Identification of the adult septic patient in the prehospital and emergency department setting

Sepsis is one of the most urgent conditions encountered within emergency care but is often difficult to recognize due to its non-specific presentations. One third of the patients lack the classic sign of infection; i.e. fever, and it is often not obvious that the patient suffers from an underlying infection, which is a prerequisite for sepsis. Identification of sepsis within emergency care is today mainly based on clinical judgment, which is known to have a low sensitivity. Timely identification and treatment influence patient outcome. We believe that screening tools may increase the identification of septic patients, which may in turn improve outcome. The problem is that current screening tools designed for emergency care are based on vital signs despite one third of the patients with severe infections present with normal vital signs. The general aim of the current thesis was to study the presentation of adult septic patients within emergency care and to find a way to improve identification of the septic patient. The thesis builds upon four studies; Study I was a retrospective cross-sectional study of 353 septic Emergency Medical Services (EMS) patients. Two previously unvalidated screening tools were compared to clinical judgment by EMS with respect to sepsis identification. The Robson screening tool (including temperature, heart rate, respiratory rate, altered mental status, plasma glucose, and a history suggestive of a new infection) surpassed both BAS 90-30-90 (refers to the vital signs systolic blood pressure, respiratory rate and oxygen saturation) and clinical judgment with respect to sensitivity for identification of septic patients in the ambulance. Study II was a retrospective cross-sectional study where time to treatment and mortality among 61 septic Emergency Department (ED) patients with ED chief complaint decreased general condition (DGC) was compared with that of 516 septic patients with other ED chief complaints. Furthermore, the sensitivity and specificity of the Robson screening tool was compared with that of clinical judgment by the ED physician among 122 patients presenting to the ED with chief complaint DGC, of which 61 were discharged with ICD-code sepsis. Septic patients with non-specific presentations, here exemplified as the chief complaint DGC, had a longer time to treatment and a higher mortality. A larger proportion of these patients was identified as septic if the Robson screening tool was applied. Clinical judgment was more specific than the Robson screening tool. In Study III the presentation of septic patients within the prehospital setting was explored and keywords relating to symptom presentation were identified. A mixed-methods analysis was conducted, starting with a content analysis of 80 EMS records from septic patients, followed by quantification of the identified keywords, among 359 septic EMS patients admitted the following year. Keywords related to patients´ symptom presentation recurred, so that a pattern was discernible, and some symptoms were particularly frequent. Furthermore, certain keywords were associated with a high mortality. Study IV was a prospective cohort study of 878 EMS patients. Symptoms, vital signs and POC variables were associated with outcome sepsis/ infection/ no infection. Variables with the strongest association to sepsis among the 551 patients with suspected infection were used to create a screening tool; the Predict Sepsis screening tool. The predictive accuracy of the Predict Sepsis screening tool exceeded that of prior proposed prehospital screening tools. Conclusions: In general, our findings indicate a low sensitivity of emergency care providers´ clinical judgment and support the use of a screening tool, with respect to sepsis identification within emergency care. However, neither earlier proposed tools nor the Predict Sepsis screening tool identifies all septic patients, and addition of novel variables such as symptoms in the screening process were not as important as we had expected. Nevertheless, this approach may be of greater benefit if tested among unselected emergency care patients, i.e. not only among those with a suspected infection, to identify septic patients with non-specific presentations. Sepsis identification remains a challenge within emergency care, mainly due to the diversity of its presentations. Increased education would most likely increase sepsis identification. However, an enhanced understanding of the underlying pathophysiology to explain the diversity in sepsis presentation is of major concern to improve identification. Future identification and management of sepsis may require consideration of delineated sub-populations of septic patients

Dynamics of serum antibodies to and load of porcine circovirus type 2 (PCV2) in pigs in three finishing herds, affected or not by postweaning multisystemic wasting syndrome

Background: Despite that PMWS commonly affects pigs aged eight to sixteen weeks; most studies of PMWS have been conducted during the period before transfer to finishing herds. This study focused on PCV2 load and antibody dynamics in finishing herds with different PMWS status. Methods: Sequentially collected blood samples from 40 pigs in each of two Swedish (A and B) and one Norwegian (C) finishing herds were analysed for serum PCV2-load and -antibodies and saliva cortisol. The two Swedish herds differed in PMWS status, despite receiving animals from the same sow pool (multi-site production). However, the PMWS-deemed herd (A) had previously also received pigs from the spot market. ResultsThe initial serum PCV2 load was similar in the two Swedish herds. In herd A, it peaked after two weeks in the finishing herd and a high number of the pigs had serum PCV2 levels above 10(7) per ml. The antibody titres increased continually with exception for the pigs that developed PMWS, that had initially low and then declining antibody levels. Pigs in the healthy herd B also expressed high titres of antibodies to PCV2 on arrival but remained at that level throughout the study whereas the viral load steadily decreased. No PCV2 antibodies and only low amounts of PCV2 DNA were detected in serum collected during the first five weeks in the PMWS-free herd C. Thereafter a peak in serum PCV2 load accompanied by an antibody response was recorded. PCV2 from the two Swedish herds grouped into genotype PCV2b whereas the Norwegian isolate grouped into PCV2a. Cortisol levels were lower in herd C than in herds A and B. Conclusions: The most obvious difference between the Swedish finishing herds and the Norwegian herd was the time of infection with PCV2 in relation to the time of allocation, as well as the genotype of PCV2. Clinical PMWS was preceded by low levels of serum antibodies and a high load of PCV2 but did not develop in all such animals. It is notable that herd A became affected by PMWS after errors in management routine, emphasising the importance of proper hygiene and general disease-preventing measures

Excess breast cancer risk and the role of parity, age at first childbirth and exposure to radiation in infancy

Exposure to ionizing radiation is a known risk factor for breast cancer and the fertility pattern is a recognized modifier of breast cancer risk. The aim of this study was to elucidate the interaction between these 2 factors. This study is based on a Swedish cohort of 17 202 women who had been irradiated for skin haemangiomas in infancy between 1920 and 1965. The mean age at treatment was 6 months and the median breast dose was 0.05 Gy (range 0–35.8 Gy). Follow-up information on vital status, parity, age at first childbirth and breast cancer incidence was retrieved through record linkage with national population registers for the period 1958–1995. Analyses of excess relative risk (ERR) models were performed using Poisson regression methods. In this cohort, the fertility pattern differed from that in the Swedish population, with significantly fewer childbirths overall and before 25 years of age but more childbirth after that age. There were 307 breast cancers in the cohort and the standardized incidence ratio (SIR) was 1.22 (95% CI 1.09–1.36). A linear dose–response model with stratification for fertility pattern and menopausal status resulted in the best fit of the data. ERR/Gy was 0.33 (95% CI 0.17–0.53). In absolute terms this means an excess of 2.1 and 5.4 cases per Gy per 104breast-years in the age groups 40–49 and 50–59 years respectively. The fertility pattern influenced the breast cancer risk in this irradiated population in a similar way to that observed in other studies. SIR at dose = 0 was highest, 2.31, among postmenopausal nulliparous women (95% CI 1.48–3.40, n = 62). SIR at dose = 0 was lowest in pre- or postmenopausal women with a first childbirth before 25 years of age; 0.89 (0.71–1.09) and 0.88 (0.58–1.25) respectively. Thus, in addition to the dose–effect response in the cohort, part of the breast cancer excess could be explained by a different fertility pattern. The estimates of ERR/Gy for the various categories of age at first childbirth, number of children, menopausal status and ovarian dose were very similar, contradicting any interaction effects on the scale of relative risk. © 2001 Cancer Research Campaign http://www.bjcancer.co

The paradox of public acceptance of bike sharing in Gothenburg

Bike sharing is one of the most promising urban planning interventions to facilitate an all-necessary transition towards a more sustainable transport paradigm. Regardless of the fact that hundreds of schemes run in more than 50 countries worldwide, bike sharing is still moderately investigated by research. This paper reports on a primarily quantitative study of 558 responses that was set to frame attitudes reflecting public acceptance towards the rapidly expanding bike-sharing scheme in Gothenburg (Styr & Ställ), in an attempt to identify the ‘formula for success’. The respondents generally believed that Styr & Ställ is a pro-environmental, inexpensive and healthy transport mode, which complements the city’s public transport services and promotes a more human-friendly identity for Gothenburg. Even the respondents that self-reported a small (or no) likelihood to use bike sharing were positive towards the scheme. This means that they recognise that bike sharing has a significant pro-social potential and is not a system favouring a particular road-user segment over others that might not be interested or able to use it. The fact that the majority of the respondents do not Bike sharing is one of the most promising urban planning interventions to facilitate an all-necessary transition towards a more sustainable transport paradigm. Regardless of the fact that hundreds of schemes run in more than 50 countries worldwide, bike sharing is still moderately investigated by research. This paper reports on a primarily quantitative study of 558 responses that was set to frame attitudes reflecting public acceptance towards the rapidly expanding bike-sharing scheme in Gothenburg (Styr & Ställ), in an attempt to identify the ‘formula for success’. The respondents generally believed that Styr & Ställ is a pro-environmental, inexpensive and healthy transport mode, which complements the city’s public transport services and promotes a more human-friendly identity for Gothenburg. Even the respondents that self-reported a small (or no) likelihood to use bike sharing were positive towards the scheme. This means that they recognise that bike sharing has a significant pro-social potential and is not a system favouring a particular road-user segment over others that might not be interested or able to use it. The fact that the majority of the respondents do not use the scheme and yet its popularity is still vast indicates that there is much potential for more use in real terms

Eradication of Salmonella Yoruba in an integrated pig herd

An integrated SPF herd with 320 sows was found infected with Salmonella Yoruba during an annual control among sows, aiming to verify freedom from Salmonella infections. It is believed that the infection was introduced to the herd by purchase of feed. The herd performed an age segregated rearing system. Sows and piglets were reared at a central farm, while growers (25-1 00 kg body weight) were reared at sub-estates. The growers were free from the infection, and as a consequence a specially designed eradication program was designed

Impairments in contractility and cytoskeletal organisation cause nuclear defects in nemaline myopathy

Nemaline myopathy (NM) is a skeletal muscle disorder caused by mutations in genes that are generally involved in muscle contraction, in particular those related to the structure and/or regulation of the thin filament. Many pathogenic aspects of this disease remain largely unclear. Here, we report novel pathological defects in skeletal muscle fibres of mouse models and patients with NM: irregular spacing and morphology of nuclei; disrupted nuclear envelope; altered chromatin arrangement; and disorganisation of the cortical cytoskeleton. Impairments in contractility are the primary cause of these nuclear defects. We also establish the role of microtubule organisation in determining nuclear morphology, a phenomenon which is likely to contribute to nuclear alterations in this disease. Our results overlap with findings in diseases caused directly by mutations in nuclear envelope or cytoskeletal proteins. Given the important role of nuclear shape and envelope in regulating gene expression, and the cytoskeleton in maintaining muscle fibre integrity, our findings are likely to explain some of the hallmarks of NM, including contractile filament disarray, altered mechanical properties and broad transcriptional alterations

A critical review of the impacts of cover crops on nitrogen leaching, net greenhouse gas balance and crop productivity

This work contributes to the UK-China Virtual Joint Centre N-Circle (grant number BB/N013484/1), SuperG (funded under EU Horizon 2020 programme) and ADVENT (grant number NE/M019691/1). DRC was supported by the UK-China Virtual joint Centre for Agricultural Nitrogen (CINAg, BB/N013468/1) and the UK-Brazil Virtual Joint Centre to deliver enhanced N-use efficiency via an integrated soil-plant systems approach (NUCLEUS), which are jointly supported by Newton fund via UK BBSRC and NERC. Jaak Truu received financing from Estonian Research Council (grant PRG548).Peer reviewedPublisher PD