to adjust screening pattern, and special measures could be developed (such as isolation in dedicated ‘’hot” rooms) for patients with high-risk features. After the performance of the examination, telemedicine applications could be also used for the consultation with the patients.Telemedicine applications may contribute to a better adjustment of nuclear cardiology services under the current demanding circumstances. Of course, no telemedicine programme can be created overnight, but this approach may be of value not only during the next months but also after the end of COVID-19 pandemic [4]. For example, our nuclear medicine laboratory is located in central Greece providing services to inhabitants of mountain villages, and nearby small islands. Consequently, the use of telemedicine applications could aid our practice in the future as well, particularly during the winter months when travelling by car or sea travels may be extremely demanding.

Attila Mokánszki

and 8 more

Background Retinoblastoma (Rb) is a malignant tumor of the developing retina that affects children before the age of five years in association with inherited or early germline mutations of the RB1 gene. The genetic predisposition is also related with second primary malignancies arising de novo, or following radiotherapy which have become the leading cause of death in retinoblastoma survivors. Procedure We describe a retinoblastoma case with a novel RB1 and a synchronous MET aberration. Our goal was to identify all germline and somatic genetic alterations in available tissue samples from different time periods and to reconstruct their clonal relations using next generation sequencing (NGS). We also used structural and functional prediction of the mutant RB and MET proteins to find interactions between the defected proteins with potential causative role in the development of this uniqe form of retinoblastoma. Results In this study we detected a retinoblastoma case of non-parental origin with a novel RB1 c.2548C>T;p.(Gln850Ter) and a synchronous MET c.3029C>T;p.(Thr1010Ile) germline mutations. Following bilateral retinoblastoma the boy further developed at least four different manifestations of two independent osteosarcomas. Both histopathology and NGS findings supported the independent nature of a chondroblastic osteosarcoma of the irradiated facial bone followed by an osteoblastic sarcoma of the leg (tibia). Conclusions Because of the expanding number of registered Rb cases, the novel rare cases publication is very important to understand the molecular mechanism of this malignancy. We reported a novel form of Rb and consequential chondroblastic and osteoblastic osteosarcoma, the latter one developing pulmonary metastatses.

Ugur Balkanci

and 2 more

An Unusual Case of Necrotizing Pneumonia Presenting with Acute Kidney InjuryUgur Berkay Balkanci, MDSchool of Public Health, University of Minnesota, Minneapolis, MNDavid J. Sas, DODivision of Pediatric Nephrology and Hypertension, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaNadir Demirel, MDDivision of Pediatric Pulmonology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MinnesotaCorresponding Author:Nadir Demirel, MDDivision of Pediatric Pulmonology200 First Street SWRochester, MN 55906Tel. No.: 5075380754Fax No.: 5072840727Demirel.nadir@mayo.eduKey words: postinfectious glomerulonephritis, pneumothorax, complications, complicated pneumoniaFinancial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.Funding: No external funding.Short title: “An unusual case of necrotizing pneumonia”To the Editor:Lower respiratory tract infections are the most common reason for hospitalization in the pediatric age group in the United States. Although pneumonia is prevalent, complicated pneumonia such as empyema, lung abscess and necrotizing pneumonia (NP) is uncommon in children1. The prevalence of complicated pneumococcal pneumonia decreased significantly after the introduction of the thirteen-valent pneumococcal vaccine in 20101. NP in the pediatric population is a severe disease characterized by extensive destruction and liquefaction of the lung tissue resulting in loss of the pulmonary parenchymal architecture, cavitation of the lung, and pleural involvement. Renal complications of complicated pneumonia are rare and mostly reported as atypical hemolytic uremic syndrome (HUS)2. Post-infectious glomerulonephritis (PIGN) is an unexpected complication of bacterial pneumonia3.We report a six-year-old otherwise healthy fully vaccinated girl with a 4-day history of fever, abdominal pain, vomiting, non-bloody diarrhea, and poor oral intake. Parents reported decreased urine output and dark-colored urine on the day of admission. Initial evaluation revealed serum creatinine of 5.01 mg/dL and blood urea nitrogen of 86 mg/dL, elevated acute phase reactants suggesting acute kidney injury (AKI) in the setting of an undiagnosed acute infectious process. The patient was admitted with decreased effective circulatory volume. Urinalysis revealed hematuria with <25% dysmorphic red blood cells (RBCs), proteinuria, pyuria, and RBC casts and granular casts, suggestive of acute glomerulonephritis.She was started on intermittent hemodialysis at day 2 of admission to address uremia, fluid overload, and hyperphosphatemia. A renal biopsy revealed diffuse exudative glomerulonephritis, consistent with infection-related glomerulonephritis. ASO, Anti-DNase B were negative; C3, C4 levels were low. She was treated with pulse IV methylprednisolone 10mg/kg/day for three days. The first 5 days in the hospital, the patient remained afebrile and her lung exam was normal without respiratory symptoms.On day six of admission, she developed acute right-sided chest pain and shortness of breath during hemodialysis. Chest x-ray (CXR) revealed a large right-sided tension pneumothorax, prompting therapeutic chest tube placement. Repeat CXR revealed reexpansion of the right lung and a significant right upper lobe consolidation with an ovoid hyperlucency and an air-fluid level. A chest CT scan confirmed the diagnosis of NP with multiple cavities (Image).Flexible bronchoscopy was performed with bronchoalveolar lavage revealing 42% neutrophils and negative cultures. She was treated with broad spectrum intravenous antibiotics.During admission, she developed hypertension, well-controlled with scheduled enalapril and amlodipine, as well as isradipine as needed. On day 14 of admission, hemodialysis was discontinued as kidney function improved, and chest tube was removed. She was discharged at day 26 of admission on intravenous ceftriaxone and oral metronidazole to complete 30 days of treatment. A repeat chest CT at end of treatment showed complete resolution of NP. Renal functions and blood pressure normalized on follow up.NP is characterized by persistent high fevers and prolonged hospitalizations even with appropriate antibiotic treatment1. Most often, NP affects immunocompetent children with no underlying risk factors4. The pathophysiology of this complication is acute liquefactive necrosis of the lung parenchyma which results in the development of pneumatoceles4. The most common pathogen causing NP is Streptococcus pneumoniae followed by Staphylococcus aureus and Streptococcus pyogenes. Other rarer bacterial and viral pathogens are Mycoplasma pneumonia, Influenza, and Adenovirus1. Identifying the microbiologic pathogen can be challenging and is only made in 50% of cases1. In our case, we did not isolate the causative microorganism. NP typically resolves without residual morbidity, even after a protracted course1,4.Pleural involvement is almost universal in NP, and the course of pleural disease often determines duration and outcome, particularly as it relates to the complication of bronchopleural fistula (BPF)1. BPF is most likely due to the necrotic development of a connection between bronchial space and pleural space4. BPF formation is associated with a significantly longer hospital stay in children with NP4. Yet, most cases heal without surgical intervention4. Tension pneumothorax has been observed as a rare complication of NP1.Renal involvement in complicated pneumonia is rare. Atypical HUS has been reported as a complication of pneumonia, particularly associated with empyema. (most commonly due to invasive Streptococcus pneumoniae)2. In a case series of 37 cases of atypical HUS, 34 patients (92%) had pneumonia with 10 patients (29%) with NP5. Less commonly, pneumonia can be associated with PIGN. PIGN is the most common glomerulonephritis in children worldwide. Pneumonia-associated PIGN is rare. In a case series from the US, PIGN accounted for 0.15% of admissions for pneumonia and 0.39% of admissions for glomerulonephritis6. Pneumonia-associated PIGN is known to be caused by various bacterial pathogens including Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae, Chlamydia pneumoniae, Nocardia, and Coxiella burnetii3. Different from the usual presentation of the PIGN (in which the time interval between a pharyngeal group A Streptococcal infection and PIGN is 6 to 10 days), pneumonia-associated PIGN is usually concomitant with the pulmonary disease3,6.Our case is unusual in several ways: pneumonia-associated PIGN typically presents with respiratory symptoms first, and acute kidney injury developing during the course of pneumonia3. More surprisingly, the patient developed NP which is characterized by even more severe respiratory symptoms1. Yet, our patient presented without respiratory complaints and pneumonia became apparent only after the development of pneumothorax. We could only identify 2 cases of pneumonia-associated PIGN who presented with renal involvement before pulmonary complaints6,7. Also, previous cases in the literature of pneumonia-associated PIGN report mostly a non-complicated course of pulmonary disease3,6. In a case series of 11 children with pneumonia-associated PIGN, only one case developed a small empyema6. Similarly, the majority of the reported cases of pneumonia-associated PIGN describe a benign course of renal disease3,6. Our patient’s kidney failure progressed rapidly, and she required 2 weeks of intermittent hemodialysis and a three-day course of pulse steroid therapy. At present, systemic corticosteroids are not recommended for patients with complicated pneumonia. A Cochrane review including 17 randomized controlled trials, of which four were conducted on children, found that corticosteroid therapy reduced mortality and morbidity in adults with severe CAP, and morbidity, but not mortality, in adults and children with non-severe CAP1. We speculate that pulse steroid treatment may have modified the course of NP in our patient.This case suggests an atypical presentation of NP with predominant renal complications is possible. Pediatricians should be aware of renal complications of respiratory diseases. Systemic steroids should be considered in the treatment of NP.References:1. de Benedictis FM, Kerem E, Chang AB, Colin AA, Zar HJ, Bush A. Complicated pneumonia in children. Lancet 2020;396:786-798.2. Spinale JM, Ruebner RL, Kaplan BS, Copelovitch L. Update on Streptococcus pneumoniae associated hemolytic uremic syndrome. Curr Opin Pediatr 2013;25:203-208.3. Carceller Lechón F, de la Torre Espí M, Porto Abal R, Écija Peiró JL. Acute glomerulonephritis associated with pneumonia: a review of three cases. Pediatr Nephrol 2010;25:161-164.4. Sawicki GS, Lu FL, Valim C, Cleveland RH, Colin AA. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur Respir J 2008;31:1285-1291.5. Banerjee R, Hersh AL, Newland J, Beekmann SE, Polgreen PM, Bender J, Shaw J, Copelovitch L, Kaplan BS, Shah SS. Streptococcus pneumoniae-associated Hemolytic Uremic Syndrome Among Children in North America. Pediatr Infect Dis J 2011;30:736-739.6. Srivastava T, Warady BA, Alon US. Pneumonia-associated acute glomerulonephritis. Clin Nephrol 2002;57:175-182.7. Schachter J, Pomeranz A, Berger I, Wolach B. Acute glomerulonephritis secondary to lobar pneumonia. Int J Pediatr Nephrol 1987;8:211-214.

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