Coming in Hot: A quality improvement approach to improving care of febrile infants.

Background and Objectives: Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period. Methods: Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods. Results: Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period. Conclusions: The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED. Purpose: To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.

Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula.

While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.

Trans-11 vaccenic acid improves insulin secretion in models of type 2 diabetes in vivo and in vitro.

SCOPE: Trans-11 vaccenic acid (VA) is a fatty acid produced by ruminants entering the human food supply through meat and dairy products, which appears not to have the health risks associated with industrially produced trans-fatty acids. In this study, we investigated the effect of VA on insulin secretion in vivo in rats and in vitro in human and rat islets after diabetogenic insult. METHODS AND RESULTS: Hyperglycemic clamp showed that VA dietary supplementation for 8 weeks significantly increased glucose turnover in rats with type 2 diabetes (T2D), accompanied by an elevated plasma C-peptide concentration, indicating improved insulin secretion. The ß-cell area and proliferation rate were higher in T2D+VA than T2D group. Isolated islets from T2D+VA rats had higher glucose-stimulated insulin secretion (GSIS) than T2D group. In vitro, VA treatment for 24 and 48 h significantly enhanced GSIS in rat and human islets after diabetogenic challenges. The mRNA expression of G-protein-coupled receptor 40 (GPR40) and regenerating islet-derived 1α (REG-1α) were consistently increased by VA in both rat and human islets. CONCLUSION: These results indicate that VA may improve insulin secretion and growth of islets in T2D, at least partly by altering GPR40 and REG-1α mRNA expression.

Improved glucose tolerance in insulin-resistant rats after pea hull feeding is associated with changes in lipid metabolism-targeted transcriptome.

Understanding of the mechanisms by which pulse grain fractions elicit beneficial effects on glucose tolerance is incomplete. An untargeted metabolomic analysis of serum from insulin-resistant rats was carried out to identify potential metabolic pathways affected by feeding rats the hull fraction of dried peas for 4 weeks. From this, we hypothesized that transcription of hepatic genes involved in lipid metabolism would be altered. cDNA was prepared from total RNA extracted from livers of rats fed a high-fat diet (HFD) or HFD + pea hulls (PH) diet. The liver lipid transcriptome of each cDNA sample was characterized using a PCR-based array of 84 genes. The activity of peroxisome-proliferator-activated receptor alpha (PPAR-α) was measured in hepatocyte nuclei. The predominant findings of the metabolomic analysis revealed a significant increase in the intermediaries of ß-oxidation: C16-OH and C16:1 acylcarnitines (>50%, p < 0.05) and 3-hydroxybutyrate (100%, p < 0.05) in the PH group compared with the HFD group. mRNA of hadha, a gene involved in ß-oxidation, was significantly reduced by 53% (p < 0.005) in the PH group compared with the HFD group, but no differences in PPAR-α activity were detected. 3-Hydroxybutyrate concentrations were associated with insulin sensitivity and reduced demand for insulin. The results indicate that feeding PH alters lipid metabolism in liver, which may contribute to improved glucose tolerance in insulin-resistant rats.