Effect of harvesting strategy of second-cut orchardgrass silage on feed intake, digestion, and milk production in dairy cows.

We investigated the effects of regrowth interval and first-cut timing on the dietary characteristics of second-cut orchardgrass silage and feed intake and milk production in dairy cows fed second-cut orchardgrass silage. The second-cut grasses were harvested 7w after the first-cut at the early stage (E7w) or at the heading stage (H7w), or harvested 6w after the first-cut at the early stage (E6w) from orchardgrass sward, and then ensiled. We evaluated the effect of regrowth interval by comparing E7w and E6w, and the effect of first-cut timing by comparing E7w and H7w. Six multiparous Holstein cows were used in a replicated 3 × 3 Latin square design, with three dietary treatments: diets containing E7w, E6w, or H7w silage at 30% dietary dry matter. We observed that feeding E6w silage instead of E7w silage increased fiber digestibility, dry matter intake, and milk production; however, the first-cut timing (E7w vs. H7w) did not affect nutrient content and digestibility, feed intake, or lactation performance. These results show that harvesting at short regrowth intervals for second-cut orchardgrass can be an effective strategy for improving feed utilization and milk yield; however, the first-cut timing for second-cut orchardgrass has little impact.

Development and validation of prediction scores for the outcome associated with persistent inflammation, immunosuppression, and catabolism syndrome among patients with trauma.

Background: Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has impacted on long-term prognosis of patients with trauma. We aimed to identify patients with trauma at risk of PICS-related complications early in the intensive care unit (ICU) course. Methods: A single-center retrospective cohort study was conducted. All consecutive patients with trauma who had stayed in the ICU for >7 days were included in the study. We developed the prediction score for the incidence of PICS-related outcomes in the derivation cohort for the initial period and then evaluated in the validation cohort for the subsequent period. Other outcomes were also assessed using the score. Results: In total, 170 and 133 patients were included in the derivation and validation cohorts, respectively. The prediction score comprised the variables indicating PICS presence, including a maximum value of C-reactive protein >15 mg/dL, minimum value of albumin <2.5 g/dL, and an episode of nosocomial infection for the first 7 days after admission. A score of 1 was assigned to each variable. The area under the receiver operating characteristic curve of the score to predict PICS incidence was 0.74 (95% CI 0.66 to 0.81) and 0.72 (95% CI 0.64 to 0.81) in the derivation and validation cohorts, respectively. The higher score was also significantly associated with a higher Sequential Organ Failure Assessment score at day 14, a longer duration of mechanical ventilation, a longer length of stay in ICU, and experienced multiple episodes of infection. Similar results were obtained in the validation cohort. Conclusions: Our scoring system could predict the outcomes associated with PICS among patients with trauma. Because the score comprised the parameters measured for the first 7 days during the ICU course, it could contribute to identifying patients at a high risk of unfavorable outcome earlier. Level of evidence: Multivariate prediction models; level IV.

Helicopter emergency medical service for patients with acute coronary syndrome: selection validity and impact on clinical outcomes.

Helicopter emergency medical service (HEMS) has the potential to improve prognosis for acute coronary syndrome (ACS). However, adequacy and effectiveness of HEMS have not been fully evaluated. A total of 862 ACS patients transferred by emergency medical services were divided into two groups: patients transferred by HEMS (n = 171) or by ground ambulance (GA; n = 691). Among them, angiography images for 718 patients (149 in HEMS and 569 in GA group) and optical coherence tomography (OCT) images for 374 patients (75 in HEMS and 299 in GA groups) were analyzed. Additional analysis to compare 2-year cardiac mortality between groups was conducted following propensity score matching to adjust for inter-group differences. ST-segment elevation myocardial infarction (81% vs. 66%, p < 0.001) and cardiogenic shock (Killip IV; 20% vs. 10%, p < 0.001) at admission were more prevalent in HEMS than GA group. Time from admission to balloon angioplasty was shorter in HEMS group (median 54 min vs. 69 min, p < 0.001). Antegrade coronary flow was worse in HEMS group (TIMI flow grade 0 or 1; 68% vs. 51%, p < 0.001). Plaque rupture was more frequently detected by OCT in HEMS group (68% vs. 49%, p = 0.029). Following propensity score matching, the incidence of cardiac death was significantly lower in HEMS group (6.3% vs. 14.9%, p = 0.019). In conclusion, severe ACS patients requiring early reperfusion were appropriately triaged and transferred more rapidly by HEMS. Lower mortality in HEMS group after propensity score matching suggests that HEMS may improve cardiac mortality in ACS patients.

Revision of 'golden hour' for hemodynamically unstable trauma patients: an analysis of nationwide hospital-based registry in Japan.

BACKGROUND: The 'golden hour' is a well-known concept, suggesting that shortening time from injury to definitive care is critically important for better outcome of trauma patients. However, there was no established evidence to support it. We aimed to validate the association between time to definitive care and mortality in hemodynamically unstable patients for the current trauma care settings. METHODS: The data were collected from the Japan Trauma Data Bank between 2006 and 2015. The inclusion criteria were patients with systolic blood pressure (SBP) <90 mm Hg and heart rate (HR) >110 beats/min or SBP <70 mm Hg who underwent definitive care within 4 hours from the onset of injury and survived for more than 4 hours. The outcome measure was in-hospital mortality. We evaluated the relationship between time to definitive care and mortality using the generalized additive model (GAM). Subgroup analysis was also conducted using GAM after dividing the patients into the severe (SBP <70 mm Hg) and moderate (SBP ≥70 mm Hg and <90 mm Hg, and HR >110 beats/min) shock group. RESULTS: 1169 patients were enrolled in this study. Of these, 386 (33.0%) died. Median time from injury to definitive care was 137 min. Only 61 patients (5.2%) received definitive care within 60 min. The GAM models demonstrated that mortality remained stable for the early phase, followed by a decrease over time. The severe shock group presented with a paradoxical decline of mortality with time, whereas the moderate shock group had a time-dependent increase in mortality. DISCUSSION: We did not observe the association of shorter time to definitive care with a decrease in mortality. However, this was likely an offset result of severe and moderate shock groups. The result indicated that early definitive care could have a positive impact on survival outcome of patients with moderate shock. LEVEL OF EVIDENCE: Level Ⅳ, prognostic study.

Delayed Expression of Circulating TGF-ß1 and BMP-2 Levels in Human Nonunion Long Bone Fracture Healing.

BACKGROUND: The healing process of bone fracture requires a well-controlled multistage and sequential order beginning immediately after the injury. However, complications leading to nonunion exist, creating serious problems and costs for patients. Transforming growth factor-beta 1 (TGF-ß1) and bone morphogenic protein 2 (BMP-2) are two major growth factors involved in human bone fracture healing by promoting various stages of bone ossification. In this study, we aimed to determine the role of these factors during the fracture healing of human long bones and assess their impacts on nonunion condition. MATERIALS AND METHODS: We performed a comprehensive analysis of plasma TGF-ß1 and BMP-2 levels in blood samples from 10 patients with proved nonunion and 10 matched patients with normal union following a predetermined time schedule. The concentrations of TGF-ß1 and BMP-2 were measured at each time point using a solid-phase ELISA. RESULTS: TGF-ß1 and BMP-2 levels were detectable in all patients. For all patients, a maximal peak for TGF-ß1 was found at 3-week. In normal union group, TGF-ß1 showed a maximal peak at 2-week while nonunion group had a delayed maximal peak at 3-week. Plasma levels of BMP-2 for all patients and for normal union group reached a maximal peak at 1-week, but nonunion group showed a delayed maximal peak at 2-week. In general, plasma TGF-ß1 or BMP-2 level was not significantly different between normal union and nonunion groups. CONCLUSION: The expression levels of TGF-ß1 and BMP-2 appeared to be delayed in nonunion patients which could play an important role in developing an early marker of fracture union condition and facilitate improved patient's management.

Impact of urgent resuscitative surgery for life-threatening torso trauma.

PURPOSE: This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. METHODS: We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). RESULTS: While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113-0.526, p < 0.010). CONCLUSION: The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.

Dispatch of Helicopter Emergency Medical Services Via Advanced Automatic Collision Notification.

BACKGROUND: Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact. OBJECTIVE: The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN. METHODS: A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process. RESULTS: AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN. CONCLUSIONS: The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

The Pedicled Omental Flap Technique for Treating Extensive Defects or Soft-Tissue Infection of the Pelvic Area: A Report of 2 Cases.

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one of the ultimately invasive procedures for managing a noncompressive torso injury. Since it is less invasive than resuscitative open aortic cross-clamping, its clinical application is expected. METHODS: We retrospectively evaluated the safety and clinical feasibility of REBOA (intra-aortic occlusion balloon, MERA, Tokyo, Japan) using the Seldinger technique to control severe hemorrhage. Of 5,230 patients admitted to our trauma center in Japan from 2007 to 2013, we included 24 who underwent REBOA primarily. The indications for REBOA were a pelvic ring fracture or hemoperitoneum with hemodynamically instability and impending cardiac arrest. Emergency hemostasis was performed during REBOA in all patients. RESULTS: All 24 patients had a blunt injury, the median age was 59 (interquartile range, 41-71 years), the median Injury Severity Score (ISS) was 47 (interquartile range, 37-52), the 30-day survival rate was 29.2% (n = 7), and the median probability survival rate was 12.5%. Indications for REBOA were hemoperitoneum and pelvic ring fracture in 15 cases and overlap in 8 cases. In 10 cases of death, the balloon could not be deflated in 5 cases. In 19 cases in which the balloon was deflated, the median duration of aortic occlusion was shorter in survivors than in deaths (21 minutes vs. 35 minutes, p = 0.05). The mean systolic blood pressure was significantly increased by REBOA (from 53.1 [21] mm Hg to 98.0 [26.6] mm Hg, p < 0.01). There were three cases with complications (12.5%), one external iliac artery injury and two lower limb ischemias in which lower limb amputation was necessary in all cases. Acute kidney injury developed in all three cases, but failure was not persistent. CONCLUSION: REBOA seems to be feasible for trauma resuscitation and may improve survivorship. However, the serious complication of lower limb ischemia warrants more research on its safety. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system.

OBJECTIVE: We investigated whether emergency thoracotomy (ET) performed in pre-hospital settings contributed to saving the lives of blunt trauma patients with impending or recent cardiac arrest. METHODS: Eighty-one consecutive cardiac arrest patients with blunt trauma were performed ET before or after arrival at the emergency department (ED). These were reviewed retrospectively and were classified into the following three groups: (1) an emergency field thoracotomy was performed (EFT group, n=34); (2) a doctor dispatched to the scene, but the thoracotomy was performed in the ED (EDT-a group, n=10); and (3) no doctor dispatched to the scene, and the thoracotomy was performed in the ED (EDT-b group, n=37). The patients in the EFT and EDT-a groups were managed within the Japanese helicopter emergency medical service system with a doctor dispatched to the scene. RESULT: The time between the arrival of the EMT at the scene and the start of the thoracotomy was significantly shorter in the EFT group than in the EDT-b group (19.2+/-7.9 min vs. 30.7+/-6.8 min, p<0.001). In the EFT group, the "ICU admission" rate was significantly higher among the patients who experienced cardiac arrest after the EMT arrival than among the patients who experienced cardiac arrest before the EMT arrival (70% vs. 8%, p=0.001). Unfortunately, however, there were no survivors in this series. CONCLUSION: These findings indicate that "early access" to a doctor's expertise and the performance of an "emergency field thoracotomy" might be two important factors for improving the possibility of saving the lives of blunt trauma patients with impending or recent cardiac arrest.