Lars Petter Bjørnsen

Changes in glial glutamate transporters in human epileptogenic hippocampus: Inadequate explanation for high extracellular glutamate during seizures

Temporal lobe epilepsy (TLE) with hippocampal sclerosis is associated with high extracellular glutamate levels, which could trigger seizures. Down-regulation of glial glutamate transporters GLAST (EAAT1) and GLT-1 (EAAT2) in sclerotic hippocampi may account for such increases. Their distribution was compared immunohistochemically in non-sclerotic and sclerotic hippocampi and localized only in astrocytes, with weaker immunoreactivity for both transporters in areas associated with pronounced neuronal loss, especially in CA1, but no decrease or even an increase in areas with less neuronal loss, like CA2 and the subiculum in the sclerotic group. Such compensatory changes in immunoreactivity may account for the lack of differences between the groups in immunoblot studies as blots show the average concentrations in the samples. These data suggest that differences in glial glutamate transporter distribution between the two groups of hippocampi may be an insufficient explanation for the high levels of extracellular glutamate in sclerotic seizure foci observed through in vivo dialysis studies.

Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality – a prospective study of patients admitted with infection to the emergency department

BackgroundWe aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS).MethodsThe study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry.ResultsOf the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert.DiscussionIn order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival.ConclusionIn this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria.

The GLT-1 (EAAT2; slc1a2) glutamate transporter is essential for glutamate homeostasis in the neocortex of the mouse

Glutamate is the major excitatory neurotransmitter, and is inactivated by cellular uptake catalyzed mostly by the glutamate transporter subtypes GLT‐1 (EAAT2) and GLAST (EAAT1). Astrocytes express both GLT‐1 and GLAST, while axon terminals in the neocortex only express GLT‐1. To evaluate the role of GLT‐1 in glutamate homeostasis, we injected GLT‐1 knockout (KO) mice and wild‐type littermates with [1‐13C]glucose and [1,2‐13C]acetate 15 min before euthanization. Metabolite levels were analyzed in extracts from neocortex and cerebellum and 13C labeling in neocortex. Whereas the cerebellum in GLT‐1‐deficient mice had normal levels of glutamate, glutamine, and 13C labeling of metabolites, glutamate level was decreased but labeling from [1‐13C] glucose was unchanged in the neocortex. The contribution from pyruvate carboxylation toward labeling of these metabolites was unchanged. Labeling from [1,2‐13C] acetate, originating in astrocytes, was decreased in glutamate and glutamine in the neocortex indicating reduced mitochondrial metabolism in astrocytes. The decreased amount of glutamate in the cortex indicates that glutamine transport into neurons is not sufficient to replenish glutamate lost because of neurotransmission and that GLT‐1 plays a role in glutamate homeostasis in the cortex.

The acute sick and injured patients: an overview of the emergency department patient population at a Norwegian University Hospital Emergency Department.

Objectives There is a lack of knowledge of the emergency department (ED) population in Norway; hence, the aim of this study was to describe the ED patient population at a Norwegian University Hospital. Materials and methods Prospective data of all ED patients admitted to the main ED over a period of 2 months were collected. The patients’ presenting complaint was registered using the International Classification of Primary Care-2 (ICPC-2). Results A total of 3163 patients arrived in the ED during the study period. The majority (71%) of patients presented with a complaint that was defined as a symptom in ICPC-2. The most common symptoms were abdominal pain (13%), chest pain (13%), and dyspnea (9%). The complaints of the remaining patients (29%) were primarily traumas, infections, and other diagnoses. Conclusion ED patients have a diverse spectrum of presenting complaints and the majority of patients present with symptoms rather than a defined medical diagnosis.

Hoping for a domino effect: a new specialty in Sweden is a breath of fresh air for the development of Scandinavian emergency medicine

Editorial Friday the 6th of July, 2012, was a great day for emergency medicine (EM) in Scandinavia: As the first in Scandinavia, the Swedish National Board of Health and Welfare (Socialstyrelsen) announced that emergency medicine (Akutsjukvard) will become a primary medical specialty in Sweden. This is a great leap forward for emergency care in Scandinavia and should be celebrated. It should also prompt medical authorities the in rest of Scandinavia to acknowledge that a specialty in EM is an important element in modern, high-quality emergency care. EM is now a specialty (or supraspecialty) in more than 60 countries including USA, UK, Australia, The Netherlands, Ireland, Iceland and Finland [1]. The number of new countries that recognize EM as a specialty is rapidly increasing. The Swedes success with securing specialty status for EM is a case study in how a specialty in EM can be established as part of a concept of high quality emergency care. Learning from the experiences from Sweden could help improve emergency care in other countries, in particular Denmark and Norway.

Patient visits to the emergency department at a Norwegian university hospital: variations in patient gender and age, timing of visits, and patient acuity

Background The patient visits to Norwegian emergency departments (EDs) have increased significantly over the last few years. A national evaluation revealed a lack of systematic activity control, resource management and quality improvement. This paper describes some variables in patient visits to an urban Norwegian university hospital. Methods The retrospective data were collected from a database (Akuttdatabasen) and included all patients admitted to the main ED at the St. Olavs University Hospital between 1 December 2010 and 1 December 2011. Results ED visits have increased by 44% over the last decade and show considerable timely variations. Almost 50% of the patients are older than 65 years of age. The rate of patients triaged with the highest acuity level was 11%, but only 1.3% of the patients were admitted to the Intensive Care Unit (ICU). The total admission rate was 89%. Conclusions The increase in ED visits to the St. Olavs Hospital in recent years follows the same trend as in other countries. The authors see a slightly higher percentage of high level acuity patients compared with international studies due the general practitioners intended ‘gatekeeper’ function. The authors also found a high total admission rate and a low ICU admission rate compared with other countries. These differences cannot be explained solely by differences in the healthcare system in Norway. The cultural and traditional organisation of the Norwegian Health Care System needs to change and this creates an excellent opportunity to improve the competence by establishing emergency medicine as a specialty in Norway.