Digital Sepsis Research Articles

Retrospective evaluation of the causes and distribution of lameness in beef and dairy cattle evaluated by ambulatory and in-house clinical services at a North American veterinary teaching hospital

Since lameness occurs so commonly and has such significant effects on cattle productivity and farm profitability, manage­ment and prevention of lameness is essential to the design of effective health and husbandry programs. Unfortunately, the causes and distribution of lameness lesions between beef and dairy cattle, as well as the different management groups within a specific production class, can differ dramatically. A recent report analyzing data from 17 dairies found infectious condi­tions, specifically digital dermatitis and foot rot, were the most common cause of lameness in first-lactation cattle. In contrast, non-infectious lesions, namely white line disease and sole and toe ulcers, were the most common cause of lameness in cows in their second or greater lactation. A report evaluating the inci­dence of specific causes of lameness in cattle on 6 commercial beef feedlots found that the most frequently identified causes of lameness were upper limb issues and deep digital sepsis. How­ever, when characterizing different causes of lameness in beef cattle outside of feedlots, there exists a dearth of published data. Therefore, the objective of this study was to describe the different causes and distribution of lameness in beef and dairy cattle presenting to either a primary care ambulatory service or in house referral services at a veterinary teaching hospital in the southeastern United States.

Prevalence of electronic screening for sepsis in National Health Service acute hospitals in England

Sepsis is a worldwide public health problem. Rapid identification is associated with improved patient outcomes—if followed by timely appropriate treatment.ObjectivesDescribe digital sepsis alerts (DSAs) in use in English National Health...

Automated digital technologies for supporting sepsis prediction in children: a scoping review protocol

IntroductionWhile there have been several literature reviews on the performance of digital sepsis prediction technologies and clinical decision-support algorithms for adults, there remains a knowledge gap in examining the development...

Acute Neonatal Upper Limb Ischemia: Topical Vasodilation, Anticoagulation and Physical Therapy-A new option for complete reversal of ischemia

Acute upper limb ischemia in neonates is extremely rare and oftenassociated with disastrous outcomes including digital gangrene, chroniclimb ischemia, sepsis and limb loss. It is usually seen in the contextof intra-arterial catheters in the preterm neonates but it can be alsoseen in cases of difficult or traumatic deliveries as well as in infantswith coagulation deficits but can also be spontaneous with no obviousaetiology. Treatment options include topical vasodilators, systemicanticoagulation and in some instances, surgical intervention. We reportthree cases of acute limb ischemia in preterm neonates in which anew treatment option was introduced. The neonates responded to acombination of topical nitro-glycerine cream, systemic anticoagulationwith heparin and physical light massaging of the area just proximalto the site of reduced flow in the vessel assuming some degree ofvasospasm of the vessel occurs with or without thrombosis.Keywords: neonatal ischemia, management of neonatal ischemia, topicalvasodilators, systemic anticoagulation, massage therapy, surgicalintervention

Corrigendum to: Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data.

Corrigendum to: Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data.

Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data.

ObjectiveThe study sought to determine the impact of a digital sepsis alert on patient outcomes in a UK multisite hospital network.Materials and MethodsA natural experiment utilizing the phased introduction (without randomization) of a digital sepsis alert into a multisite hospital network. Sepsis alerts were either visible to clinicians (patients in the intervention group) or running silently and not visible (the control group). Inverse probability of treatment-weighted multivariable logistic regression was used to estimate the effect of the intervention on individual patient outcomes.OutcomesIn-hospital 30-day mortality (all inpatients), prolonged hospital stay (≥7 days) and timely antibiotics (≤60 minutes of the alert) for patients who alerted in the emergency department. ResultsThe introduction of the alert was associated with lower odds of death (odds ratio, 0.76; 95% confidence interval [CI], 0.70-0.84; n = 21 183), lower odds of prolonged hospital stay ≥7 days (OR, 0.93; 95% CI, 0.88-0.99; n = 9988), and in patients who required antibiotics, an increased odds of receiving timely antibiotics (OR, 1.71; 95% CI, 1.57-1.87; n = 4622).DiscussionCurrent evidence that digital sepsis alerts are effective is mixed. In this large UK study, a digital sepsis alert has been shown to be associated with improved outcomes, including timely antibiotics. It is not known whether the presence of alerting is responsible for improved outcomes or whether the alert acted as a useful driver for quality improvement initiatives.ConclusionsThese findings strongly suggest that the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.

Evaluating a digital sepsis alert in a multi-site hospital: a natural experiment

Abstract Background This study investigated the impact of a digital sepsis alert on patient outcomes in a busy London multi-site hospital. Sepsis is a serious illness and common cause of death, but rapid diagnosis and treatment improve patient outcomes. Digital health records allow algorithms to be embedded which ‘alert’ clinicians to patients who are at risk of developing sepsis. Despite the current promotion of ‘digital health’, evidence of the impact of algorithm driven alerts on patient outcomes is limited. Methods A retrospective natural experiment utilising the phased introduction of a digital sepsis alert into a large, multi-site hospital in England. Silent alerts (not visible to clinicians) acted as controls. Outcome measures were in-hospital all-cause mortality within 30 days of the alert, extended hospital stay (≥7 days) and timely antibiotics (≤60 minutes of the alert). Inversely weighted multivariable logistic regression was used to determine associations between alert and patient outcomes. Results In a sample of 21,183 inpatients, the mortality rate was 5.9%. The active, visible alert was associated with lower odds of death (Odds Ratio (OR):0.76; 95%CI:(0.70, 0.84)). In 9988 emergency department attendances ending in admission, 40.6% had an extended hospital stay and 41.5% received timely antibiotics. The active alert was associated with lower odds of extended hospital stay (OR:0.93; 95%CI:(0.88, 0.99)) and increased odds of receiving timely antibiotics (OR:1.71; 95%CI:(1.57, 1.87)). Conclusions This study demonstrates that a move to digital health, through an automated sepsis alert, embedded in digital health records, was associated with improved health outcomes. Further work is needed to identify the causal pathway, which is likely to include more rapid treatment with antibiotics, and possible unintended consequences. These findings support the ongoing roll out of digital alerting and provide a model for robustly evaluating their impact. Key messages The introduction of an automated sepsis alert associated with the use of improvement methodology was associated with improved process measures and patient outcomes. Introduction of digital health interventions can, and should, be robustly evaluated with appropriate statistical approaches.

Therapy for deep digital sepsis

Therapy for deep digital sepsis (DDS) can be both challenging and rewarding. It can be as routine as digit amputation or as complex as invasive corrective surgery. The precise mode of therapy will be dictated by numerous factors including the structures involved, value of the animal, its intended use and expected longevity, body size, and the experience and facilities available to the veterinarian. This discussion will be limited to techniques applicable to being performed on a tilt table under local/regional anesthesia rather than more advanced techniques involving arthroscopy/tenoscopy that require general anesthesia, expensive equipment, and considerable training to implement. Description of the methods for differentiation of various causes of deep digital sepsis are reviewed in an earlier manuscript in this volume (see Deep digital sepsis in cattle - clinical differentiation). Additionally, techniques for digit salvage via facilitated ankylosis of the distal interphalangeal joint may be mentioned but not fully detailed.

Deep digital sepsis in cattle

Deep digital sepsis (DDS) as applied to bovine lameness is not strictly defined, but for the purposes of this discussion will include infection of bones, joints, bursa or tendon sheaths within the foot. Often, there are infections of several of these structures in the same digit. Such infections are most commonly due to extension of infection from more superficial layers as in the case of advanced sole ulceration, white line disease or toe tip necrosis, but can be secondary to direct penetration or trauma. Deep digital sepsis should be suspected when lameness is severe coupled with 1 or more of the following: asymmetrical swelling of the foot, swelling extending proximal to the pastern region, and a duration of severe lameness of >2 weeks. Lameness associated with deep digital sepsis (DDS) is severe and requires aggressive and somewhat expensive therapy to resolve. Recognition of the development of DDS is critical to appropriate management of a lameness case. Description of therapeutic options will be provided in another paper in this volume (see Therapy of Deep Digital Sepsis).

Local anaesthesia and analgesia guidance for surgical treatment of cows with necrotic hoof lesions

Necrotic hoof lesions are an increasingly common finding amongst chronically lame cows in UK dairy herds. Some vets have reported these lesions as the most common indication for claw amputation, replacing historic causes such as deep digital sepsis. More recently, some hoof trimmers and cattle veterinarians have adopted a surgical debridement approach with some success, leading to resolution of lesions once called ‘non-healing’. A key part of success is ensuring there is regional or local anaesthesia of the distal limb, and sufficient analgesia during and following the procedure to manage pain. This article reviews some of the considerations for cattle practitioners.

Lymphoedema of the limbs: an experience from a tertiary clinic in the central province of Sri Lanka

Objective A descriptive study to evaluate the pattern of presentation of lymphoedema of limbs to a tertiary care clinic in the central province of Sri Lanka. Patients and Method Patients with lymphoedema seen over 28 years, (1980-2007) in the vascular clinic at the General Hospital Peradeniya were reviewed retrospectively. Results 649 cases of lymphoedema of limbs were seen. 47 were in the upper limb, 36 of whom were secondary, mostly following axillary clearance associated with a mastectomy, and 11 cases were idiopathic. 602 patients had their lower limbs involved, with 96 cases amongst them being secondary, mostly to trauma, filariasis and a few with pelvic carcinoma and lymphoma. The rest (n =506) were considered to have lymphoedema of primary aetiology. The involvement of the legs was predominantly below the knees. A late onset group of lymphoedema patients, predominantly males above 60 years posed a problem in diagnosis and is worth future study. Complications among patients with lymphoedema of lower limbs with no overt secondary cause included inter digital cleft sepsis in 54.5 %, cellulitis or a history of the same in 66 %, lymphangitis 16 % lymphadenitis 3.5% and 11 % had septicaemia which aggravated the clinical state. Conclusion Primary lymphoedema needs recognition as the dominant cause of limb lymphoedema especially in the Central Province. This diagnosis is required to prevent complications which need long term treatment. A filarial aetiology for most cases, as is popularly believed, is not evidence based. Secondary causes for lower limb lymphoedema must be looked for, such as pelvic malignancy and lymphoma. Trauma or surgery over lymphatic pathways should be avoided to prevent limb lympheodema.

Surgical treatment in deep digital sepsis in cattle – Claw preserving methods and claw amputation

Still today lameness represents a major health problem in many dairy farms with prevalences ranging from 0 to 70%; mean prevalence rates of about 36% were reported by many authors. Unfortunately, the lameness prevalence is highly underestimated by farmers. An acceptable lameness prevalence in dairy herds regarding ethical and economical considerations is 5% to maximal 10%. Lameness continues to be one of the largest economic drains on dairy farming and is one of the three most common reason for culling, preceded by reproductive failure and mastitis. Lameness results in direct loss via culling as well as indirect loss via decreased production of milk, milk fat and protein, reproductive failure, prolonged calving interval, extra labor of the dairy farmer and the foot trimmer, extra visits of the veterinarian, treatment costs and costs for discarded milk.

Incidence of lameness and association of cause and severity of lameness on the outcome for cattle on six commercial beef feedlots.

OBJECTIVE To describe the incidence of specific causes of lameness and the associations of cause and severity of lameness on the outcome for cattle on commercial feedlots. DESIGN Dynamic population longitudinal study. ANIMALS Cattle on 6 commercial feedlots in Kansas and Nebraska during a 12-month period (mean daily population, 243,602 cattle; range, 223,544 to 252,825 cattle). PROCEDURES Feedlot personnel were trained to use a standardized diagnostic algorithm and locomotion score (LMS) system to identify and classify cattle by cause and severity of lameness. Information regarding lameness cause, severity, and treatments was recorded for individual cattle. Cattle were monitored until they left the feedlot (ie, outcome; shipped with pen mates [shipped], culled prematurely because of lameness [realized], or euthanized or died [died]). Incidence rates for various causes of lameness, LMSs, and outcomes were calculated. The respective associations of cause of lameness and LMS with outcome were evaluated. RESULTS Lameness was identified in 2,532 cattle, resulting in an overall lameness incidence rate of 1.04 cases/100 animal-years. Realized and mortality rates were 0.096 cattle/100 animal-years and 0.397 deaths/100 animal-years, respectively. Injury to the proximal portion of a limb was the most frequently identified cause of lameness followed by undefined lameness, septic joint or deep digital sepsis, and interdigital phlegmon (foot rot). As the LMS (lameness severity) at lameness detection increased, the percentage of cattle that died but not the percentage of cattle that were realized increased. CONCLUSIONS AND CLINICAL RELEVANCE Results provided clinically useful prognostic guidelines for management of lame feedlot cattle.

Predicting Sepsis Risk Using the "Sniffer" Algorithm in the Electronic Medical Record.

The Sepsis "Sniffer" Algorithm (SSA) has merit as a digital sepsis alert but should be considered an adjunct to versus an alternative for the Nurse Screening Tool (NST), given lower specificity and positive predictive value. The SSA reduced the risk of incorrectly categorizing patients at low risk for sepsis, detected sepsis high risk in half the time, and reduced redundant NST screens by 70% and manual screening hours by 64% to 72%. Preserving nurse hours expended on manual sepsis alerts may translate into time directed toward other patient priorities.

Comments on the dilemma in the November/December issue: ‘Fate of a severely lame cow’

The dilemma in the November/December issue concerned a severely lame cow with deep digital sepsis. It had lost a lot of condition and was 10/10 lame. Despite your opinion that...

Bacteremia in the pedal circulation following regional intravenous perfusion of a 2% lidocaine solution in cattle with deep digital sepsis.

To evaluate whether pedal bacteremia develops following regional IV perfusion (RIVP) of a 2% lidocaine hydrochloride solution in cattle with deep digital sepsis (DDS) and to determine which bacterial pathogens are most commonly isolated from the pedal circulation. Prospective observational cohort study. 9 adult cattle with DDS in 10 limbs and 10 healthy adult cattle with no evidence of lameness or digital infection. Blood samples were obtained aseptically from the dorsal common digital vein immediately following tourniquet application and 30 to 60 minutes after aseptic RIVP with a 2% lidocaine solution. Aerobic and anaerobic bacterial cultures were performed on all samples collected. For cattle with DDS, clinical examination with or without debridement of digital lesions was performed after RIVP. Bacteria were isolated from pedal blood prior to RIVP in 1 cow with DDS and after RIVP and examination with or without debridement in that cow and 4 additional cattle with DDS. Bacteria were not isolated from any blood sample obtained from the healthy cattle. Of the 8 bacterial isolates identified, 5 were gram-positive facultative anaerobes. Cattle with DDS were significantly more likely to develop bacteremia in the pedal circulation than were healthy cattle following RIVP. Results indicated that bacteremia may be present in the pedal circulation before and following RIVP and examination with or without debridement in cattle with DDS. Thus, systemic or local antimicrobial treatment might be warranted prior to or concurrently with RIVP in cattle with DDS.

Strategies for Managing Septic Arthritis of the Digit in Cattle

Conservative therapy of deep sepsis of the digit is generally unrewarding even with prolonged administration of antibiotics. What we consider prolonged antibiotic administration in bovine practice is clearly different from that employed in other species. In nonruminant species including humans, treatment with antibiotics for septic arthritis typically extends for 2 months or 3 weeks after all clinical signs have resolved. This duration of therapy is clearly not practical in cattle and still might not resolve the types of lesions occurring in the digits. The end result following a common 1 to 2-week course of antibiotics for septic digital arthritis is usually euthanasia or culling after appropriate withholding for drug residues. In the author's opinion, less than 5% of cases of deep digital sepsis respond satisfactorily to such conservative treatment. Why? Possibilities include failure to choose an appropriate antibiotic, inability of the antibiotic to penetrate to the site of infection, or drug resistant strains of bacteria. Most digital infections are caused by a mixed population of bacteria including at least Arcanobacterium pyogenes and Fusobacterium necrophorum; there may also be various Streptococci, Staph. aureus, and other anaerobes involved.8