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.

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.

Complement anaphylatoxin receptors on neurons: new tricks for old receptors?

Activation of the complement system has been reported in a variety of inflammatory diseases and neurodegenerative processes of the CNS. Recent evidence indicates that complement proteins and receptors are synthesized on or by glial cells and, surprisingly, neurons. Among these proteins are the receptors for the chemotactic and anaphylactic peptides, C5a and C3a, which are the most-potent mediators of complement inflammatory functions. The functions of glial-cell C3a and C5a receptors (C3aR and C5aR) appear to be similar to immune-cell C3aRs and C5aRs. However, little is known about the roles these receptors might have on neurons. Indeed, when compared with glial cells, neurons display a distinct pattern of C3aR and C5aR expression, in either the normal or the inflamed CNS. These findings suggest unique functions for these receptors on neurons.

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.

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.

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.

Interleukin-8 released into the cerebrospinal fluid after brain injury is associated with blood-brain barrier dysfunction and nerve growth factor production.

Interleukin (IL) 8 was measured in CSF of 14 patients with severe traumatic brain injury. IL-8 levels were significantly higher in CSF (up to 8,000 pg/ml) than serum (up to 2,400 pg/ml) (p < 0.05), suggesting intrathecal production. Maximal IL-8 values in CSF correlated with a severe dysfunction of the blood-brain barrier. Nerve growth factor (NGF) was detected in CSF of 7 of 14 patients (range of maximal NGF: 62-12,130 pg/ml). IL-8 concentrations were significantly higher in these patients than in those without NGF (p < 0.01). CSF containing high IL-8 (3,800-7,900 pg/ml) induced greater NGF production in cultured astrocytes (202-434 pg/ml) than samples with low IL-8 (600-1,000 pg/ml), which showed a smaller NGF increase (0-165 pg/ml). Anti-IL-8 antibodies strongly reduced (52-100%) the release of NGF in the group of high IL-8, whereas in the group with low IL-8, this effect was lower (0-52%). The inability of anti-IL-8 antibodies to inhibit the synthesis of NGF completely may depend on cytokines like tumor necrosis factor alpha and IL-6 found in these CSF samples, which may act in association with IL-8. Thus, IL-8 may represent a pivotal cytokine in the pathology of brain injury.

Experimental closed head injury: analysis of neurological outcome, blood-brain barrier dysfunction, intracranial neutrophil infiltration, and neuronal cell death in mice deficient in genes for pro-inflammatory cytokines.

Cytokines are important mediators of intracranial inflammation following traumatic brain injury (TBI). In the present study, the neurological impairment and mortality, blood-brain barrier (BBB) function, intracranial polymorphonuclear leukocyte (PMN) accumulation, and posttraumatic neuronal cell death were monitored in mice lacking the genes for tumor necrosis factor (TNF)/lymphotoxin-alpha (LT-alpha) (TNF/LT-alpha-/-) and interleukin-6 (IL-6) and in wild-type (WT) littermates subjected to experimental closed head injury (total n = 107). The posttraumatic mortality was significantly increased in TNF/LT-alpha-/- mice (40%; P < 0.02) compared with WT animals (10%). The IL-6-/- mice also showed a higher mortality (17%) than their WT littermates (5.6%), but the difference was not statistically significant (P > 0.05). The neurological severity score was similar among all groups from 1 to 72 hours after trauma, whereas at 7 days, the TNF/LT-alpha-/- mice showed a tendency toward better neurological recovery than their WT littermates. Interestingly, neither the degree of BBB dysfunction nor the number of infiltrating PMNs in the injured hemisphere was different between WT and cytokine-deficient mice. Furthermore, the analysis of brain sections by in situ DNA nick end labeling (TUNEL histochemistry) at 24 hours and 7 days after head injury revealed a similar extent of posttraumatic intracranial cell death in all animals. These results show that the pathophysiological sequelae of TBI are not significantly altered in mice lacking the genes for the proinflammatory cytokines TNF, LT-alpha, and IL-6. Nevertheless, the increased posttraumatic mortality in TNF/LT-alpha-deficient mice suggests a protective effect of these cytokines by mechanisms that have not been elucidated yet.

A randomized study of gemcitabine monotherapy versus etoposide/cisplatin in the treatment of locally advanced or metastatic non-small cell lung cancer.

This randomized, multinational, multicenter study was designed to determine the response rate of gemcitabine monotherapy and cisplatin/etoposide combination therapy in chemotherapy-naive patients with advanced, recurrent, and/or metastatic non-small cell lung cancer (stage IIIA [if inoperable], IIIB, or IV). One group of patients received gemcitabine 1,000 mg/m2 intravenously once a week for 3 weeks (days 1, 8, and 15) followed by a 1-week rest period. The second group received cisplatin 100 mg/m2 intravenously on day 1 of each 28-day cycle in combination with etoposide 100 mg/m2, administered on days 1, 2, and 3 following the cisplatin infusion. Each patient was allowed to remain on study up to a maximum of six cycles. The planned interim analysis was based on the 117 patients in the study, 116 of whom were randomized up until November 20, 1995. The efficacy analysis was performed on the 107 patients who had data from a minimum of two cycles, whereas the safety analysis was based on data from all 116 randomized patients. In the gemcitabine arm there were 10 of 52 (19%) partial responders; in the cisplatin/etoposide arm there were four (7%) of 54 partial responders. There was a statistically significant difference in the response rates between the two arms, with a 95% confidence interval of 0.6% to 32.1% (P = .040). The median time to progressive disease was 4.2 months for gemcitabine patients and 3.7 months for cisplatin/etoposide patients. There was significantly more alopecia and nausea and vomiting in the cisplatin/etoposide arm compared with the gemcitabine arm, as well as two cases of neutropenic sepsis in the cisplatin/etoposide arm. These data indicate that single-agent gemcitabine is at least as effective as the combination of cisplatin/etoposide in the treatment of advanced non-small cell lung cancer and has an improved safety profile.

Elevated levels of the complement components C3 and factor B in ventricular cerebrospinal fluid of patients with traumatic brain injury.

Immunological events occurring in the central nervous system (CNS) as a result of head trauma are largely unexplored. We report here that the levels of the alternative pathway complement proteins C3 and factor B are elevated in the cerebrospinal fluid (CSF) of head-injured patients. C3 and factor B indices suggest that changes in C3 and factor B levels in CSF are most likely due to altered blood-brain barrier integrity and not to intrathecal synthesis. These data demonstrate, for the first time, elevated levels of complement proteins in CSF of patients with severe traumatic brain injury. Elevated complement levels in brain injury may contribute to secondary damage.

Intracerebral complement C5a receptor (CD88) expression is regulated by TNF and lymphotoxin-alpha following closed head injury in mice.

The anaphylatoxin C5a is a potent mediator of inflammation in the CNS. We analyzed the intracerebral expression of the C5a receptor (C5aR) in a model of closed head injury (CHI) in mice. Up-regulation of C5aR mRNA and protein expression was observed mainly on neurons in sham-operated and head-injured wild-type mice at 24 h. In contrast, in TNF/lymphotoxin-alpha knockout mice, the intracerebral C5aR expression remained at low constitutive levels after sham operation, whereas it strongly increased in response to trauma between 24 and 72 h. Interestingly, by 7 days after CHI, the intrathecal C5aR expression was clearly attenuated in the knockout animals. These data show that the posttraumatic neuronal expression of the C5aR is, at least in part, regulated by TNF and lymphotoxin-alpha at 7 days after trauma.

Role of cerebral inflammation after traumatic brain injury: a revisited concept.

Neuroinflammation occuring after traumatic brain injury (TBI) is a complex phenomenon comprising distinct cellular and molecular events involving the injured as well as the healthy cerebral tissue. Although immunoactivation only represents a one of the many cascades initiated in the pathophysiology of TBI, the exact function of each mediator, activated cell types or pathophysiological mechanism, needs to be further elucidated. It is widely accepted that inflammatory events display dual and opposing roles promoting, on the one hand, the repair of the injured tissue and, on the other hand, causing additional brain damage mediated by the numerous neurotoxic substances released. Most of the data supporting these hypotheses derive from experimental work based on both animal models and cultured neuronal cells. More recently, evidence has been provided that a complete elimination of selected inflammatory mediators is rather detrimental as shown by the attenuation of neurological recovery. However, there are conflicting results reported on this issue which strongly depend on the experimental setting used. The history of immunoactivation in neurotrauma is the subject of this review article, giving particular emphasis to the comparison of clinical versus experimental studies performed over the last 10 years. These results also are evaluated with respect to other neuropathologies, which are years ahead as compared to the research in TBI. The possible reciprocal influence of peripheral and intrathecal activation of the immune system will also be discussed. To conclude, the future directions of research in the field of neurotrauma is considered.

Experimental diffuse axonal injury induces enhanced neuronal C5a receptor mRNA expression in rats.

Several studies suggest the involvement of the complement system in the pathophysiology of traumatic brain injury (TBI). Since the intrathecal generation of anaphylatoxin C5a has been shown to mediate inflammatory effects within the central nervous system, we sought to characterize the cellular expression of the mRNA for the C5a receptor (C5aR, CD88) in brains of rats with experimental diffuse axonal injury (DAI) by in situ hybridization. Infiltrating leukocytes expressing C5aR mRNA were seen in meninges and lateral ventricles as early as 4 h after induction of DAI. The number of infiltrating C5aR-positive cells increased gradually up to 24 h after trauma. Within the brain parenchyma, up-regulation of C5aR mRNA expression was first seen in cerebellar Purkinje cells within 8 h. At 24 h after TBI, expression of C5aR mRNA was widespread bilaterally throughout the cortex and cerebellum, the cellular expression being restricted to pyramidal neurons and Purkinje cells. The intensity of C5aR transcript signals on neurons increased further up to 96 h after trauma. Ligand binding of C5a to its receptor on neurons might mediate previously unknown functions, thus possibly leading to neurotoxicity and secondary neuronal damage after TBI.