Management and documentation of pneumonia - a comparison of patients consulting primary care and emergency care.

OBJECTIVE: To compare management and documentation of vital signs, symptoms and infection severity in pneumonia patients seeking primary care and emergency care without referral. DESIGN: Medical record review of vital signs, examination findings and severity of pneumonia. SETTING: Primary and emergency care. SUBJECTS: Two hundred and forty patients diagnosed with pneumonia. MAIN OUTCOME MEASURES: Vital signs, examination findings and severity of pneumonia. Assessments of pneumonia severity according to the reviewers, the traffic light score and CRB-65. RESULTS: Respiratory rate, blood pressure, heart rate and oxygen saturation were less often documented in primary care (p < .001). Chest X-ray was performed in 5% of primary care patients vs. 88% of emergency care patients (p < .01). Primary care patients had longer symptom duration, higher oxygen saturation and lower respiratory rate. In total, the reviewers assessed 63% of all pneumonias as mild and 9% as severe. The traffic light scoring model identified 11 patients (9%) in primary care and 53 patients (44%) in emergency care at high risk of severe infection. CONCLUSIONS: Vital signs were documented less often in primary care than in emergency care. Patients in primary care appear to have a less severe pneumonia, indicating attendance to the correct care level. The traffic light scoring model identified more patients at risk of severe infection than CRB-65, where the parameters were documented to a limited extent.

Pneumonia patients attending primary care have less affected vital signs than those attending emergency care.Vital signs were less documented in primary care than in emergency care.Patients with pneumonia seem to attend the correct level of care when they have the possibility to choose without a referral.CRB-65 was not possible to count in most primary care patients due to lack of documentation.

Diagnostic methods and written advice for acute otitis media in primary health care.

BACKGROUND: Otomicroscopy and pneumatic methods are superior to otoscopy alone in diagnosing acute otitis media (AOM). There is a lack of knowledge regarding the use of different diagnostic methods for AOM in primary health care in Sweden and Norway. METHODS: This cross-sectional study included a questionnaire completed by general practitioners (GPs) and specialist trainees (STs/residents/registrars) working in primary care in Sweden and Norway. Multivariable binary logistic regressions were performed to evaluate the use of diagnostic methods and written advice adjusted for educational level, sex and country. RESULTS: Otoscopy was the most frequently used method. Sweden had greater access to the more accurate diagnostic methods. In Norway, the following methods were used to a lesser extent: pneumatic otoscopy, adjusted OR 0.15 (95% CI 0.10-0.23; p < .001), otomicroscopy, adjusted OR 0.013 (95% CI 0.070-0.027; p < .001), pneumatic otomicroscopy, adjusted OR 0.028 (95% CI 0.010-0.078; p < .001) and tympanometry, adjusted OR 0.31 (95% CI 0.21-0.45; p < .001). Written advice was used to a greater extent in Norway, adjusted OR 4.5 (95% CI 3.1-6.7; p < .001). The STs used pneumatic otoscopy and pneumatic otomicroscopy to a lesser extent, adjusted OR 0.65 (95% CI 0.45-0.93; p = .019) and 0.63 (95% CI 0.43-0.92; p = .016). CONCLUSIONS: Swedish physicians both used and had greater access to the significantly better diagnostic methods compared with Norwegian physicians while the opposite applied to the use of written information. The GPs used pneumatic otoscopy and pneumatic otomicroscopy to a greater extent than STs. Compared with 2012, the Swedish physicians now more frequently used pneumatic otoscopy.

Use of chest X-ray in the assessment of community acquired pneumonia in primary care - an intervention study.

OBJECTIVES: The aim of this study was to explore if consequent use of chest X-ray (CXR), when the physician is not sure of the diagnosis of pneumonia after clinical examination and CRP-testing, favors a more restrictive prescribing of antibiotics. DESIGN: This was an intervention study conducted between September 2015 and December 2017. SETTING: Two intervention primary health care centers (PHCCs) and three control PHCCs in the southeast of Sweden. INTERVENTION: All patients were referred for CXR when the physician´s suspicion of pneumonia was 'unsure', or 'quite sure' after CRP-testing. Control units managed patients according to their usual routine after clinical examination and CRP-testing. SUBJECTS: A total of 104 patients were included in the intervention group and 81 patients in the control group. The inclusion criteria of the study were clinically suspected pneumonia in patients ≥18 years, with respiratory symptoms for more than 24 h. Main outcome measure: Antibiotic prescribing rate. RESULTS: In the intervention group, 85% were referred for CXR and 69% were prescribed antibiotics, as compared to 26% and 77% in the control group. The difference in antibiotic prescribing rate was not statistically significant, unadjusted OR 0.68 [0.35-1.3] and adjusted OR 1.1 [CI 0.43-3.0]. A total of 24% of patients with negative CXR were prescribed antibiotics. CONCLUSION: This study could not prove that use of CXR when the physician was not sure of the diagnosis of pneumonia results in lowered antibiotic prescribing rate in primary care. In cases of negative findings on CXR the physicians do not seem to rely on the outcome when it comes to antibiotic prescribing. Key Points Routine use of chest X-ray when the clinical diagnosis of pneumonia is uncertain has not been proven to result in lowered antibiotic prescribing rate. Physicians do not fully rely on chest X-ray outcome and to some extent prescribe antibiotics even if negative, when community-acquired pneumonia is suspected. Chest X-ray is already used in one out of four cases in routine primary care of pneumonia patients in Sweden.

Biophysical Screens Identify Fragments That Bind to the Viral DNA-Binding Proteins EBNA1 and LANA.

The human gamma-herpesviruses Epstein-Barr virus (EBV) (HHV-4) and Kaposi's sarcoma-associated herpesvirus (KSHV) (HHV-8) are responsible for a number of diseases, including various types of cancer. Epstein-Barr nuclear antigen 1 (EBNA1) from EBV and latency-associated nuclear antigen (LANA) from KSHV are viral-encoded DNA-binding proteins that are essential for the replication and maintenance of their respective viral genomes during latent, oncogenic infection. As such, EBNA1 and LANA are attractive targets for the development of small-molecule inhibitors. To this end, we performed a biophysical screen of EBNA1 and LANA using a fragment library by saturation transfer difference (STD)-NMR spectroscopy and surface plasmon resonance (SPR). We identified and validated a number of unique fragment hits that bind to EBNA1 or LANA. We also determined the high-resolution crystal structure of one fragment bound to EBNA1. Results from this screening cascade provide new chemical starting points for the further development of potent inhibitors for this class of viral proteins.

Multiplexed experimental strategies for fragment library screening against challenging drug targets using SPR biosensors.

Surface plasmon resonance (SPR) biosensor methods are ideally suited for fragment-based lead discovery.  However, generally applicable experimental procedures and detailed protocols are lacking, especially for structurally or physico-chemically challenging targets or when tool compounds are not available. Success depends on accounting for the features of both the target and the chemical library, purposely designing screening experiments for identification and validation of hits with desired specificity and mode-of-action, and availability of orthogonal methods capable of confirming fragment hits. The range of targets and libraries amenable to an SPR biosensor-based approach for identifying hits is considerably expanded by adopting multiplexed strategies, using multiple complementary surfaces or experimental conditions. Here we illustrate principles and multiplexed approaches for using flow-based SPR biosensor systems for screening fragment libraries of different sizes (90 and 1056 compounds) against a selection of challenging targets. It shows strategies for the identification of fragments interacting with 1) large and structurally dynamic targets, represented by acetyl choline binding protein (AChBP), a Cys-loop receptor ligand gated ion channel homologue, 2) targets in multi protein complexes, represented by lysine demethylase 1 and a corepressor (LSD1/CoREST), 3) structurally variable or unstable targets, represented by farnesyl pyrophosphate synthase (FPPS), 4) targets containing intrinsically disordered regions, represented by protein tyrosine phosphatase 1B  (PTP1B), and 5) aggregation-prone proteins, represented by an engineered form of human tau  (tau K18M). Practical considerations and procedures accounting for the characteristics of the proteins and libraries, and that increase robustness, sensitivity, throughput and versatility are highlighted. The study shows that the challenges for addressing these types of targets is not identification of potentially useful fragments per se, but establishing methods for their validation and evolution into leads.

Antibiotic Treatment for Lower Respiratory Tract Infections in Primary Care: A Register-Based Study Examining the Role of Radiographic Imaging.

When imaging (i.e., chest-x-ray or computed tomography) is used to differentiate between acute bronchitis and pneumonia, many patients are being prescribed antibiotics despite the absence of radiographic pneumonia signs. This study of lower respiratory tract infections (LRTIs) with negative chest imaging compares cases where antibiotics were prescribed and not prescribed to find characteristics that could explain the prescription. Data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for patients aged 18-79 years diagnosed with acute bronchitis or pneumonia and who had any chest radiologic imaging between 2007-2014. Of 696 cases without evidence of pneumonia on imaging, 55% were prescribed antibiotics. Age, sex, and co-morbidity did not differ between those with or without antibiotics. The median level of C-reactive protein was low in both groups but differed significantly (21 vs. 10 mg/L; p < 0.001). Resident physicians prescribed antibiotics more frequently than interns or specialists (p < 0.001). It is unclear what features prompted the antibiotic prescribing in those with negative imaging indicating overuse of antibiotics for LRTIs.

Elucidating Novel Targets for Ovarian Cancer Antibody-Drug Conjugate Development: Integrating In Silico Prediction and Surface Plasmon Resonance to Identify Targets with Enhanced Antibody Internalization Capacity.

Antibody-drug conjugates (ADCs) constitute a rapidly expanding category of biopharmaceuticals that are reshaping the landscape of targeted chemotherapy. The meticulous process of selecting therapeutic targets, aided by specific monoclonal antibodies' high specificity for binding to designated antigenic epitopes, is pivotal in ADC research and development. Despite ADCs' intrinsic ability to differentiate between healthy and cancerous cells, developmental challenges persist. In this study, we present a rationalized pipeline encompassing the initial phases of the ADC development, including target identification and validation. Leveraging an in-house, computationally constructed ADC target database, termed ADC Target Vault, we identified a set of novel ovarian cancer targets. We effectively demonstrate the efficacy of Surface Plasmon Resonance (SPR) technology and in vitro models as predictive tools, expediting the selection and validation of targets as ADC candidates for ovarian cancer therapy. Our analysis reveals three novel robust antibody/target pairs with strong binding and favourable antibody internalization rates in both wild-type and cisplatin-resistant ovarian cancer cell lines. This approach enhances ADC development and offers a comprehensive method for assessing target/antibody combinations and pre-payload conjugation biological activity. Additionally, the strategy establishes a robust platform for high-throughput screening of potential ovarian cancer ADC targets, an approach that is equally applicable to other cancer types.

Initial symptoms and three months follow-up after acute COVID-19 in outpatients: An international prospective cohort study.

BACKGROUND: Most studies on long-term follow-up of patients with COVID-19 focused on hospitalised patients. No prospective study with structured follow-up has been performed in non-hospitalised patients with COVID-19. OBJECTIVES: To assess long-COVID and post-COVID (WHO definition: symptomatic at least 12 weeks), describe lingering symptoms, their impact on daily activities, and general practice visits and explore risk factors for symptom duration in outpatients. METHODS: A prospective study of adult outpatients with confirmed SARS-CoV-2 infection and symptoms consistent with COVID-19 in 11 European countries, recruited during 2020 and 2021 from primary care and the community. Structured follow-up by phone interviews (symptom rating, symptom impact on daily activities and general practice visits) was performed at weeks 2, 4, 8, and 12 by study personnel. Data was analysed descriptively by using correlation matrixes and Cox regression. RESULTS: Of 270 enrolled patients, 52% developed long-COVID and 32% post-COVID-syndrome. When only considering the presence of moderate or (very) severe symptoms at weeks 8 and 12, these percentages were 28% and 18%, respectively. Fatigue was the most often reported symptom during follow-up. The impact of lingering symptoms was most evident in sports and household activities. About half (53%) had at least one general practice contact during follow-up. Obese patients took twice as long to return to usual health (HR: 0.5, 95%CI: 0.3-0.8); no other risk profile could predict lingering symptoms. CONCLUSION: Long-COVID and post-COVID are also common in outpatients. In 32%, it takes more than 12 weeks to return to usual health.

Prehospital delay is an important risk factor for mortality in community-acquired bloodstream infection (CA-BSI): a matched case-control study.

OBJECTIVES: The aim of this study was to identify prehospital and early hospital risk factors associated with 30-day mortality in patients with blood culture-confirmed community-acquired bloodstream infection (CA-BSI) in Sweden. METHODS: A retrospective case-control study of 1624 patients with CA-BSI (2015-2016), 195 non-survivors satisfying the inclusion criteria were matched 1:1 with 195 survivors for age, gender and microorganism. All forms of contact with a healthcare provider for symptoms of infection within 7 days prior CA-BSI episode were registered. Logistic regression was used to analyse risk factors for 30-day all-cause mortality. RESULTS: Of the 390 patients, 61% (115 non-survivors and 121 survivors) sought prehospital contact. The median time from first prehospital contact till hospital admission was 13 hours (6-52) for non-survivors and 7 hours (3-24) for survivors (p<0.01). Several risk factors for 30-day all-cause mortality were identified: prehospital delay OR=1.26 (95% CI: 1.07 to 1.47), p<0.01; severity of illness (Sequential Organ Failure Assessment score) OR=1.60 (95% CI: 1.40 to 1.83), p<0.01; comorbidity score (updated Charlson Index) OR=1.13 (95% CI: 1.05 to 1.22), p<0.01 and inadequate empirical antimicrobial therapy OR=3.92 (95% CI: 1.64 to 9.33), p<0.01. In a multivariable model, prehospital delay >24 hours from first contact remained an important risk factor for 30-day all-cause mortality due to CA-BSI OR=6.17 (95% CI: 2.19 to 17.38), p<0.01. CONCLUSION: Prehospital delay and inappropriate empirical antibiotic therapy were found to be important risk factors for 30-day all-cause mortality associated with CA-BSI. Increased awareness and earlier detection of BSI in prehospital and early hospital care is critical for rapid initiation of adequate management and antibiotic treatment.

C-reactive protein influences the doctor's degree of suspicion of pneumonia in primary care: a prospective observational study.

BACKGROUND: In primary care, the diagnosis of pneumonia is often based on history and clinical examination alone. However, a previous study showed that the general practitioner's degree of suspicion correlates well with findings on chest X-ray, when the C-reactive protein (CRP) value is known. OBJECTIVES: The present study aimed to investigate to what extent the physician's degree of suspicion is affected by the CRP level when community-acquired pneumonia is suspected in primary care. METHODS: A prospective observational study was conducted at five primary health care centres in Sweden between October 2015 and December 2017. Adult patients (n = 266) consulting their health care centre with symptoms of lower respiratory tract infection, where the physician suspected pneumonia, were included consecutively. Anamnestic information and findings from clinical examination were documented in a case report form. All patients were tested for CRP. The physicians rated their degree of suspicion as 'unsure,' 'quite sure,' and 'sure' before and after the CRP result. RESULTS: The degree of suspicion of pneumonia changed in 69% of the cases; most often to a lower degree (40%). In 28% of the cases, there was no longer any suspicion of pneumonia after CRP. CONCLUSION: Our results indicate that CRP testing highly influences the physician's degree of suspicion of pneumonia in primary care and that it seems to be of most value when not sure of the diagnosis.

Change in the use of diagnostic tests in the management of lower respiratory tract infections: a register-based study in primary care.

BACKGROUND: Differentiating between pneumonia and acute bronchitis is often difficult in primary care. There is no consensus regarding clinical decision rules for pneumonia, and guidelines differ between countries. Use of diagnostic tests and change of management over time is not known. AIM: To calculate the proportion of diagnostic tests in the management of lower respiratory tract infections (LRTIs) in a low antibiotic prescribing country, and to evaluate if the use and prescription pattern has changed over time. DESIGN & SETTING: A register-based study on data from electronic health records from January 2006 to December 2014 in the Kronoberg county of south east Sweden. METHOD: Data regarding use of C-reactive protein (CRP), chest x-rays (CXRs), microbiological tests, and antibiotic prescriptions were assessed for patients aged 18-79 years, with the diagnosis pneumonia, acute bronchitis, or cough. RESULTS: A total of 54 229 sickness episodes were analysed. Use of CRP increased during the study period from 61.3% to 77.5% for patients with pneumonia (P<0.001), and from 53.4% to 65.7% for patients with acute bronchitis (P<0.001). Use of CXR increased for patients with acute bronchitis from 3.1% to 5.1% (P<0.001). Use of microbiological tests increased for patients with pneumonia, from 1.8% to 5.1% (P<0.001). The antibiotic prescription rate decreased from 18.6 to 8.2 per 1000 inhabitants per year for patients with acute bronchitis, but did not change for patients with pneumonia. CONCLUSION: Use of CRP and microbiological tests in the diagnostics of LRTIs increased despite the fact that the incidence of pneumonia and acute bronchitis was stable.

Elastin- and collagen-rich human carotid plaques have increased levels of the cysteine protease inhibitor cystatin C.

BACKGROUND: Cystatin C is a major inhibitor of the elastin- and collagen-degrading cysteine proteases and may therefore have an important role in preserving atherosclerotic plaque stability. In this study we analyzed the associations between human carotid plaque cystatin C expression and the plaque content of collagen and elastin. METHODS: Thirty-one plaques were removed by endarterectomy and homogenized. Cystatin C levels were analyzed by densitometry of Western blots and elastin and collagen levels were determined colorimetrically. RESULTS: The plaque content of cystatin C correlated with total elastin (r = 0.58, p = 0.001) and collagen (r = 0.50, p = 0.004), as well as with cross-linked forms of elastin (r = 0.42, p = 0.022) and collagen (r = 0.52, p = 0.003). Immunohistochemical analysis demonstrated that cystatin C colocalized with elastin and collagen. No correlation was seen between cystatin C and the amount of degraded elastin or collagen in plaques. CONCLUSION: The positive correlation between cystatin C levels and collagen and elastin levels in plaques supports the notion that cystatin C plays an important role in maintaining atherosclerotic plaque stability.

Inhibition of homophilic dimerization and disruption of cell adhesion by P-cadherin-specific small molecules from SPR-based assays.

The inhibitor for the homophilic dimerization of P-cadherin was discovered by SPR-based screening using fragment compounds. Our SPR assays identified a specific P-cadherin binder, which was able to inhibit the cell adhesion of living CHO cells that expressed P-cadherin.

Determination of vitamin B12 in milk products and selected foods by optical biosensor protein-binding assay: method comparison.

Biomolecular interaction analysis was evaluated for the automated determination of vitamin B12 in a range of foods. The analytical technique was configured as a biosensor-based, nonlabeled inhibition protein-binding assay using nonintrinsic R-protein. Sample extraction conditions were optimized, and both ligand specificity and nonspecific binding considerations were evaluated. Performance parameters included a quantitation range of 0.08-2.40 ng/mL, recoveries of 89-106%, agreement against assigned reference values for 3 independent certified food reference materials, and a mean between-laboratory reproducibility relative standard deviation of 4.9%. The proposed method was compared with reference microbiological and radioisotope protein-binding methods for a range of food samples. A wide selection of milks, infant formulas, meats, and liver were evaluated for their vitamin B12 content. The influence of season was studied in herd milk, early lactation was followed for a single animal, and the cobalamin content of bovine, caprine, and ovine milks was compared.

Increased sensitivity of SPR assays in plasma through efficient parallel assay optimization.

The sensitivity of biosensor assays in complex media such as plasma or serum is often limited by non-specific binding. The degree of binding often varies between individuals and therefore a large number of different plasma samples have to be used during assay development. Some surface plasmon resonance (SPR) biosensors allow for parallel screening of several running buffer compositions, with a number of different immobilization levels for each buffer. These technical possibilities combined with statistical design of experiments (DoE) enable efficient parallel optimization of multiple assay conditions. In this paper we outline how to increase the sensitivity in SPR-based assays by minimizing background binding and variability from negative control plasma while retaining high signals from positive samples. To mimic immunogenicity studies of biotherapeutics we have used a model assay with anti-rituximab as an anti-drug antibody to be detected in plasma by binding to immobilized rituximab. Immobilization level and sodium chloride concentration were found to be the most important factors to optimize. There were also a number of significant interaction effects and strong non-linearites between the buffer composition/immobilization level and the assay performance, which necessitated DoE based optimization strategies. The applicability of the optimized conditions was verified with several assays (anti-erythropoietin, omalizumab, anti-IgE and anti-myoglobin) in spiked plasma samples resulting in detection levels in the range of 80-170 ng ml(-1). The buffer conditions presented in this paper can be used for other immunogenicity assays on biosensor platforms or as a good starting point for further assay development for new immunogenicity assays.

Use of a novel micro-fluidic device to create arrays for multiplex analysis of large and small molecular weight compounds by surface plasmon resonance.

There is an increasing demand to develop biosensor monitoring devices capable of biomarker profiling for predicting animal adulteration and detecting multiple chemical contaminants or toxins in food produce. Surface plasmon resonance (SPR) biosensors are label free detection systems that monitor the binding of specific biomolecular recognition elements with binding partners. Essential to this technology are the production of biochips where a selected binding partner, antibody, biomarker protein or low molecular weight contaminant, is immobilised. A micro-fluidic immobilisation device allowing the covalent attachment of up to 16 binding partners in a linear array on a single surface has been developed for compatibility with a prototype multiplex SPR analyser. The immobilisation unit and multiplex SPR analyser were respectively evaluated in their ability to be fit-for-purpose for binding partner attachment and detection of high and low molecular weight molecules. The multiplexing capability of the dual technology was assessed using phycotoxin concentration analysis as a model system. The parent compounds of four toxin groups were immobilised within a single chip format and calibration curves were achieved. The chip design and SPR technology allowed the compartmentalisation of the binding interactions for each toxin group offering the added benefit of being able to distinguish between toxin families and perform concentration analysis. This model is particularly contemporary with the current drive to replace biological methods for phycotoxin screening.

Implementing an integrated computerized patient record system: Towards an evidence-based information system implementation practice in healthcare.

A large number of health information system (HIS) implementations fail due to insufficient organizational harmonization. The aim of this study is to examine whether these problems remain when implementing technically integrated and more advanced generations of HISs. In a case study, data from observations, interviews, and organizational documents were analyzed using qualitative methods. We found that critical issues in the case study implementation process were the techniques employed to teach the staff to use the integrated system, involvement of the users in the implementation process, and the efficiency of the human computer interface. Comparisons with a literature review showed both recurrence of previously reported implementation problems and new issues specific to the integrated system context. The results indicate that the development of evidence-based implementation processes should be considered.