Strategies for increasing diagnostic yield of community-onset bacteraemia within the emergency department: A retrospective study

Bloodstream infections (BSI) are associated with high mortality. Therefore, reliable methods of detection are of paramount importance. Efficient strategies to improve diagnostic yield of bacteraemia within the emergency department (ED) are needed. We conducted a retrospective analysis of all ED encounters in a high-volume, city-centre university hospital within Germany during a five-year study period from October 2013 to September 2018. A time-series analysis was conducted for all ED encounters in which blood cultures (BCs) were collected. BC detection rates and diagnostic yield of community-onset bacteraemia were compared during the study period (which included 45 months prior to the start of a new diagnostic Antibiotic Stewardship (ABS) bundle and 15 months following its implementation). BCs were obtained from 5,191 out of 66,879 ED admissions (7.8%). Bacteraemia was detected in 1,013 encounters (19.5% of encounters where BCs were obtained). The overall yield of true bacteraemia (defined as yielding clinically relevant pathogens) was 14.4%. The new ABS-related diagnostic protocol resulted in an increased number of hospitalised patients with BCs collected in the ED (18% compared to 12.3%) and a significant increase in patients with two or more BC sets taken (59% compared to 25.4%), which resulted in an improved detection rate of true bacteraemia (2.5% versus 1.8% of hospital admissions) without any decrease in diagnostic yield. This simultaneous increase in BC rates without degradation of yield was a valuable finding that indicated success of this strategy. Thus, implementation of the new diagnostic ABS bundle within the ED, which included the presence of a skilled infectious disease (ID) team focused on obtaining BCs, appeared to be a valuable tool for the accurate and timely detection of community-onset bacteraemia

Die Wirkung von Procalcitonin auf die glatte Muskulatur von Rattenaorten in vitro

HINTERGRUND: Es ist bekannt, dass bei septischen Patienten die Procalcitonin(PCT)-Konzentration im Blut erhöht ist. Die Mikrozirkulation dieser Patienten ist verschlechtert. Diese Veränderung der arteriellen Reaktivität könnte unter anderem mit den erhöhten PCT-Werten in Verbindung stehen. Wir testeten in vitro den direkten Effekt von PCT auf die isometrische Spannung von gesunden Rattenaorten. METHODE: Zu den in unseren Versuchsaufbau in Krebslösung eingespannten 2-3mm langen Aortenringen gaben wir PCT in ansteigenden Dosen; zum Teil präkontrahierten wir die Ringe mit 5*10-7M Phenylephrin (PE), um auch eine mögliche relaxierende Wirkung von PCT festzustellen. Nach Inkubation (30 Minuten oder 24 Stunden) in 5µg/ml PCT wurde die Dosis-Wirkbeziehung von PE mit der Kontrollgruppe verglichen. Für alle weiteren Versuche inkubierten wir die eine Hälfte der Präparationen mit 5µg PCT über 24 Stunden (zum Vergleich wurde die andere Hälfte in reiner Krebslösung inkubiert). Den Präparationen einer Versuchsreihe wurde das Endothel vor Inkubation mechanisch entfernt. Nach Präkontraktion mit PE 5*10-8M bzw. 5*10-7M wurden Veränderungen der Relaxation von Natrium-Nitroprussid (SNP) im Vergleich zur Kontrolle untersucht. In anderen Versuchen inkubierten wir (nach Präkontraktion mit PE) mit Thapsigargin (Ca-ATPase-Hemmer am sakroplasmatischen Retikulum)10-6M, L-NAME (NO-Synthase-Hemmer) 5*10-4M, SQ (cAMP-Produktions-Hemmer)10-4M, bzw. ODQ 10-5M (cGMP-Produktions-Hemmer) über 10 Minuten, um dann SNP in ansteigenden Dosen zu geben. Außerdem relaxierten wir die Ringe mit Isoproterenol (ISO) und Natriumazid (SA), und kontrahierten sie mit Natrium-orthovanadat (SOV). ERGEBNISSE: Es lässt sich für die direkte Gabe von PCT weder eine signifikante Relaxation bzw. Kontraktion feststellen. Des Weiteren hat PCT keinen Effekt auf die Kontraktion mit PE (weder nach 30minütiger bzw. 24stündiger Inkubation). Nach Kontraktion mit PE 5*10-8M lassen sich die Aortenringe mit SNP relaxieren, wobei die in PCT inkubierte Aortenringe (EC50:13,3 ± 0,22) im Vergleich zur Kontrollgruppe (13,5 ± 0,19) signifikant schlechter relaxieren (Mittelwert ± Standardfehlervon EC50; p< 0,024; n=12). Auch nach Präkontraktion mit PE 5*10-7M ist eine signifikante Verschlechterung der Relaxation der inkubierten Gruppe zu erkennen (EC50: 8,2 ± 0,05 für die Inkubation vs. 8,5 ± 0,06 für die Kontrolle; p< 0,017; n=8). Durch den Zusatz von Thapsigargin, L-NAME bzw. SQ nach Präkontraktion mit PE lässt sich der Unterschied, der bei Relaxation mit SNP zwischen den beiden Gruppen bestand, aufheben. Auch die Entfernung des Endothels führt zu einer Angleichung der Dosis-Wirkbeziehung von SNP in beiden Gruppen. ODQ inhibiert die Wirkung von SNP an den Präparationen, und es kommt zu keiner Relaxation. PCT hatte keinen signifikanten Einfluss auf die Relaxationen mit ISO und SA, bzw. Kontraktionen mit SOV. SCHLUSSFOLGERUNG: PCT hatte keinen direkten Effekt auf die glatte Muskulatur der Aortenringe. Aber nach langer Inkubation (24Stunden) kommt es zur Hemmung der Wirkung von SNP. Es lässt sich vermuten, dass PCT eine Inhibition der Wirkungskaskade von SNP hervorruft. Diesem Effekt könnte die erhöhte intrazelluläre Ca2+-Konzentration und/oder die verminderte Bereitstellung von NO in der glatten Muskelzelle zu Grunde liegen. Begründet werden kann diese These mit der Tatsache, dass nach Inkubation mit Thapsigargin, L-NAME und SQ, bzw. nach Endothelentfernung die SNP-Wirkung nicht beeinflusst wird.Background. The septic patients display, between numbers of other disturbances, vascular hyporeactivity. They often have an increased blood level of procalcitonin (PCT) but the mechanisms responsible for that increase and possible effects of PCT, particularly on the blood vessels, are not known. We examined whether PCT could have influence on normal rat blood vessel tension in vitro. Methods. Aortal rings, 2mm breit, with or without endothelium (-Endo), were suspended in an organ bath and isometric tension registered. Direct effects of the PCT and the effects of incubation with PCT on various contracting or relaxing agents were examined. Results. At rest or following pre-contraction with phenylephrine (PE, 10-8 or 10-7) PCT had no direct effect on rat aortal tension. Similarly pre-incubation (short, 30 min or long, 24 hours) with PCT (5µg/ml) did not influence responses to PE. Short incubationit with PCT also did not influence sodium nitroprusside (SNP) relaxation. However, long pre-incubation with PCT partially inhibited the relaxing effects of SNP of the preparations pre-contracted with PE. (PCT v.s. Controls, PE 5x10-8 EC50: 13.34 ± 0.22 v.s. 13.51 ± 0.19 (p< 0.02; n=12,) or by PE 5x10-7: 8.21 ± 0,05 vs. 8.53 ± 0.06; p< 0.02; n=8). These effects were abolished in preparations (–Endo), or following pre-incubated with Thapsigargin (10-6; SERCA inhibitor), SQ (10-4; cAMP synthesis inhibitor), or L-NAME (5x10-4, NO-synthesis inhibitor). The ODQ (10-5; cGMP synthesis inhibitor) completely inhibited the relaxing effects of SNP while relaxation with ISO (10-9-10-3M, beta adrenergic agonist) and contraction induced by sodium orthovanadate (10-8-10-3M; tyrosine-phosphatase inhibitor) were not affected by PCT incubation. The sodium azide (inhibitor of the mitochondrial Ca++ removal) had slight relaxing effects independent of PCT incubation. Conclusion. The PCT partially inhibited the relaxing effects of the SNP in rat aorta in vitro. These effects seam to be endothelium-dependent and may be linked to NO and intracellular Ca++ removal pathways

Staged Ultrasound-Assisted Catheter-Directed Thrombolysis for Bilateral Pulmonary Embolism: “All with one Catheter-Technique”

A 70-year-old male presented with two days increasing dyspnea. His past medical history was notable for deep venous thrombosis with consecutive pulmonary embolism (PE). Diagnostic workup showed normal blood pressure (130/80mmHg), sinus tachycardia with SIQIII-pattern on electrocardiogram, and elevation of thrombolysis-catheter with a staged infusion protocol since the patient was hemodynamically stable. For this purpose, an ultrasound assisted catheter (EkoSonic MACH4e Endovascular System, EKOS Corporation, Bothwell, WA) was positioned into the left lower PA-branch via the right femoral vein and rtPA-thrombolysis was administered over 16h (0.8mg/hour) until the next morning. On the next day, a second venous access was placed into the left femoral vein and with the help of a 6F-right-amplatz-catheter, the thrombolysis troponin (0.22ng/nl). Immediate chest computed tomography (CT) demonstrated PE in both pulmonary arteries (PA) and right ventricular (RV) dilation compatible with PE of intermediate-high risk for early mortality (Figure 1).</p

Die COVID-19-Pandemie veränderte nicht die Zahl, aber die Art psychiatrischer Notfälle

Background!#!Due to the demographic change dementia is a common and dramatically increasing reason for medical presentations. In approximately 8% of cases dementia occurs before the age of 65 years. The psychosocial and economic consequences are often severe, particularly in younger patients. Clinicians face major diagnostic challenges. A rapid diagnosis is crucial for patient counselling and management.!##!Objective!#!This review article presents the special features of dementia in younger people, the most important underlying diseases and a rational clinical diagnostic approach.!##!Methods!#!Narrative review. The literature search was carried out in PubMed.!##!Results!#!The differential diagnostic spectrum of dementia in younger people under the age of 65 years is very broad. The most common causes are Alzheimer's disease with typical or atypical clinical presentations and frontotemporal lobar degeneration. The younger the age of onset, the higher the proportion of treatable and potentially reversible causes of dementia.!##!Conclusion!#!The diagnostics of primary neurodegenerative diseases have continuously improved, especially due to the availability of an increasing number of clinical, molecular and imaging biomarkers. Nevertheless, in order to avoid unnecessary and burdensome examinations, the diagnostic work-up of young onset dementia must be hypothesis-driven, i.e. following a precise clinical syndromic classification of the symptoms