Short communication: Parameters of abomasal emptying and glucose-insulin dynamics in Holstein-Friesian calves at 2 ages and 2 levels of milk replacer intake.

Elevated planes of nutrition in the preweaning period of dairy calf management can increase average daily gain, shorten age at puberty, and increase milk yield. In a previous study, 12 Holstein calves were fed 2 meals/d of 4 or 2 L milk replacer up to 7 wk of age. The objective of the current study was to estimate parameters of abomasal emptying and glucose-insulin dynamics in these calves by fitting a mechanistic model to postprandial appearances of plasma glucose, insulin, and the abomasal emptying marker acetaminophen measured at 4 and 7 wk of age. Higher intake of milk replacer resulted in longer bouts of abomasal emptying at a slower rate. Parameters of glucose and insulin dynamics were not affected by milk replacer intake. However, older calves had decreased insulin-stimulated glucose utilization indicating impaired insulin sensitivity, as well as increased pancreatic responsiveness. Neither of these effects were apparent from i.v. glucose tolerance tests on the calves and may have been related to postprandial gut hormone release. Effects of age on parameters of glucose-insulin dynamics were larger than effects of milk replacer intake. Conversely, effects of milk replacer intake on abomasal emptying were larger than effects of age.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

The role of biofilm on orthopaedic implants: the "Holy Grail" of post-traumatic infection management?

The development of post-traumatic infection is potentially a limb threatening condition. The orthopaedic trauma literature lags behind the research performed by our arthroplasty colleagues on the topic of implant-related infections. Surgical site infections in the setting of a recent ORIF are notoriously hard to eradicate due to biofilm formation around the implant. This bacteria-friendly, dynamic, living pluri-organism structure has the ability to morph and adapt to virtually any environment with the aim to maintain the causative organism alive. The challenges are twofold: establishing an accurate diagnosis with speciation/sensitivity and eradicating the infection. Multiple strategies have been researched to improve diagnostic accuracy, to prevent biofilm formation on orthopaedic implants, to mobilize/detach or weaken the biofilm or to target specifically bacteria embedded in the biofilm. The purpose of our paper is to review the patho-physiology of this mysterious pluri-cellular structure and to summarize some of the most pertinent research performed to improve diagnostic and treatment strategies in biofilm-related infections.

[Is the standard retention of syndesmotic positioning screws after ankle fracture fixation safe and feasible? A retrospective cohort study in 140 consecutive patients at a North American trauma centre]. / Ist das routinemäßige Belassen von Syndesmosenschrauben nach operativer Versorgung instabiler Sprunggelenksfrakturen gerechtfertigt? Erfahrung eines US-Traumazentrums an 140 konsekutiven Patienten.

BACKGROUND: Unstable ankle injuries with associated disruption of the distal-fibular syndesmosis are typically managed by adjunctive placement of temporary syndesmotic positioning screws. The widespread notion that positioning screws must be removed by default after healing of the syndesmosis remains a topic of debate which lacks scientific support. The present study was designed to test the hypothesis that syndesmotic positioning screws are safely retained per protocol in asymptomatic patients. PATIENTS AND METHODS: A retrospective analysis of an institutional prospective database was performed during a 5-year time-window at an academic level 1 trauma centre in the United States. All ankle fractures requiring surgical fixation were included in the analysis. The primary outcome parameter consisted of the rate of elective hardware removal for syndesmotic positioning screws within 6 months after surgical fixation. RESULTS: A total of 496 consecutive patients with 496 isolated ankle fractures managed by surgical fixation were included in this study. Of these, 140 injuries were managed by placement of syndesmotic positioning screws. Within 6 months follow-up, 17.1% of all syndesmotic screws were found to be radiographically broken, and 13.6% of syndesmotic screws revealed radiographic signs of loosening. Only 2 patients (1.4%) required the elective removal of symptomatic positioning screws within 6 months of surgical fracture fixation. CONCLUSION: Despite the high rate of radiographic complications related to breaking or loosening of syndesmotic screws in almost one third of all cases, more than 98% of all patients remain asymptomatic and do not require a scheduled hardware removal. The routine removal of syndesmotic positioning screws does not appear to be justified from a patient safety perspective.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy.

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Evidence-based medicine: a 'hidden threat' for patient safety and surgical innovation?

We explore the limitations of complete reliance on evidence-based medicine which can be diminished by confounding issues and sampling bias. Other strategies which may be reasonably invoked are discussed.

Use of dietary feather meal to induce histidine deficiency or imbalance in dairy cows and effects on milk composition.

Removing His from a postruminal AA infusion decreases milk protein and increases milk fat content. Feather meal is an inexpensive protein source, high in rumen undegradable protein but low in His. The objective of our study was to investigate dietary feather meal as a method for creating a His deficiency or imbalance to alter milk composition. Four dietary treatments were fed for 4 wk each to 8 multiparous mid-lactation Holstein cows in a replicated 4 × 4 Latin square design. A standard-protein control diet (SP-C) was formulated to provide 3,100g/d of metabolizable protein (MP). Feather meal was added to the control diet either to replace the MP isonitrogenously (SP-FM) or to increase the MP supply to 3,484 g/d (HP-FM). As an isonitrogenous control for HP-FM, a high-protein diet (HP-C) was formulated with His-adequate protein sources to provide the same MP content as HP-FM. Dry matter intake tended to decrease when feather meal was fed. Predicted flows of digestible His, Met, and Lys, and plasma concentrations of these AA were reduced on both feather meal diets. Predicted flows of total digestible essential AA were not different between HP-FM and SP-C. We concluded that the DMI depression on HP-FM prevented an imbalance of excess AA over His, and created a deficiency of His, Met, and Lys compared with SP-C. Milk production decreased on the 2 feather meal treatments, partly explained by a tendency for DMI to decrease. Milk yield was lowest on SP-FM at 30.3 kg/d and highest on HP-C at 37.9 kg/d. Milk fat yield was not affected by diet but protein and lactose yields were both lower with feather meal. Protein yields were 860 and 998 g/d, whereas lactose yields were 1,384 and 1,561 g/d for SP-FM and HP-FM, respectively. This resulted in a higher fat content and lower protein percentage on FM diets. The ratio of solids-not-fat:fat in milk was lowest on SP-FM at 2.11 compared with 2.56 on SP-C. Adding feather meal to the diet by replacing MP isonitrogenously was more effective at lowering the solids-not-fat:fat ratio than increasing the MP content with an imbalanced protein source.

[Challenging the dogma on inferiority of stainless steel implants for fracture fixation. An end of the controversy?]. / Das Dogma der Minderwertigkeit von Stahlimplantaten zur Frakturversorgung. Ein Ende der Kontroverse?

BACKGROUND: Titanium plates represent the predominant implants of choice for fracture care in Central Europe, based on the apparently favourable properties related to improved "biocompatibility". The present study was designed to test the hypothesis that the use of stainless steel implants for selected fractures represents a safe and efficient treatment modality, which is not associated with an increased rate of complications and surgical revisions. METHODS: We conducted a retrospective analysis of a prospective database during a 5-year study period (01/01/2006-12/31/2010) at an academic Level 1 Trauma Center on all fractures treated by stainless steel plates. Inclusion criteria consisted of all consecutive patients >15 years of age whose fractures were fixated with a stainless steel plate. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of complications and surgical revisions, and the data were placed into context with the published complication rates for titanium plates. RESULTS: A total of 1,001 consecutive patients who underwent surgical fixation of fractures in the indication spectrum of this study were screened. Of these, 751 patients fulfilled the inclusion criteria. These patients had 774 fractures which were fixated with 859 stainless steel plates. Open fractures accounted for 9.6% of all injuries (n=74). The complication rate of the 774 fractures treated with stainless steel plates was 8.01% (n=62), with a surgical revision rate of 5.16% (n=40). These data are below the reported incidence of complications and surgical revisions for titanium plates in the identical indication spectrum in the pertinent literature published. CONCLUSIONS: The fixation of selected fractures with stainless steel implants represents a safe and efficient treatment option, which does not appear to be associated with increased complication rates. These data challenge the anecdotal superiority of titanium plates and should spur a new discussion on the use of stainless steel implants, particularly under the aspect of cost savings in the DRG era.

[Surgical treatment of ankle fractures as an outpatient procedure. A safe and resource-efficient concept?]. / Ambulante Versorgung operativer Spunggelenkfrakturen an einem US-Traumazentrum. Ein valides Modell im DRG-Zeitalter?

BACKGROUND: In many European countries, patients requiring surgical treatment of ankle fractures are generally hospitalized for an average of 8-11 days. This anecdotal concept is largely based on the premise that the inpatient monitoring of soft tissue conditions may lead to a decreased complication rate. The present study was designed to test the hypothesis that the surgical care of isolated ankle fractures as an outpatient procedure represents a safe and feasible concept which is not associated with an increased complication rate. METHODS: A retrospective analysis was performed of a prospective database during a 5-year period (01/01/2005-12/31/2009) at a US academic level 1 trauma center with an institutional protocol of outpatient surgery for isolated ankle fractures. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of postoperative complications and frequency of unplanned surgical revisions outpatient isolated versus inpatient isolated with surgical fixation of ankle isolated fractures. RESULTS: Among 810 consecutive patients with ankle fractures during the study period, 476 met the inclusion criteria. Of these, 256 patients (53.8%) were treated as outpatients. The average length of stay of patients who were admitted as inpatients was 1.5±0.8 days (range 1-5 days). The age distribution was in a similar range for inpatients and outpatients (39±14.1 vs 35±12.8 years), and the injury severity based on the AO/OTA fracture classification revealed a similar distribution of fracture patterns in both groups. The rate of postoperative complications (9.1 vs 3.1%) and of unplanned surgical revisions (3.6 vs 1.2%) was significantly increased in the hospitalized group, compared to patients with ambulatory surgery (P<0.05). CONCLUSION: The surgical treatment of isolated ankle fractures as an outpatient procedure represents a safe and resource-efficient concept which is not associated with an increased complication rate. Cultural differences in the domestic environment of individual patients may have to be taken into consideration.

[Current concepts of patient safety: rapid response system]. / Aktuelle Konzepte der Patientensicherheit : Das "Rapid-response"-System.

The "100,000 lives campaign" initiated a wide-spread implementation of rapid response teams in the United States. A standardized rapid response system (RRS) is designed to reduce the preventable mortality of hospitalized patients who frequently have progressive signs of physiological deterioration minutes to hours before cardiac arrest. The implementation and maturation of a team-based RRS has been shown to significantly reduce the incidence of "COR zero" calls and, in some studies, the in-hospital mortality rate. An alternative model to rapid response teams has been recently proposed which is based on defined clinical triggers to initiate a "rapid response escalation". This clinical triggers program overcomes the classic limitations of a team-based system, such as the overuse of resources and the fragmentation of patient care. The present review outlines the basic RRS concept with a focus on the debate related to the "perfect" patient safety system, namely the validity of a distinct rapid response teams approach versus a trigger-based escalation modality. The implementation of a standardized RRS should also be considered in German hospitals with the aim of improving patient safety and reducing preventable in-hospital mortality.

Impact of the complement cascade on posttraumatic cartilage inflammation and degradation.

The limited ability of articular cartilage to recover from injury, remains an unsolved clinical challenge in orthopaedic surgery. Persistent injury of the articular surface can lead to the development of posttraumatic osteoarthritis. The local inflammatory response contributes to the pathogenesis of osteoarthritis by inducing chondrocyte apoptosis and the de-regulation of chondrocyte matrix remodelling. The role of the complement system in contributing to secondary inflammation-mediated cartilage degradation represents a newer field of investigation. The purpose of this review article is to summarize the known complement-mediated actions in cartilage homeostasis and injury. This article focuses on the known effects of complement on secondary chondrocyte apoptosis, and the interplay of the complement system with pro-inflammatory cytokines. Pharmacological therapies related to complement inhibition will be discussed as they potentially represent a new avenue for attenuating the effect of the complement system on cartilage repair.

[The relevance of the inflammatory response in the injured brain]. / Die Bedeutung der posttraumatischen Entzündungsreaktion im verletzten Gehirn.

Research efforts in recent years have defined traumatic brain injury (TBI) as a predominantly immunological and inflammatory disorder. This perception is based on the fact that the overwhelming neuroinflammatory response in the injured brain contributes to the development of posttraumatic edema and to neuropathological sequelae which are, in large part, responsible for the adverse outcome. While the "key" mediators of neuroinflammation, such as the cytokine cascade and the complement system, have been clearly defined by studies in experimental TBI models, their exact pathways of interaction and pathophysiological implications remain to be further elucidated. This lack of knowledge is partially due to the concept of a "dual role" of the neuroinflammatory response after TBI. This notion implies that specific inflammatory molecules may mediate diverse functions depending on their local concentration and kinetics of expression in the injured brain. The inflammation-induced effects range from beneficial aspects of neuroprotection to detrimental neurotoxicity. The lack of success in pushing anti-inflammatory therapeutic concepts from"bench to bedside" for patients with severe TBI strengthens the further need for advances in basic research on the molecular aspects of the neuroinflammatory network in the injured brain. The present review summarizes the current knowledge from experimental studies in this field of research and discusses potential future targets of investigation.

Immunohistochemical characterization of Fas (CD95) and Fas Ligand (FasL/CD95L) expression in the injured brain: relationship with neuronal cell death and inflammatory mediators.

Traumatic brain injury causes progressive tissue atrophy and consequent neurological dysfunction, resulting from neuronal cell death in both animal models and patients. Fas (CD95) and Fas ligand (FasL/CD95L) are important mediators of apoptosis. However, little is known about the relationship between Fas and FasL and neuronal cell death in mice lacking the genes for inflammatory cytokines. In the present study, double tumor necrosis factor/lymphotoxin-alpha knockout (-/-) and interleukin-6-/- mice were subjected to closed head injury (CHI) and sacrificed at 24 hours or 7 days post-injury. Consecutive brain sections were evaluated for Fas and FasL expression, in situ DNA fragmentation (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling; TUNEL), morphologic characteristics of apoptotic cell death and leukocyte infiltration. A peak incidence of TUNEL positive cells was found in the injured cortex at 24 hours which remained slightly elevated at 7 days and coincided with maximum Fas expression. FasL was only moderately increased at 24 hours and showed maximum expression at 7 days. A few TUNEL positive cells were also found in the ipsilateral hippocampus at 24 hours. Apoptotic, TUNEL positive cells mostly co-localized with neurons and Fas and FasL immunoreactivity. The amount of accumulated polymorphonuclear leukocytes and CD11b positive cells was maximal in the injured hemispheres at 24 hours. We show strong evidence that Fas and FasL might be involved in neuronal apoptosis after CHI. Furthermore, Fas and FasL upregulation seems to be independent of neuroinflammation since no differences were found between cytokine-/- and wild-type mice.

[Role of gene therapy in trauma and orthopedic surgery]. / Stellenwert der Gentherapie in Unfallchirurgie und Orthopädie.

Modern molecular and genetic technologies enable the modification of a cellular genome through transfer of specific genes. The various procedures alter specific cell functions, which allow the transfected cell to produce any encoded transgene information. The transfected cell then synthesizes proteins that are normally not produced or only in very small amounts. Numerous animal studies have demonstrated that gene therapy may support and accelerate the healing and regeneration of specific tissues such as skin, tendons, cartilage, and bones. Currently, further animal studies are evaluating new vectors with reduced immunogenicity in the continuous effort to improve the efficacy and safety of gene transfer. In the forthcoming decade we expect gene therapy to have an important influence on the treatment of fractures, cartilage lesions, and infection.

Erythropoietin is neuroprotective, improves functional recovery, and reduces neuronal apoptosis and inflammation in a rodent model of experimental closed head injury.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young people in industrialized countries. Although various anti-inflammatory and antiapoptotic modalities have shown neuroprotective effects in experimental models of TBI, to date, no specific pharmacological agent aimed at blocking the progression of secondary brain damage has been approved for clinical use. Erythropoietin (Epo) belongs to the cytokine superfamily and has traditionally been viewed as a hematopoiesis-regulating hormone. The newly discovered neuroprotective properties of Epo lead us to investigate its effect in TBI in a mouse model of closed head injury. Recombinant human erythropoietin (rhEpo) was injected at 1 and 24 h after TBI, and the effect on recovery of motor and cognitive functions, tissue inflammation, axonal degeneration, and apoptosis was evaluated up to 14 days. Motor deficits were lower, cognitive function was restored faster, and less apoptotic neurons and caspase-3 expression were found in rhEpo-treated as compared with vehicle-treated animals (P<0.05). Axons at the trauma area in rhEpo-treated mice were relatively well preserved compared with controls (shown by their density; P<0.01). Immunohistochemical analysis revealed a reduced activation of glial cells by staining for GFAP and complement receptor type 3 (CD11b/CD18) in the injured hemisphere of Epo- vs. vehicle-treated animals. We propose that further studies on Epo in TBI should be conducted in order to consider it as a novel therapy for TBI.