Improving the management of medical emergency team calls due to suspected infections: A before-after study

Objective

To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics.

Design

Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed.

Setting

A public university linked hospital in Melbourne, Australia.

Participants

Adult patients with MET calls related to sepsis/infection were included.

Main outcome measures

The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials.

Results

There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035).

Conclusions

Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.

Quantitative plaque characterisation and association with acute coronary syndrome on medium to long term follow up: insights from computed tomography coronary angiography

Background

Computed tomography coronary angiography (CTCA) is an established imaging modality widely used for diagnosing coronary artery stenosis with expanding potential for comprehensive assessment of coronary artery disease (CAD). Lesion-based analyses of high-risk plaques (HRP) on CTCA may aid further in prognostication presenting with stable chest pain. We conduct qualitative and quantitative assessments to identify HRPs that are associated with acute coronary syndrome (ACS) on a medium to long term follow-up.

Methods

Retrospective cohort study of patients who underwent CTCA for suspected CAD. Obstructive stenosis (OS) is defined as ≥50% and the presence of HRP and its constituents: positive-remodelling (PR), low-attenuation-plaque (LAP; <56 HU), very-low-attenuation-plaque (vLAP; <30 HU) and spotty-calcification (SC) were recorded. A cross-sectional quantitative analysis of HRP was performed at the site of minimum-luminal-area (MLA). The primary endpoint was fatal or non-fatal ACS on follow-up.

Results

A total of 1,257 patients were included (mean age 61±14 years old and 51% male) with a median follow-up of 7.24 years (interquartile range 5.5 to 7.7 years). The occurrence of ACS was significantly higher in HRP (+) patients compared to HRP (−) patients and patients with no plaques (20.5% vs. 1.6% vs. 0.4%, log-rank test P<0.001). ACS was more frequent in HRP (+)/OS (+) patients (20.7%) compared to HRP (+)/OS (−) patients (8.6%), HRP (−)/OS (+) patients (1.8%) and HRP (−)/OS (−) patients (1.0%). OS, cross-sectional plaque area (PA) and the presence of vLAP identified those HRP lesions that were more likely to cause future ACS. Cross-sectional LAP area (<56 HU) in HRP lesions added incremental prognostic value to OS in predicting ACS (P=0.008).

Conclusions

The presence of OS and the LAP area at the site of MLA identify the HRP lesions that have the greatest association with development of future ACS.

Association of Epicardial Adipose Tissue and High-Risk Plaque Characteristics: A Systematic Review and Meta-Analysis

Background

Epicardial adipose tissue (EAT) is hypothesized to alter atherosclerotic plaque composition, with potential development of high‐risk plaque (HRP). EAT can be measured by volumetric assessment (EAT‐v) or linear thickness (EAT‐t). We performed a systematic review and random‐effects meta‐analysis to assess the association of EAT with HRP and whether this association is dependent on the measurement method used.

Methods and Results

Electronic databases were systematically searched up to October 2016. Studies reporting HRP by computed tomography or intracoronary imaging and studies measuring EAT‐v or EAT‐t were included. Odds ratios were extracted from multivariable models reporting the association of EAT with HRP and described as pooled estimates with 95% confidence intervals (CIs). Analysis was stratified by EAT measurement method. Nine studies (n=3772 patients) were included with 7 measuring EAT‐v and 2 measuring EAT‐t. Increasing EAT was significantly associated with the presence of HRP (odds ratio: 1.26 [95% CI, 1.11–1.43]; P<0.001). Patients with HRP had higher EAT‐v than those without (weighted mean difference: 28.3 mL [95% CI, 18.8–37.8 mL]; P<0.001). EAT‐v was associated with HRP (odds ratio: 1.19 [95% CI, 1.06–1.33]; P<0.001); however, EAT‐t was not (odds ratio: 3.09 [95% CI, 0.56–17]; P=0.2). Estimates remained significant when adjusted for small‐study effect bias (odds ratio: 1.13 [95% CI, 1.03–1.28]; P=0.04).

Conclusions

Increasing EAT is associated with the presence of HRP, and patients with HRP have higher quantified EAT‐v. The association of EAT‐v with HRP is significant compared with EAT‐t; however, a larger scale study is still required, and further evaluation is needed to assess whether EAT may be a potential therapeutic target for novel pharmaceutical agents.

Clinical Trial Registration

URL: https://www.crd.york.ac.uk/. Unique identifier: CRD42017055473.

The flagellum in malarial parasites

The malarial parasites assemble flagella exclusively during the formation of the male gamete in the midgut of the female mosquito vector. The observation of gamete formation ex vivo reported by Laveran (Laveran MA: De la nature parasitaire des accidents de l'impaludisme. Comptes Rendues De La Societe de Biologie. Paris 1881, 93:627-630) was seminal to the discovery of the parasite itself. Following ingestion of malaria-infected blood by the mosquito, microgamete formation from the terminally arrested gametocytes is exceptionally rapid, completing three mitotic divisions in just a few minutes, and is precisely regulated. This review attempts to draw together the diverse original observations with subsequent electron microscopic studies, and recent work on the signalling pathways regulating sexual development, together with transcriptomic and proteomic studies that are paving the way to new understandings of the molecular mechanisms involved and the potential they offer for effective interventions to block the transmission of the parasites in natural communities.