Rural hospital mass casualty response to a terrorist shooting spree.

BACKGROUND: Civilian mass casualty incidents may occur infrequently and suddenly, and are caused by accidents, natural disasters or human terrorist incidents. Most reports deal with trauma centre management in large cities, and data from small local hospitals are scarce. A rural hospital response to a mass casualty incident caused by a terrorist shooting spree was evaluated. METHODS: An observational study was undertaken to evaluate the triage, diagnosis and management of all casualties received from the Utøya youth camp in Norway on 22 July 2011 by a local hospital, using data from the hospital's electronic records. Descriptive data are presented for patient demographics, injuries and patient flow. RESULTS: The shooting on Utøya youth camp left 69 people dead and 60 wounded. A rural hospital (Ringerike Hospital) triaged 35 patients, of whom 18 were admitted. During the main surge, the hospital triaged and treated 22 patients within 1 h, of whom 13 fulfilled the criteria for activating the hospital trauma team, including five with critical injuries (defined as an Injury Severity Score above 15). Ten computed tomography scans, two focused assessment with sonography for trauma (FAST) scans and 25 conventional X-rays were performed. During the first 24 h, ten surgical procedures were performed and four chest drains inserted. No patient died. CONCLUSION: Critical deviation from the major incident plan was needed, and future need for revision is deemed necessary based on the experience. Communication systems and the organization of radiological services proved to be most vulnerable.

Early neonatal lamb mortality: postmortem findings.

An investigation of stillbirth and early neonatal lamb mortality was conducted in sheep flocks in Norway. Knowledge of actual causes of death are important to aid the interpretation of results obtained during studies assessing the risk factors for lamb mortality, and when tailoring preventive measures at the flock, ewe and individual lamb level. This paper reports on the postmortem findings in 270 liveborn lambs that died during the first 5 days after birth. The lambs were from 17 flocks in six counties. A total of 27% died within 3 h after birth, 41% within 24 h and 80% within 2 days. Most lambs (62%) were from triplet or higher order litters. In 81% of twin and larger litters, only one lamb died. The most frequently identified cause of neonatal death was infectious disease (n=97, 36%); 48% (n=47) of these died from septicaemia, 25% (n=24) from pneumonia, 22% (n=21) from gastrointestinal infections and 5% (n=5) from other infections. Escherichia coli accounted for 65% of the septicaemic cases, and were the most common causal agent obtained from all cases of infection (41%). In total, 14% of neonatal deaths resulted from infection by this bacterium. Traumatic lesions were the primary cause of death in 20% (n=53) of the lambs. A total of 46% of these died within 3 h after birth and 66% within 24 h. Severe congenital malformations were found in 10% (n=27) of the lambs, whereas starvation with no concurrent lesions was the cause of death in 6% (n=17). In 16% (n=43) of the lambs, no specific cause of death was identified, lambs from triplet and higher order litters being overrepresented among these cases. In this study, the main causes of neonatal lamb mortality were infection and traumatic lesions. Most neonatal deaths occurred shortly after birth, suggesting that events related to lambing and the immediate post-lambing period are critical for lamb survival.

Pregnancy associated glycoproteins (PAG) in postpartum cows, ewes, goats and their offspring.

Determination of plasma concentrations of pregnancy associated glycoproteins (PAG) has been used for early pregnancy diagnosis in cows. However, this is complicated by the presence of PAG in plasma for an extended period postpartum. The main objective of the present study was to investigate the postpartum elimination rates of pregnancy associated glycoproteins (PAG) in sheep, goats and cows in order to gain background information applicable to the use of PAG for pregnancy diagnosis in domestic ruminants. A second objective was to investigate whether PAG are transferred to the foetus and newborn, by measuring plasma PAG concentrations in calves, lambs and goat kids before and after colostrum feeding. PAG in the blood at parturition were eliminated by a first order process in the cows and ewes, while a two-step log-linear decline occurred in the goats. Estimated postpartum half-life of plasma PAG in the cows and ewes was 9 and 4.5 days, respectively. In the goats, half-lives were 3.6 and 7.5 days in the initial fast and terminal slow phase. Basal levels were reached 80-90 days postpartum in cows. Plasma PAG concentration can be used for pregnancy diagnosis from day 28 after AI, provided that the time interval from calving to AI is >60 days. Using a heterologous antibody RIA, we found 4 ng/mL to be the appropriate cut-off. Due to the presence of PAG residues from the previous gestation, the interval from AI to pregnancy diagnosis should increase by approximately 0.5 days beyond 28 days for each day of AI closer to calving than 60. Measurements in newborn ruminants suggested that PAG enter the foetal blood in utero and that colostral PAG are transferred to the newborn. Following the peak plasma concentration observed 1 day after birth in most of the animals, PAG were rapidly eliminated in a log-linear fashion.

Polyethylene wear, osteolysis and acetabular loosening with an HA-coated hip prosthesis. A follow-up of 94 consecutive arthroplasties.

We have followed up for a period of seven to nine years 100 consecutive arthroplasties of the hip in which an entirely HA-coated implant had been used. The clinical results were excellent and bony incorporation was extensive in all components. No stem became loose or subsided but five cups were revised because of loosening after 3.8 to 5.5 years, having functioned painlessly and shown radiological ingrowth. Revision procedures because of excessive polyethylene wear have been performed on 18 hips and are planned for six more. Two eroded metal backings with worn-through polyethylene were exchanged; six hips showed metallosis without polyethylene wear-through. There were two cases of granulomatous cysts in the groin and 66 hips had osteolysis located periarticularly, in the greater trochanter or in the acetabulum.

Influence of new infection with bovine virus diarrhoea virus on udder health in Norwegian dairy cows.

A retrospective longitudinal study was conducted to examine whether the exposure of dairy herds to bovine virus diarrhoea virus (BVDV) affected udder health. All Norwegian dairy herds that had experienced a marked increase in the BVDV antibody titres in bulk milk (from a level corresponding to an optical density (OD) <0.25 to >0.55, as determined by an indirect enzyme-linked immunosorbent assay) between two nation-wide herd screening examinations carried out late in 1992 and 1993, respectively, were considered to have been exposed to BVDV during the period between the examinations. The reference group included all dairy herds in which the bulk milk was BVDV antibody-negative or had only very low titres of BVDV antibodies (OD <0.25) each year from 1992 to 1995. The annual incidence rate of clinical mastitis, the bulk-milk somatic-cell count, and the annual rate of culling because of mastitis in the herds, were compared in the year of BVDV exposure (1993) as well as in a period prior to exposure (from 1988 to 1992) and two years following the year of exposure. In herds exposed to BVDV, there was a 7% increase in the incidence rate of clinical mastitis in the year of exposure, as compared with the nonexposed herds. No significant changes attributable to BVDV exposure were observed in the bulk-milk somatic-cell count or in the rate of culling because of mastitis.

Clinical bovine mastitis in Norway.

A brief description of the Norwegian Health Card System for Cattle (NHCSC) is given. The incidence of clinical mastitis (CM) for dairy cows in Norway was determined using NHCSC data recorded from 1992 to 1995. Incidence density (ID) (which included repeated episodes of CM in the same cow) and various measures of risk were estimated. The ID for the entire study period, comprising almost 1.2 million cow-years, was 49 CM episodes per 100 cow-years at risk. Twenty-six percent of the cows with CM experienced at least two episodes of CM in 1 year. For the entire study period (1992-1995), the ID was 30 episodes per 100 cow-years at risk for acute CM (ACM). Annual risk of CM for fixed cohorts of cows that were at risk 1 January the particular year, as estimated by the actuarial method and accounting for the exact time of removal of culled cows, varied between 0.32 (1992) and 0.35 (1994 and 1995). Numerically similar risk estimates were found when using the density method for fixed cohorts. Lactational incidence risk for cows that calved in 1992-1994 varied between 0.32 and 0.34. In herds of a size greater than five cow-years, the crude ID of CM tended to decrease with increasing herd size. The ID of CM varied considerably between counties, and was higher in coastal areas than in inland areas.

Plasma concentrations of cortisol in cows with hypocalcaemia in relation to their responses to treatment with calcium.

The mean plasma concentration of cortisol at the time of the first treatment for hypocalcaemia at calving was significantly higher in 17 cows which did not recover, than in 53 cows which recovered. Healthy periparturient cows had significantly lower cortisol levels than cows with hypocalcaemia. There was a negative correlation between plasma cortisol and plasma calcium at the time of the first treatment. After adjustment for differences in plasma calcium there was no significant difference between cortisol concentrations in healthy cows and paretic cows which recovered. Plasma cortisol was positively correlated with both packed cell volume (PCV) and serum creatine kinase (CK). At first treatment cows which did not recover had higher levels of PCV and serum CK than cows which recovered, and the difference between the mean plasma cortisol concentrations of these two groups was related to differences in plasma calcium, PCV and serum CK. Plasma cortisol concentrations remained high in cases of protracted paresis.

Comparison of two regimens for the treatment of clinical bovine mastitis caused by bacteria sensitive to penicillin.

The efficacies of two regimens for the treatment of acute clinical mastitis were compared in a randomised multi-centre field trial in Norway, using 657 cows. The purpose was to determine whether repeated intramuscular injections of penicillin G for three days were more effective than a single injection, when given in combination with intramammary treatment for five days. The results were evaluated on the basis of clinical and microbiological examinations and cell count determinations of quarter milk samples taken at the initial visit and four weeks later. There were no significant differences between the effects of the treatments, either for all the cows, or for subgroups of the cows based on age, stage of lactation, and systemic reaction, or the type of causal bacteria.

Diagnostic alternatives used by veterinary surgeons for the recording of udder diseases in the Norwegian Health Card System for Cattle.

A questionnaire, in which 7 cases of udder disease were described, was distributed to 890 veterinarians in Norway. They were requested to classify the cases according to the diagnostic alternatives listed in the Norwegian Health Card System for Cattle (NHCSC). The NHCSC recordings are used for progeny testing of bulls, for disease monitoring, and for research purposes. The aim of this study was to evaluate the quality of the recordings for udder diseases. The questionnaire was answered by 633 veterinary surgeons. Four cases of clinical mastitis (CM) with abnormal secretion as well as other clinical signs of inflammation were correctly classified as CM by almost 100% of the veterinary surgeons. A cow in the final stage of lactation, showing no clinical signs except for clots in the milk, was considered not to be a clinical case by more than 25% of the veterinary surgeons. A typical case of subclinical mastitis (SM) was reported as SM by 83% of the veterinary surgeons, and as CM by 16%. A subclinical case with a recent history of clots in the secretion was classified as SM by 66% of the veterinary surgeons, but almost 40% either reported CM as their sole diagnosis or considered the case to be CM in combination with SM. Of the clinical cases, those exhibiting marked local signs of inflammation and a systemic reaction were correctly classified as acute clinical mastitis (ACM) by 96%-98% of the veterinary surgeons. In the NHCSC, the diagnostic alternatives for cases of CM are ACM and chronic clinical mastitis (CCM). One case, for which the diagnosis subacute clinical mastitis was appropriate according to standard definitions, was classified as CCM by 66%, and as ACM by 6%. Based on the information given in the questionnaire, the diagnosis for 2 of the clinical cases could have been either ACM or CCM, and for both cases each of these 2 alternatives was reported by more than 43% of the veterinary surgeons. A teat lesion, which was present together with ACM in one cow, was reported by 91% of the veterinary surgeons.

Evaluation of a cow-side test for detection of gram-negative bacteria in milk from cows with mastitis.

A modified Limulus amebocyte lysate (LAL) cow-side test was evaluated under field conditions. The principle of the test is to visualize reactions between test components and endotoxin from the cell wall of Gram-negative bacteria. The practical purpose is to detect such bacteria in mastitic milk. Secretions from 789 udder quarters with clinical mastitis were examined by the LAL-test. Parallel quarter milk samples were sent to a mastitis laboratory of microbiological examination. Eleven veterinary surgeons in three veterinary districts in Norway performed the field investigations. Results of the LAL-test and culture agreed in 93% of all milk samples tested, agreement measured by kappa being 0.63. The sensitivity of the test in detecting Gram-negative bacteria was 63%, while the specificity was 97%. The predictive value of a positive test result was 70%, the figure being somewhat higher (75%) when the material was limited to milk samples without antibiotic residues. The predictive value of a negative test result was 95%. The LAL-test is considered to constitute a valuable cow-side test for the veterinary practitioner, aiding the selection of antibacterial drug of choice for the initial treatment of clinical mastitis.

A study of phage- and ribotype patterns of Staphylococcus aureus isolated from bovine mastitis in the Nordic countries.

This study was conducted to investigate the geographical distribution of phage and ribotypes of Staphylococcus aureus causing bovine mastitis in the 5 Nordic countries. A total of 403 isolates of S. aureus was isolated from 403 different dairy herds. One hundred five strains were isolated in Denmark, 81 in Finland, 17 in Iceland, 96 in Norway and 104 in Sweden. The isolates were phage typed and characterized for their EcoRI restriction fragment length polymorphisms of the genes encoding ribosomal RNA (ribotyping). A total of 351 (87%) of the 403 isolates could be typed by phages assigning them to 25 different phage types. Two to 3 different phage types predominated within each country. One type (29/52) accounted for 36% of all the isolates and was found in 4 of the countries. A total of 87 different ribotypes was found among the isolates investigated. As for phage typing 2 to 3 different types predominated within countries. However, except for one type (ribotype 1), which was commonly found in Denmark, Sweden and Finland, different ribotypes predominated within each country. The combination of phage and ribotyping assigned the isolates to 178 different types. Ninety-six percent of the isolates of ribotype 1 belonged to phage type 29/52. This combined type accounted for 17% of all the 403 isolates. These findings show that a large number of different types of S. aureus can be isolated from cases of bovine mastitis. However, few types predominate within different countries. These predominating types seem to be specific in each country, however, a single type was common for both Denmark, Sweden and Finland. This could suggest differences in the virulence or in modes of transmission of predominating and rare types of S. aureus associated with bovine mastitis.

Transfer of the second toe for reconstruction of the hand after trauma.

Twenty-six transfers of second toe to hand have been carried out in 25 cases. On 25 occasions the toe was anastomosed to the stump of the thumb, and in one to a metacarpal hand. Revascularization failed in five cases, but the remaining 21 healed with bony union occurring within six weeks in all cases. The mean follow up period was 52 months, range 14-81, and the results in 19 thumb cases were classified as excellent and in one as good by the Tamai score. We conclude that the microsurgical technique of transferring the second toe to the hand is challenging, but if revascularization is successful the functional results are good. Morbidity at the donor site is minimal.

Persistence of staphylococcal species and genotypes in the bovine udder.

Staphylococci are a major cause of intramammary infections (IMI) in ruminants. The main aim of this study was to investigate staphylococcal IMI in dairy cattle with emphasis on persistence and distribution of staphylococcal species and genotypes. With a sampling interval of 4-8 weeks, over a year, 4030 samples from 206 cows in 4 herds were collected. Coagulase-negative staphylococci (CNS) and Staphylococcus aureus were detected in 13.2% and 4.2% of the samples, respectively. Selected CNS isolates from quarter milk samples were identified to species level using sodA sequencing. Staphylococcus chromogenes (32%) and Staphylococcus simulans (25%) predominated. The proportion of S. chromogenes was greater in primiparous (52%) than in multiparous cows (12%), while the opposite was the case for Staphylococcus epidermidis (6% and 21%, respectively). Isolates from possibly persistent IMI were selected for pulsed-field gel electrophoresis (PFGE). Six staphylococcal species were found to cause persistent IMI; S. aureus, S. chromogenes, S. simulans, S. epidermidis, Staphylococcus haemolyticus and Staphylococcus warneri. It was shown that several pulsotypes (PTs) within each species were associated with persistent infections, but only a few were spread and caused persistent IMI in multiple cows within a herd. Of special interest was the observation that only one, or a few, strains of each species caused persistent IMI in multiple cows within a same herd. This indicates strain differences with respect to transmissibility and pathogenicity.

Comparison of Staphylococcus aureus genotypes recovered from cases of bovine, ovine, and caprine mastitis.

Staphylococcus aureus is an important pathogen in domestic ruminants. The main objective of this study was to determine the similarity of epidemiologically unrelated S. aureus isolates from bovine, ovine, and caprine mastitis. By pulsed-field gel electrophoresis, 160 different pulsotypes (PTs) were identified among 905 isolates recovered from 588 herds in 12 counties in Norway. Based on estimates of similarity, using an 80% cluster cutoff, the isolates were assigned to 47 clusters. One cluster included 62% of all the isolates and more than 45% of the isolates from each host species. Twenty-three PTs included isolates from more than one host species; these 23 PTs represented 72% of all the isolates. The six most prevalent PTs included isolates from all host species and contained 45% of the bovine isolates, 54% of the ovine isolates, and 37% of the caprine isolates. Antimicrobial susceptibility testing of 373 of the isolates revealed resistance to penicillin in 2.9% and to streptomycin in 2.4%; only 1.9% were resistant to 1 of the other 11 antimicrobials tested. The results of this study suggest that a small number of closely related genotypes are responsible for a great proportion of S. aureus mastitis cases in cows, ewes, and goats in Norway and that these genotypes exhibit little or no host preference among these species. Selection due to antimicrobial resistance appears not to have contributed to the predominance of these genotypes.

Persisting hypocalcaemia in the cow--predisposing factors.

Results from a clinical study involving 540 cows which recovered after one treatment for hypocalcaemia, 159 cows which recovered after two treatments for hypocalcaemia, and 61 cows which recovered after at least three treatments for hypocalcaemia, showed that the number of treatments before recovery was significantly related to the following factors: Plasma Ca, plasma Mg, packed cell volume, time of first treatment in relation to calving, season of the year, previous milk fever history, management system and the cow's body condition.

The relationship between certain clinical characteristics and course of disease in milk fever in dairy cows.

Recovery rate after one treatment and mortality rate in cows with clinical milk fever were related to several clinical characteristics recorded immediately prior to first treatment, namely: Appetite, mobility, demeanour, whether or not hyperhidrosis was present, pulse quality, pulse rhythm, pulse rate and rectal temperature. Furthermore, the same symptoms at second treatment and subsequent course of disease in milk fever cows which received at least two treatments were found to be related. Recovery rate after first treatment was lower in cows which had been recumbent for more than one hour before treatment than in those which had been down for a shorter period. As regards cows which received at least two treatments, the recovery rate after second treatment was higher in those which had been on their feet for a shorter or longer period between first and second treatment than in those which has been recumbent during this period.

The relationship between packed cell volume and the course of disease in milk fever in dairy cows.

Results from a field investigation involving 1086 cows with clinical milk fever, revealed a clear relationship between PCV at the time of first treatment and the subsequent course of the disease. Average PCV was progressively higher as the cows required one, two, or more than two treatments before recovery, and was highest in cows which subsequently failed to recover. PCV in healthy, periparturient cows was considerably lower than in cows with milk fever. PCV was negatively correlated with plasma Ca, and varied, moreover, with the time of first treatment in relation to calving, and also with the length of time the cow had been recumbent before being treated for the first time. PCV was also measured during the further course of the disease in cows which received more than one treatment (2nd to 6th treatments).

Milk fever in the cow--course of disease in relation to the serum activity of aspartate aminotransferase, alanine aminotransferase, creatine kinase and gamma-glutamyltransferase.

The serum activity of aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), creatine kinase (CK), and gamma-glutamyltransferase (GGT) was determined at the time of first and subsequent treatments in milk fever cows which responded differently to treatment, and in a number of healthy, periparturient cows. Serum ASAT, ALAT and CK levels were lower in the healthy cows than in the milk fever cows at first treatment. Serum ASAT and serum CK were, at first treatment, higher in the milk fever cows which did not recover than in those which recovered. At second and subsequent treatments, serum ASAT and serum ALAT were higher in the cows which failed to recover, and these cows also showed the highest levels of serum CK up-to and including fourth treatment. After an overall assessment of serum activity of the various enzymes, it is concluded that muscle damage was a significant complication both in cows which recovered and in those which failed to recover, while liver damage was of little importance.

Hypocalcaemia in the ewe.

Hypocalcaemia was verified in 74.4% of 78 ewes with a clinical diagnosis of hypocalcaemia, the corresponding figure for 99 ewes with an uncertain clinical diagnosis of hypocalcaemia being 21.2%. The tendency to developed hypocalcaemia increased with increasing age. Hypocalcaemic cases were recorded from about 2 months prior to lambing to approx. 11/2 months after lambing, most frequently occurring during the period 2-4 weeks before lambing. The number of lambs in ewes which developed hypocalcaemia was on the average greater than in a group of healthy control ewes. Plasma Ca was higher in ewes with hypocalcaemia which stood firmly as compared with atactic or recumbent cases, and higher in those which showed tetany, were restless or which appeared to be relatively normal, than in those which were dull or comatose. Plasma Mg was lowest in the ewes with tetany. Values for ASAT, ALAT, bilirubin, haemoglobin and packed cell volume were significantly higher in hypocalcaemic ewes than in the healthy control ewes. In the hypocalcaemic ewes, plasma Ca and packed cell volume were negatively correlated, while plasma Ca and plasma P were positively correlated. Approx. 20% of the ewes with hypocalcaemia did not recover. These had higher average plasma Ca and lower average plasma Mg at first treatment than those which recovered. The mortality rate in ewes treated after parturition was higher than in those treated before parturition. Of the hypocalcaemic cases which recovered, approx. 25% required more than one treatment. Ewes which developed hypocalcaemia before lambing and which recovered, lost 22% of their lambs, the main reason probably being premature birth. The differential diagnosis of hypocalcaemia is discussed in the light of clinical and clinico-chemical findings in normocalcaemic ewes to which a diagnosis of clinical or uncertain clinical hypocalcaemia had been given.