No fever, no worries? A retrospective audit of bacteraemic patients in the emergency department.

BACKGROUND: Early identification and treatment of serious infections improve clinical outcomes. Previous studies have found that septic patients without fever are more likely to die than those with fever, due to delay in antibiotic administration. AIM: To determine whether antibiotic treatment and mortality differed in afebrile adult patients presenting to the emergency department (ED) with bacteraemia, compared with those with a history of fever. METHODS: Retrospective 6-month audit of all adult patients with positive blood cultures taken in the ED of a single tertiary hospital. Outcomes included the receipt of antibiotics within 4 and 24 h of ED arrival, in-hospital mortality and 30-day mortality. RESULTS: A total of 227 patients with clinically significant bacteraemia was identified, of which 38 (16.7%) were afebrile in the ED. There was no statistically significant difference in the proportion of afebrile or febrile patients receiving antibiotics within 4 h (44.7% vs 55.6%, P = 0.222) or 24 h (89.5% vs 95.2%, P = 0.163) of arrival at the ED. Inpatient mortality was not statistically different in the afebrile and febrile groups 15.8% vs 6.9%, P = 0.070), but 30-day mortality was higher among afebrile patients (27.6% vs 10.1%, P = 0.010). CONCLUSIONS: There was no significant difference in receipt of antibiotics within 4 h or 24 h ED arrival between the febrile and afebrile groups. However, afebrile patients experienced higher 30-day mortality. While most bacteraemic patients received antibiotics within 24 h, only half received antibiotics within 4 h, representing a key area for improvement.

Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient.

We report a case of fatal disseminated varicella zoster virus (VZV) with delayed-onset rash in a 66-year-old female more than 2 years following uncomplicated deceased donor renal transplantation. Whilst on a stable regimen of maintenance immunosuppression, the patient presented with chest and abdominal pain with concomitant hepatitis and pancreatitis. After pursuing multiple other potential causes of her symptoms, the correct diagnosis of VZV was only suspected after the development of a widespread vesicular rash-11 days after her initial symptoms. Despite antiviral therapy and inotropic support in the intensive care unit, the patient died. Simultaneous VZV hepatitis and pancreatitis in solid organ transplant recipients is uncommon. The new inactivated VZV vaccines have the potential to prevent post-transplant infections, with promising early clinical data on safety and efficacy in renal transplant recipients. VZV is an important preventable infection that should be considered in immunocompromised patients, even in the absence of rash.

Epidemiology of Buruli Ulcer Infections, Victoria, Australia, 2011-2016.

Buruli ulcer (BU) is a destructive soft-tissue infection caused by the environmental pathogen Mycobacterium ulcerans. In response to rising BU notifications in the state of Victoria, Australia, we reviewed all cases that occurred during 2011-2016 to precisely map the time and likely place of M. ulcerans acquisition. We found that 600 cases of BU had been notified; just over half were in residents and the remainder in visitors to defined BU-endemic areas. During the study period, notifications increased almost 3-fold, from 66 in 2013 to 182 in 2016. We identified 4 BU-endemic areas: Bellarine Peninsula, Mornington Peninsula, Frankston region, and the southeastern Bayside suburbs of Melbourne. We observed a decline in cases on the Bellarine Peninsula but a progressive increase elsewhere. Acquisitions peaked in late summer. The appearance of new BU-endemic areas and the decline in established areas probably correlate with changes in the level of local environmental contamination with M. ulcerans.

Economic Impact of Routine Cavity Margins Versus Standard Partial Mastectomy in Breast Cancer Patients: Results of a Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare costs associated with excision of routine cavity shave margins (CSM) versus standard partial mastectomy (PM) in patients with breast cancer. BACKGROUND: Excision of CSM reduces re-excision rates by more than 50%. The economic implications of this is, however, unclear. METHODS: Between October 21, 2011 and November 25, 2013, 235 women undergoing PM for Stage 0-III breast cancer were randomized to undergo either standard PM ("no shave", n = 116) or have additional CSM taken ("shave", n = 119). Costs from both a payer and a hospital perspective were measured for index surgery and breast cancer surgery-related care through subsequent 90 days. RESULTS: The 2 groups were well-matched in terms of baseline characteristics. Those in the "shave" group had a longer operative time at the initial surgery (median 76 vs 66 min, P < 0.01), but a lower re-excision rate for positive margins (13/119 = 10.9% vs 32/116 = 27.6%, P < 0.01). Actual direct hospital costs associated with operating room time ($1315 vs. $1137, P = 0.03) and pathology costs ($1195 vs $795, P < 0.01) were greater for the initial surgery in patients in the "shave" group. Taking into account the index surgery and the subsequent 90 days, there was no significant difference in cost from either the payer ($10,476 vs $11,219, P = 0.40) or hospital perspective ($5090 vs $5116, P = 0.37) between the "shave" and "no shave" groups. CONCLUSIONS: Overall costs were not significantly different between the "shave" and "no shave" groups due to significantly fewer reoperative surgeries in the former.

Renal denervation in male rats with heart failure improves ventricular sympathetic nerve innervation and function.

Heart failure is characterized by the loss of sympathetic innervation to the ventricles, contributing to impaired cardiac function and arrhythmogenesis. We hypothesized that renal denervation (RDx) would reverse this loss. Male Wistar rats underwent myocardial infarction (MI) or sham surgery and progressed into heart failure for 4 wk before receiving bilateral RDx or sham RDx. After additional 3 wk, left ventricular (LV) function was assessed, and ventricular sympathetic nerve fiber density was determined via histology. Post-MI heart failure rats displayed significant reductions in ventricular sympathetic innervation and tissue norepinephrine content (nerve fiber density in the LV of MI+sham RDx hearts was 0.31 ± 0.05% vs. 1.00 ± 0.10% in sham MI+sham RDx group, P < 0.05), and RDx significantly increased ventricular sympathetic innervation (0.76 ± 0.14%, P < 0.05) and tissue norepinephrine content. MI was associated with an increase in fibrosis of the noninfarcted ventricular myocardium, which was attenuated by RDx. RDx improved LV ejection fraction and end-systolic and -diastolic areas when compared with pre-RDx levels. This is the first study to show an interaction between renal nerve activity and cardiac sympathetic nerve innervation in heart failure. Our findings show denervating the renal nerves improves cardiac sympathetic innervation and function in the post-MI failing heart.

Antimicrobial susceptibility of bacterial isolates from clinical specimens in four Pacific Island countries, 2017-2021.

Background: There are limited antimicrobial resistance (AMR) surveillance data from low- and middle-income countries, especially from the Pacific Islands region. AMR surveillance data is essential to inform strategies for AMR pathogen control. Methods: We performed a retrospective analysis of antimicrobial susceptibility results from the national microbiology laboratories of four Pacific Island countries - the Cook Islands, Kiribati, Samoa and Tonga - between 2017 and 2021. We focused on four bacteria that have been identified as 'Priority Pathogens' by the World Health Organization: Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Findings: Following deduplication, a total of 20,902 bacterial isolates was included in the analysis. The most common organism was E. coli (n = 8455) followed by S. aureus (n = 7830), K. pneumoniae (n = 2689) and P. aeruginosa (n = 1928). The prevalence of methicillin resistance among S. aureus isolates varied between countries, ranging from 8% to 26% in the Cook Islands and Kiribati, to 43% in both Samoa and Tonga. Ceftriaxone susceptibility remained high to moderate among E. coli (87%-94%) and K. pneumoniae (72%-90%), whereas amoxicillin + clavulanate susceptibility was low against these two organisms (50%-54% and 43%-61%, respectively). High susceptibility was observed for all anti-pseudomonal agents (83%-99%). Interpretation: Despite challenges, these Pacific Island laboratories were able to conduct AMR surveillance. These data provide valuable contemporary estimates of AMR prevalence, which will inform local antibiotic formularies, treatment guidelines, and national priorities for AMR policy. Funding: Supported by the National Health and Medical Research Council.

Retrospective analysis of postinjection ultrasound imaging after platelet-rich plasma or autologous blood: observational review of anatomic distribution of injected material.

OBJECTIVE: Characterization of the distribution and imaging characteristics of platelet-rich plasma (PRP) and autologous blood after injection is currently limited despite the growing use. We sought to improve understanding of the distribution of PRP or autologous blood after it has been injected into a tendon to evaluate whether injected materials truly stayed within the local region of injection. MATERIALS AND METHODS: Fifty ultrasound-guided PRP or autologous blood injections performed for tendinopathy were retrospectively reviewed. Consensus review of the imaging data was performed by two radiologists to characterize the distribution of the injectate (i.e., within the tendon, along the tendon sheath, along the paratenon, or leakage into the adjacent joint or surrounding soft tissues). The presence of fluid and microbubbles from the injectate served as an indicator of material distribution. RESULTS: Image review verified the injectate within the tendon in 100% of cases. In 98% of reviewed cases, injected PRP or autologous blood dissected beyond the local injection site (defined as >2 cm from the site of injection) and was identified in adjacent soft tissues in 51% of cases. Visualization of injectate along a paratenon or tendon sheath (when applicable) was seen in 86% and 100% of cases respectively; however, intraarticular extension was uncommon (8%). CONCLUSION: Our study showed that postinjection imaging may be of value in assessing the anatomic distribution of injectate after intratendinous therapy. Furthermore, our initial review found that in the majority of cases injected blood products tended to distribute beyond the local area of injection.

Interventions and outcomes of COVID-19 patients in a community hospital-A single center study comparing the first and second waves.

BACKGROUND: We have had 3 coronavirus-related pandemics in the last two decades. Each has brought significant toll and with each case there was no cure. Even as vaccines have been developed for the current strain of the virus thereby increasing the prospects of bringing transmissions in communities to a minimum, lessons from this pandemic should be explored in preparation for future pandemics. Other studies have looked at differences in characteristics of patients and mortality rates between the first two waves. In our study we not only identify the differences in outcomes but also explore differences in hospital specific interventions that were implemented at Jersey City Medical Center, NJ, a community-based hospital. AIM: The aim of this study is to assess the differences between the first two waves of the COVID -19 pandemic in terms of management and outcomes to help identify any key lessons in the handling of future pandemics. We compared the population demographics, interventions and outcomes used during the first two waves of COVID-19 in a community-based hospital. METHODS: This is a retrospective single-center cross-sectional study including Laboratory confirmed COVID-19 patients requiring oxygen supplementation admitted at Jersey City Medical Center during the first wave (April 1 to June 30, 2020) and the second wave between (October 1, 2020, and January 1, 2021). The Chi-squared test was used to assess the relationship between categorical variables and the T- test for continuous variables. A Logistic regression model was built comparing the second to the first wave while accounting for important covariates. RESULTS: There was a combined total of 473 patients from both waves. Patients in the first wave were older (66.17 years vs 60.38 years, p <0.01), had more comorbidities (2.75 vs 2.29, p 0.003), had more severe disease (50% vs 38.78% p of 0.002), had a longer length of stay (14.18 days vs 8.77 days, p <0.001) and were more likely to be intubated (32.49% vs 21.9 4%, p 0.01). In the univariate model, the odds of mortality in the second wave compared to the first wave was 0.63 (CI, 0.41-0.96) and 1.73 (CI, 0.65-4.66) in the fully adjusted model. CONCLUSION: Overall, there was no statistically significant difference in mortality between the two waves. Interventions that were noted to be significantly different between the two waves were, increased likelihood of mechanical intubation in the first wave and increased use of steroids in the second wave compared to the first.

Attributable mortality and excess length of stay associated with third-generation cephalosporin-resistant Enterobacterales bloodstream infections: a prospective cohort study in Suva, Fiji.

OBJECTIVES: There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the effect of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji. METHODS: We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and we used multistate modelling to estimate the excess length of hospital stay. RESULTS: From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs; 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio [aHR] 1.13, 95% confidence interval [CI] 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission. CONCLUSION: Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.

Epidemiology, antimicrobial resistance and outcomes of Staphylococcus aureus bacteraemia in a tertiary hospital in Fiji: A prospective cohort study.

Background: Staphylococcus aureus bacteraemia (SAB) is one of the commonest bloodstream infections globally and is associated with a high mortality rate. Most published data comes from temperate, high-income countries. We describe the clinical epidemiology, microbiology, management and outcomes of patients with SAB treated in a tropical, middle-income setting at Fiji's largest hospital. Methods: A prospective, observational study was performed of consecutive SAB cases admitted to Colonial War Memorial Hospital (CWMH) in Suva, between July 2020 and February 2021. Detailed demographic, clinical and microbiological data were collected, including the key outcome of in-patient mortality. To estimate the population incidence, all SAB cases diagnosed at the CWMH laboratory were included - even if not admitted to CWMH - with the population of Fiji's Central Division used as the denominator. Findings: A total of 176 cases of SAB were detected over eight-months, which equated to an incidence of 68.8 cases per 100,000 population per year. Of these, 95 cases were admitted to CWMH within 48 h of index culture. Approximately 8.4% (8/95) of admitted cases were caused by methicillin-resistant Staphylococcus aureus (MRSA). All cause in-patient mortality was 25.3%, increasing to 55% among patients aged 60 or older. Interpretation: This reported incidence of SAB in central Fiji is one of the highest in the world. SAB was associated with significant mortality, especially in those over 60 years of age, despite a relatively low frequency of methicillin resistance. Funding: Supported by the National Health and Medical Research Council (Australia) and the GRAM (Global Research on Antimicrobial Resistance) Project, Oxford University (United Kingdom).

Automated framework for digital radiation dose index reporting from CT dose reports.

OBJECTIVE: Radiation exposure from CT studies has increased over the past 30 years in the United States and now constitutes approximately 50% of the radiation dose index administered in the health care setting. Tracking CT dose index (CTDI) is cumbersome because it relies on a manufacturer-generated screen capture, which contains the estimated dose index exposure for the patient. The radiation dose index information is not digital but, rather, is "burned" into the image (i.e., not in numeric form, not as part of the image header or elsewhere associated with the study), making it difficult to automatically share these data with other information systems. The purpose of the dose index reporting application (DIRA) we developed for CT is to extract the radiation dose index information from the CTDI reports to eventually perform automated quality control, promote radiation safety awareness, and provide a longitudinal record of patient-specific health care-related radiation exposure. MATERIALS AND METHODS: A random selection of 518 CTDI reports were processed by the DIRA and the dose index information was extracted. CTDI reports using a standard DICOM C-STORE to the DIRA allow an automated process to compile radiation dose index and patient information in a Web-based framework using a structured query language (SQL) database. RESULTS: Our initial tests showed that the DIRA accurately extracted dose index information from 518 of 518 CTDI reports (100%). Because the extracted CTDI descriptor-dose-length product-is based on standard CTDI measurements obtained using fixed-size cylindric polymethylmethacrylate phantoms, preliminary studies have been performed to correct for patient size by applying correction factors derived from CTDI measurements using a range of phantom sizes from 6 to 32 cm in diameter. Our system provides a way to automatically track CTDI on existing CT scanners and does not rely on the DICOM SR Dose Index Report standard, which is available on only the newest CT scanners. CONCLUSION: A modular and vendor-independent DIRA system can be integrated with any existing CT scanner. This system greatly facilitates digital dose index reporting and makes it possible to provide a longitudinal record of the health care radiation exposure estimate in an individual patient's health record.

Utilization guidelines for reducing radiation exposure in the evaluation of aneurysmal subarachnoid hemorrhage: A practice quality improvement project.

OBJECTIVE: The purpose of this study was to reduce the cumulative radiation exposure from CT of patients with aneurysmal subarachnoid hemorrhage. MATERIALS AND METHODS: Baseline data on 30 patients with aneurysmal subarachnoid hemorrhage were collected retrospectively for all CT examinations of the head performed throughout the hospital course. Radiation exposure estimates were obtained by recording dose-length products for each examination. As a departmental practice quality improvement project, an imaging protocol was implemented that included utilization guidelines to reduce radiation exposure in CTA and CT perfusion examinations performed to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage. Ten months after implementation of this protocol, data on 30 additional patients were analyzed. Means, medians, and SD estimates were compared for cumulative radiation exposure and absolute numbers of each examination. RESULTS: Sixty patients were included in the study: 30 patients at baseline and 30 patients after implementation of the quality improvement plan. These patients underwent 435 CT examinations: 248 examinations at baseline and 187 examinations with the new protocol. With the new algorithm, the mean number of CT examinations per patient was 5.8 compared with 7.8 at baseline, representing a decrease of 25.6%. The number of CT perfusion examinations per patient decreased 32.1%. Overall, there was a 12.1% decrease in cumulative radiation exposure (p > 0.05). CONCLUSION: With the structured imaging algorithm, the cumulative radiation exposure and number of CT examinations of the head decreased among patients with aneurysmal subarachnoid hemorrhage because utilization guidelines defined the appropriate imaging time points for detection of vasospasm. Application of these methods to other patient populations with high use of CT may reduce cumulative radiation exposure while the clinical benefits of imaging are maintained.

Treatment of Neisseria meningitidis prosthetic joint infections with short-course antibiotics: three cases and a literature review.

Neisseria meningitidis is a rare cause of prosthetic joint infection (PJI), with only three cases previously reported. Here we report three further cases, all of which were successfully treated with implant retention and short-course antibiotics ( < 6  weeks).

Antimicrobial resistance in the Pacific Island countries and territories.

Antimicrobial resistance (AMR) is a critical global health threat with a disproportionate impact on low-income and middle-income countries (LMICs) due to their higher burden of infections, reduced laboratory surveillance infrastructure and fewer regulations governing antimicrobial use among humans or animals. While there have been increasing descriptions of AMR within many LMICs in WHO's Western Pacific and South East Asian regions, there remains a paucity of data from Pacific Island countries and territories (PICTs). The PICTs represent 22 predominantly middle-income countries and territories with a combined population of 12 million people and 20 official languages, spread over hundreds of separate islands spanning an area corresponding to more than 15% of the earth's surface. Our paper outlines the present state of the evidence regarding AMR in PICTs-discussing the present estimates of AMR and their accompanying limitations, important drivers of AMR, as well as outlining key priorities and potential solutions for tackling AMR in this region. Significant areas for action include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community. Ensuring adequate funding for AMR activities in PICTs is challenging given competing health and environmental priorities, in this context global or regional funding initiatives such as the Fleming Fund can play a key role.

Large paraspinal abscess as a complication of infliximab therapy in Crohn's disease.

We report a 36-year-old man who developed a large epidural and paraspinal abscess as a complication of infliximab therapy being used for underlying Crohn's disease. Cultures of the collection grew methicillin-susceptible Staphylococcus aureus, and treatment consisted of abscess drainage, prolonged intravenous and oral flucloxacillin and temporary withholding of his infliximab. While infection-related complications are well described with infliximab therapy, this is the first description of a large paraspinal abscess with epidural extension.

Delays in Patient Presentation and Diagnosis for Buruli Ulcer (Mycobacterium ulcerans Infection) in Victoria, Australia, 2011-2017.

Uncertainty regarding transmission pathways and control measures makes prompt presentation and diagnosis for Buruli ulcer critical. To examine presentation and diagnosis delays in Victoria, Australia, we conducted a retrospective study of 703 cases notified between 2011 and 2017, classified as residing in an endemic (Mornington Peninsula; Bellarine Peninsula; South-east Bayside and Frankston) or non-endemic area. Overall median presentation delay was 30 days (IQR 14-60 days), with no significant change over the study period (p = 0.11). There were significant differences in median presentation delay between areas of residence (p = 0.02), but no significant change over the study period within any area. Overall median diagnosis delay was 10 days (IQR 0-40 days), with no significant change over the study period (p = 0.13). There were significant differences in median diagnosis delay between areas (p < 0.001), but a significant decrease over time only on the Mornington Peninsula (p < 0.001). On multivariable analysis, being aged <15 or >65 years; having non-ulcerative disease; and residing in the Bellarine Peninsula or South-East Bayside (compared to non-endemic areas) were significantly associated with shorter presentation delay. Residing in the Bellarine or Mornington Peninsula and being notified later in the study period were significantly associated with shorter diagnosis delay. To reduce presentation and diagnosis delays, awareness of Buruli ulcer must be raised with the public and medical professionals, particularly those based outside established endemic areas.