A Quality Improvement Initiative: Developing a Multi-Disciplinary Team for Infective Endocarditis.

BACKGROUND: As guidelines do not describe how to develop a multi-disciplinary team(MDT), we provide a model using quality improvement tools to design a MDT for infective endocarditis (IE). METHODS: Primary service, specialty teams and whether they had surgery or not (indications, reasons, outcomes and complications) were recorded for IE patients for January-December 2016. Criteria: age >18years and definite IE per modified Duke criteria. RESULTS: Of all cases, 29/82 met criteria. Primary service: internal medicine 18(62.1%), medical intensive care and cardiology 4(13.8%) each, family medicine 2(7.9%) and pediatrics 1(3.4%). Surgery was indicated in 21(72.4%), 9 (42.9%) underwent surgery, 12 (57.1%) did not [6/9(66.67%) left side IE died, all right side IE (3,25%) survived] and 2 (22.2%) had missed opportunities and this was chosen as the leverage point. MDT was developed to reduce the number of left sided IE patients not undergoing surgery despite indications. CONCLUSIONS: Quality improvement and team development tools help in developing MDT for IE.

Differential coronary microvascular exchange responses to adenosine: roles of receptor and microvessel subtypes.

OBJECTIVE: To assess the role of adenosine receptors in the regulation of coronary microvascular permeability to porcine serum albumin (P(s)(PSA)). METHODS: Solute flux was measured in single perfused arterioles and venules isolated from pig hearts using fluorescent dye-labeled probes by microspectro-fluorometry. Messenger RNA, protein, and cellular distribution of adenosine receptors in arterioles and venules were analyzed by RT-PCR, immunoblot, and immunofluorescence. RESULTS: Control venule P(s)(PSA) (10.7 +/- 4.8 x 10(- 7) cm x s(- 1)) was greater than that of arterioles (6.4+/- 2.8 x 10(-7) cm . s(-1); p < .05). Arteriolar P(s)(PSA) decreased (p < .05) with adenosine suffusion over the range from 10(- 8) to 10(-5) M, while venular P(s)(PSA) did not change. The nonselective A(1) and A(2) receptor antagonist, 8-(p-sulfophenyl) theophylline, blocked the adenosine-induced decrease in arteriolar P(s)(PSA). Messenger RNA for adenosine A(1), A(2A), A(2B), and A(3) receptors was expressed in arterioles and venules. Protein for A(1), A(2A), and A(2B), but not A(3), was detected in both microvessel types and was further demonstrated on vascular endothelial cells. CONCLUSION: Arteriolar P(s)(PSA) decreases with adenosine suffusion but not venular P(s)(PSA). Adenosine A(1), A(2A), and A(2B) receptors are expressed in both arterioles and venules. Selective receptor-linked cellular signaling mechanisms underlying the regulation of permeability remain to be determined.

Sexual dimorphism in the permeability response of coronary microvessels to adenosine.

Gender influences volume regulation via several mechanisms; whether these include microvascular exchange, especially in the heart, is not known. In response to adenosine (Ado), permeability (P(s)) to protein of coronary arterioles of female pigs decreases acutely. Whether Ado induces similar P(s) changes in arterioles from males or whether equivalent responses occur in coronary venules of either sex has not been determined. Hypotheses that 1) basal P(s) properties and 2) P(s) responses to vasoactive stimuli are sex independent were evaluated from measures of P(s) to two hydrophilic proteins, alpha-lactalbumin and porcine serum albumin (PSA), in arterioles and venules isolated from hearts of adult male and female pigs. Consistent with hypothesis 1, basal P(s) values of both microvessel types were independent of sex. Contrary to hypothesis 2, P(s) responses to Ado varied with sex, protein, and vessel type. Confirming earlier studies, Ado induced a approximately 20% decrease in P(s) to both proteins in coronary arterioles from females. In arterioles from males, Ado did not change P(s) for alpha-lactalbumin (P(s)(alpha-lactalb), 3 +/- 13%), whereas P(s) for PSA (P(s)(PSA)) decreased by 27 +/- 8% (P < 0.005). In venules from females, Ado elevated P(s)(PSA) by 44 +/- 20% (P < 0.05), whereas in those from males, Ado reduced P(s)(PSA) by 24 +/- 5% (P < 0.05). The variety of outcomes is consistent with transvascular protein and protein-carried solute flux being regulated by multiple sex-dependent mechanisms in the heart and provides evidence of differences in exchange homeostasis of males and females in health and, likely, disease.