Effect of a dairy farmworker stewardship training program on antimicrobial drug usage in dairy cows.

Antimicrobial use (AMU) is critical to preserving animal health and welfare. However, the development of antimicrobial resistance (AMR) represents a public health threat. Although most antimicrobials used on the farm require a veterinarian prescription, farmworkers make daily on-farm treatment decisions. Therefore, farmworker training is vital to promote responsible AMU. This research project aimed to evaluate the effect of farmworker antimicrobial stewardship (AMS) training on the quantity of AMU on dairy farms in Ohio and California. We hypothesized that farms receiving AMS training would have reduced AMU in dairy cattle compared with farms where training wasn't administered. We designed a quasiexperimental study with 18 conventional dairy farms enrolled in Ohio and California. Twelve farms received AMS training, and 6 farms did not. The AMS program included a 12-wk training focused on accurate identification of cows requiring antimicrobial treatment. We quantified AMU by collecting used drug containers, manually counted by researchers during farm visits. Treatment incidence (TI) was calculated using animal daily doses (ADD), and Poisson regression models were used to analyze the TI data. Disease incidence rate (DIR) in lactating cows was 2.2, 1.5, 1.0, 0.4, 0.3, 0.2, and 0.03/1,000 cow-days for mastitis, lameness, metritis, pneumonia, retained placenta, diarrheas, and other diseases (e.g., conjunctivitis, injuries), respectively. The highest TI by antimicrobial class (provided in ADD/1,000 cow-days) was cephalosporin (5.9), penicillin (5.2), tetracyclines (0.4), lincosamides (0.2), and sulfonamides (0.1). Among the trained farms using a within-treatment group analysis, no significant differences were observed in TI pre-intervention (10.9 ADD/1,000 cow-days) compared with TI postintervention (10.3 ADD/1,000 cow-days). Treatment incidence from the training group was 10.8 ADD/1,000 cow-days and although numerically lower, it was not significantly different compared with TI in the control groups at 13.9 ADD/1,000 cow-days (rate ratio = 0.77, CI = 0.25-2.38). Future research on AMS should incorporate farmworker training with social science approaches to overcome barriers and promote on-farm responsible use.

A novel risk assessment tool for bovine respiratory disease in preweaned dairy calves.

Due to the increased morbidity and mortality of bovine respiratory disease (BRD) in dairy calves, as well as an increasing urgency for the judicious use of antimicrobials in farm animals, a comprehensive risk assessment tool for BRD in preweaned dairy calves has been designed based on a longitudinal and a cross-sectional study. As a multifactorial disease complex in which immune function stressors increase susceptibility to respiratory pathology, risk management programs for environmental and husbandry practices may be an effective approach for BRD control. Practices of known or suspected effect on BRD in preweaned calves have been explored in 2 large studies correlating management factors to BRD prevalence (BRD 100 study) and incidence (BRD 10K study) and forming the scores presented here. Priority was given to results from multivariable over univariable model estimates. However, when used, univariable model estimates were adjusted for confounders or stratified by effect modifiers if necessary. Regression coefficients were translated into scores, which are presented in a field-ready tool consisting of (1) a risk assessment questionnaire, which identifies the herd-specific risk factors and the risk scores associated with each; (2) the California BRD scoring system to estimate the BRD prevalence at the time of risk assessment for future comparison with the prevalence after interventions; and (3) the BRD control and prevention herd management plan, which can be used to plan and track the interventions identified. Scores for 100 dairies across California were used to benchmark a dairy's risk on a spectrum. With the help of the risk assessment tool, dairy producers, calf managers, and veterinarians may be able to adjust management factors that affect BRD risk on a farm and objectively monitor BRD prevalence before and after management interventions. As a result, the BRD risk assessment tool described here is the first comprehensive effort for herd-specific BRD control and prevention.

Preweaning cost of bovine respiratory disease (BRD) and cost-benefit of implementation of preventative measures in calves on California dairies: The BRD 10K study.

Bovine respiratory disease (BRD) is a multifactorial disease that is estimated to affect 22% of preweaned dairy calves in the United States and is a leading cause of preweaning mortality in dairy calves. Overall cost of calfhood BRD is reflected in both the immediate cost of treating the disease as well as lifetime decrease in production and increased likelihood of affected cattle leaving the herd before their second calving. The goal of this paper was to develop an estimate of the cost of BRD based on longitudinal treatment data from a study of BRD with a cohort of 11,470 preweaned dairy calves in California. Additionally, a cost-benefit analysis was performed for 2 different preventative measures for BRD, an increase of 0.47 L of milk per day for all calves or vaccination of all dams with a modified live BRD vaccine, using differing assumptions about birth rate and number of calves raised per year. Average short-term cost of BRD per affected calf was $42.15, including the use of anti-inflammatory medications in the treatment protocols across all management conditions. The cost of treating BRD in calves appears to have increased in recent years and is greater than costs presented in previous studies. A cost-benefit analysis examined different herd scenarios for a range of cumulative incidences of BRD from 3 to 25%. Increasing milk fed was financially beneficial in all scenarios above a 3% cumulative incidence of BRD. Use of a modified live vaccine in dams during pregnancy, examining only its value as a form of BRD prevention in the calves raised on the farm, was financially beneficial only if the cumulative incidence of BRD exceeded 10 to 15% depending on the herd size and whether the dairy farm was raising any bull calves. The cost-benefit analysis, under the conditions studied, suggests that producers with high rates of BRD may benefit financially from implementing preventative measures, whereas these preventative measures may not be cost effective to implement on dairy farms with very low cumulative incidences of BRD. The long-term costs of calfhood BRD on lifetime productivity were not factored into these calculations, and the reduction in disease may be associated with additional cost savings and an improvement in calf welfare and herd life.

Needs assessment for cooperative extension dairy programs in California.

The present study aimed to identify dairy producer needs and how best to direct and deliver cooperative extension (CE) programming. In March 2017, we mailed a needs assessment survey to grade A dairy producers in California (n = 1,080). The response rate was 15.4% (n = 166) and herd size averaged 1,405 milking cows (range 83-5,500). The geographic distribution of survey responses was representative of the distribution of dairies throughout the state. Producers were asked to indicate the level of concern for a predetermined list of 11 issues. Rank of concern had 3 numeric levels: (1) very concerned, (2) somewhat concerned, or (3) not concerned. Mean and percentage of responses in each rank for each issue topic were calculated. The top 5 concerns/obstacles indicated were (1) milk price, (2) labor availability/quality, (3) environmental issues/regulations, (4) labor costs, and (5) water quality/availability. Surveyed respondents were also asked to determine the level of priority of a predetermined list of 13 CE research and educational opportunities. Producers ranked topics as low, medium, or high priority. The 5 highest priority research topics were (1) herd health, (2) environmental issues, (3) reproduction, (4) milk quality, and (5) water quality. The 5 highest priority educational topics were (1) herd health, (2) milk quality, (3) reproduction, (4) environmental issues, and (5) calf and heifer management. Producers were then asked to identify the target audience for CE information delivery and preferred information delivery method. Most respondents indicated that the target audience should be dairy owners (93%) or managers (66%). Fewer producers indicated a target audience of dairy employees (27%) or allied industry (23%). Preferable information delivery methods were newsletter or magazine articles (81%), half-day/short meetings (47%), and on-farm training/meetings (39%). Webinars and 2- or 3-d destination meetings were the least preferable methods (27 and 9%, respectively). Survey results will serve to develop future dairy cooperative extension programs in California.

Bovine respiratory disease (BRD) cause-specific and overall mortality in preweaned calves on California dairies: The BRD 10K study.

Mortality in preweaned dairy calves is a significant source of economic loss for dairy producers. In particular, bovine respiratory disease (BRD) is a leading cause of death in preweaned dairy calves. The objectives of this study were to investigate management practices and their effects on mortality, both that specifically attributed to BRD and overall mortality due to all causes, in preweaned dairy calves. Rates of failure of passive transfer of immunity (FPT) are also reported. The study consisted of a convenience sample of 5 dairies across California, selected based on management practices, calf records, location, and size. Trained study personnel performed comprehensive calf management surveys on every dairy at least once every season. Calves were enrolled in the study at birth and followed until weaning. Mixed-effect logistic regression models were specified for the outcomes all-cause mortality (any death before weaning) and mortality attributed to BRD. The 2 final models included a total of 11,470 calves that were born on the study dairies and followed until weaning. The study cohort's overall crude mortality was 2.8%, with crude mortality of individual dairies ranging from 1.7 to 7.2%. The proportion of mortality attributed to BRD was 19.3%, with a range of 0 to 27.1% on the study dairies. Increasing the frequency of changing maternity pen bedding was associated with a decreased risk of mortality due to BRD. Calves diagnosed with BRD in the spring had an increased risk of mortality compared with calves born in the summer; mortality in calves with fall and winter BRD diagnoses did not different significantly from that in summer. Season of mortality was not significant in either model. Feeding ≥5.7 L of milk per day per calf (vs. ≤3.7 L/d) decreased the risk of mortality in calves over 21 d of age. Twins had a 68% increased risk of all-cause mortality compared with calves born as singletons. Both mortality models showed an association between administration of a modified live vaccine in dams (targeting BRD pathogens) and a decreased risk of mortality in calves. Using a serum total protein cut-off of 5.2 g/dL, 16.8% of calves had FPT, with a mean serum total protein concentration of 5.94 ± 0.06 g/dL across all calves sampled.

Epidemiology of bovine respiratory disease (BRD) in preweaned calves on California dairies: The BRD 10K study.

Bovine respiratory disease (BRD) is one of the leading causes of death in dairy heifers. The objective of this prospective cohort study was to characterize the epidemiology of BRD in preweaned dairy calves and to identify management practices associated with decreased risk of BRD. Dairies were chosen for the study based on management practices, location, size, and willingness to participate. A total of 6 dairies, ranging in size from 700 to 3,200 milking cows, in 6 counties across California's Central Valley, were enrolled in the study for at least 1 year. A total of 11,945 calves were born on the study dairies and followed until weaning. Incidence of BRD was estimated using treatment records. Trained study personnel performed comprehensive calf management surveys and estimated BRD prevalence on every dairy at least once every season. A shared frailty model was used to model the associations between management practices and BRD hazard. The final models included data from complete records of 11,470 calves. The overall BRD study period prevalence across the study herds was 22.8%. The mean BRD incidence density rate on all the study dairies was 0.17 BRD cases [95% confidence interval (CI) = 0.16-1.74] per calf-month at risk. The shared frailty model identified that feeding only waste or saleable milk (compared with use of milk replacer), feeding over 3.8 L of milk per day to calves under 21 d of age, frequent changing of maternity pen bedding, and administration of modified live or killed BRD vaccines to dams before calving significantly reduced the risk of BRD. Risk factors for BRD included housing calves in wooden hutches with metal roofs, compared with all-wood hutches, twin births, and perception of dust occurring "regularly," as reported by calf managers, compared with a perception of "no dust" in the calf-raising area. All 4 seasons were analyzed, and both summer (hazard ratio = 1.15; 95% CI = 1.01 to 1.32) and spring (hazard ratio = 1.26; 95% CI = 1.11 to 1.44) were associated with a higher risk of BRD compared with winter. The current longitudinal study identified specific housing and feeding practices that could be modified to decrease risk of BRD. In addition, season was observed to have a strong effect on calves' risk of developing BRD on California dairies.

Management factors associated with bovine respiratory disease in preweaned calves on California dairies: The BRD 100 study.

The objective of this cross-sectional study was to determine how management practices on California dairies may be associated with bovine respiratory disease (BRD) in preweaned calves. A convenience sample of 100 dairies throughout California, providing a study population of 4,636 calves, were visited between May 2014 and April 2016. During each farm visit, in-person interviews with the herd manager or calf caretaker were conducted to collect information about herd demographics, maternity pen, colostrum and calf management, herd vaccinations, and dust abatement. A random sample of preweaned calves was identified and evaluated for the presence of BRD using a standardized tool. A survey-adjusted generalized linear mixed model with a logit link function was fitted with calf as the unit of analysis and dairy as the random effect. Mean study herd size (±SE) was 1,718 (±189.9) cows. Survey-adjusted estimates of breed types in the sample were 81.6% (±0.6) Holstein, 13.1% (±0.4) Jersey, and 5.3% (±0.5) crossbred or other purebred breeds, and calf sex proportions were 73.8% (±1.0) female and 26.2% (±1.0) male. Overall survey-adjusted BRD prevalence in the study herds was 6.91% (±0.69). Housing factors positively associated with BRD were metal hutches compared with wood hutches [odds ratio (OR) = 11.19; 95% confidence interval (CI) = 2.80-44.78], calf-to-calf contact in calves >75 d of age (OR = 9.95, 95% CI = 1.50-65.86), feeding Holstein calves <2.84 L of milk or replacer per day (OR = 7.16, 95% CI = 1.23-41.68), and lagoon water used for flushing manure under hutches compared with no flush (OR = 12.06, 95% CI = 1.93-75.47). Providing extra shade over hutches (OR = 0.08; 95% CI = 0.02-0.37), feeding calves at least 90% saleable milk (OR = 0.27, 95% CI = 0.13-0.54) or pasteurized milk (OR = 0.10; 95% CI = 0.03-0.36), and feeding >5.68 L of milk or replacer per day to Jersey calves (OR = 0.04; 95% CI = 0.01-0.28) were negatively associated with BRD. Our study identified management practices on California dairies with variability and that may contribute to differences in BRD prevalence, which will be incorporated into a risk-assessment tool to control and prevent BRD in preweaned dairy calves.

Regional management practices and prevalence of bovine respiratory disease in California's preweaned dairy calves.

The objective of this cross-sectional study was to estimate the prevalence of bovine respiratory disease (BRD) in California preweaned dairy calves and identify management practices that are associated with BRD. A convenience sample of 100 dairies in the 3 distinct dairy regions of California was surveyed. Regions evaluated were Northern California (NCA), northern San Joaquin Valley (NSJV), and greater Southern California (GSCA). A questionnaire on calf management practices and demographic information was administered via in-person interviews at each dairy and a random sample of preweaned calves was evaluated using the California BRD scoring system on the same day. Prevalence of BRD varied between the 3 dairy regions: 9.30% in NCA, 4.51% in NSJV, and 7.35% in GSCA. Breed was not associated with BRD prevalence at the statewide level, but differences in prevalence were observed between breeds across the regions with a higher prevalence in NCA for Jerseys and in GSCA for Holsteins, compared with NSJV. Prevalence of BRD was not different between organic and conventional dairies. Colostrum management practices, including heat treatment and feeding colostrum from multiparous cows, varied by region and were associated with lower BRD prevalence. Calves housed in group pens, a practice observed primarily in NCA, had a higher BRD prevalence than those in individual housing. Feeding salable milk was also more common in NCA and was associated with lower BRD prevalence. Ground and road surfaces adjacent to the calf raising area were also variable by region, and paved surfaces were associated with lower BRD prevalence. Management practices associated with BRD varied across the state and may be addressed to inform the adoption and implementation of potentially protective management decisions on California dairies and other regions with similar dairy systems.

Multidrug residues and antimicrobial resistance patterns in waste milk from dairy farms in Central California.

Waste milk (WM) is a common source of feed for preweaned calves in US dairy farms. However, limited information is available about characteristics of this product, including concentration of drug residues and potential hazards from antibiotic-resistant bacteria present in the milk. The aims of this cross-sectional study were to (1) identify and measure the concentration of antimicrobial residues in raw WM samples on dairy farms in the Central Valley of California, (2) survey farm management practices for factors associated with the occurrence of specific antimicrobial residues in raw WM, (3) characterize the antimicrobial resistance patterns of E. coli cultured from raw WM samples, and (4) evaluate the potential association between WM quality parameter and risk of identifying drug residues in milk. A single raw bulk tank WM sample was collected from dairy farms located in California's Central Valley (n = 25). A questionnaire was used to collect information about farm management practices. Waste milk samples were analyzed for a multidrug residue panel using liquid chromatography-tandem mass spectrometry. Bacteria were cultured and antimicrobial resistance was tested using standard techniques; milk quality parameters (fat, protein, lactose, solids-not-fat, somatic cell count, coliform count, and standard plate count) were also measured. Of the 25 samples collected, 15 (60%) contained detectable concentrations of at least 1 antimicrobial. Of the drug residue-positive samples, 44% (11/25) and 16% (4/25) had detectable concentrations of ß-lactams and tetracycline, respectively. The most prevalent drug residues were ceftiofur (n = 7, 28%), oxytetracycline (n = 4, 16%), and cephapirin (n = 3, 12%). No significant associations were identified between farm characteristics or management practices and presence of drug residues in WM. In this study, 20% of farms did not pasteurize WM before feeding to calves. Two of the 10 Escherichia coli isolated from WM samples were multidrug resistant. Streptococcus spp. (n = 21, 84%) was the most common genus cultured from WM samples, followed by Staphylococcus spp. (n = 20, 80%) and E.coli (n = 10, 40%). Mycoplasma spp. was cultured from 2 WM samples (n = 2, 8%). The presence of drug residues in WM at concentrations that increase selection of resistant bacteria indicates the need for additional studies targeting on-farm milk treatments to degrade drug residues before feeding to calves. The presence of multidrug-resistant E. coli in WM urges the need for on-farm practices that reduce calf exposure to resistant bacteria, such as pasteurization.

Survey of management practices related to bovine respiratory disease in preweaned calves on California dairies.

In the spring of 2013, a survey of California (CA) dairies was performed to characterize management practices related to bovine respiratory disease in preweaned calves, compare these practices across geographic regions of the state, and determine the principal components that explain the variability in management between herds. The questionnaire consisted of 53 questions divided into 6 sections to assess management practices affecting dairy calves from precalving to weaning. The questionnaire was mailed to 1,523 grade A licensed dairies in CA and 224 responses (14.7%) were collected. Survey response rates were similar over the 3 defined regions of CA: northern CA, northern San Joaquin Valley, and the greater southern CA region. The mean size of respondent herds was 1,423 milking cows. Most dairies reported raising preweaned calves on-site (59.7%). In 93.3% of dairies, preweaned calves were raised in some form of individual housing. Nonsaleable milk was the most frequent liquid diet fed to preweaned heifers (75.2%). Several important differences were identified between calf-raising practices in CA and practices reported in recent nationwide studies, including herd sizes, housing practices, and sources of milk fed to heifers. The differences between the CA and nationwide studies may be explained by differences in herd size. Regional differences within CA were also identified. Compared with the 2 other regions, northern CA dairies were found to have smaller herds, less Holstein cattle, calves remained with dams for longer periods of time after calving, were more likely to be certified organic dairies, and raised their own calves more often. Principal component analysis was performed and identified 11 components composed of 28 variables (questions) that explained 66.5% of the variability in the data. The identified components and questions will contribute to developing a risk assessment tool for bovine respiratory disease in preweaned dairy calves.

Prospective study on complications following a lower body lift after massive weight loss.

BACKGROUND: Lower body lift procedures are in high demand following the increase of massive weight loss patients. As surgical complication rates in this patient group are generally high, patients need to be prepared for risk factors and complications in lower body lift surgery. The aim of this study was to identify the complications and possible risk factors of a lower body lift as concrete data for this procedure are limited. METHODS: A prospective study on 50 consecutive patients who underwent a lower body lift procedure was performed. Measures included co-morbidities and complications. Risk factors assessed included patient age, gender, highest lifetime body mass index (BMI) (BMI max), current BMI, excess weight loss (EWL), type of weight loss and nicotine consumption. RESULTS: There were 50 patients (44 females, six males) with a mean age of 41±10.8 years and a mean EWL of 86.4±15.6%. Mean BMI max was 49.5±10.5 kg m(-2), current BMI was 27.8±4.0 kg m(-2). A total of 35 (70%) patients developed at least one complication. Five patients (10%) suffered a major complication that necessitated surgical revision. Wound dehiscence occurred in 30 patients (60%), followed by seroma in 17 patients (34%). A surgical complication was directly related to BMI max (p=0.02) and age of the patient at the time of surgery (p=0.03). CONCLUSIONS: The overall complication rate following a lower body lift was 70%, which is comparable with that known for high-risk patient groups. The most important risk factors are BMI max and age of the patient (Clinical trial registration number (ISRCTN): NCT01551862).

Four-corner arthrodesis--does the source of graft affect bony union rate? Iliac crest versus distal radius bone graft.

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

Survey of dairy housing and manure management practices in California.

In 2007, a descriptive survey was mailed to all dairies in Glenn (G) and Tulare (T) Counties to identify current and future opportunities of manure management practices on California dairies. The purpose was to provide baseline information for development of outreach curriculum and a decision support tool to quantify potential benefits of various N management options on dairy farms. Such baseline information is valuable to staff regulating dairy facilities (e.g., San Joaquin Valley Unified Air Pollution Control District and Central Valley Regional Water Quality Control Board), dairy trade association representatives, and technology vendors. Response rates for each county were similar at 29.7% (n=19; G) and 26.7% (n=88; T). Mean milking herd size averaged 570 (range 50 to 3,000) cows in G and 1,800 (range 196 to 9,286) cows in T. Survey data are reported by location due to differences between counties in herd size, housing facilities, and climate. Freestalls are common housing facilities (63.2%, G; 38.6%, T) and separated solids and corral scrapings are commonly used as bedding in freestalls (81.8% G and 79.4% T). The most common methods of manure collection were flushing and scraping (18.8%, G; 44.7%, T), only flushing (43.8%, G; 34.1%, T), or only scraping daily or less frequently than daily (37.5%, G; 20.0%, T). Most dairy farms in G (63.2%) and T (70.5%) used some method of separating solids from liquids. However, mechanical separation systems alone were used by 5.3% G and 11.4% T of dairy farms. Storage or treatment ponds were found on 95.9% of dairies. Respondents identified existing manure management practices and did not indicate any new technologies were in use or being considered for manure management. Survey results were used to describe the 2 predominant manure management pathways of manure collection, storage, treatment, and utilization. Survey results will be used to develop and disseminate targeted information on manure treatment technologies, and on-farm evaluation of implemented technologies related to anaerobic digesters, solid liquid separation, and pond additives.

[Use of V.A.C. Therapy in the surgical treatment of severe burns: the Viennese concept]. / Einsatz der V.A.C.-Therapie in der Behandlung Schwerbrandverletzter: Das Wiener Konzept.

INTRODUCTION: General principle in the treatment of severe burns is early wound closure. A good take of split-thickness-skin-grafts is essential for fast wound healing and thereby for the outcome of the patient. The aim of the study was to evaluate the impact of V.A.C. therapy in the field of acute burn surgery. PATIENTS AND METHODS: All patients of the Vienna burn centre who were treated with V.A.C. between 2004 and 2006, were evaluated concerning burn surface area, burn degree and outcome. RESULTS: 28 out of 29 patients, suffering from deep dermal and full thickness burns, were discharged with complete wound closure, only one patient died. CONCLUSION: In our opinion, split-thickness skin-fixation by using V.A.C. therapy is suitable for moist and irregular wound surfaces, for areas exposed to movements and especially for the treatment of older patients with co-morbidities.

[Scaphoid fractures--operative or conservative treatment? A CT-based classification]. / Kahnbeinfrakturen--wann operativ, wann konservativ? CT-basierte Klassifikation.

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

Linking on-farm dairy management practices to storm-flow fecal coliform loading for California coastal watersheds.

How and where to improve water quality within an agricultural watershed requires data at a spatial scale that corresponds with individual management decision units on an agricultural operation. This is particularly true in the context of water quality regulations, such as Total Maximum Daily Loads (TMDLs), that identify agriculture as one source of non-point source pollution through larger tributary watershed scale and above and below water quality investigations. We have conducted a systems approach study of 10 coastal dairies and ranches to document fecal coliform concentration and loading to surface waters at the management decision unit scale. Water quality samples were collected on a storm event basis from loading units that included: manure management systems; gutters; storm drains; pastures; and corrals and lots. In addition, in-stream samples were collected above and below the dairy facilities and from a control watershed, managed for light grazing and without a dairy facility or human residence and corresponding septic system. Samples were analyzed for fecal coliform concentration by membrane filtration. Instantaneous discharge was measured for each collected sample. Storm runoff was also calculated using the curve number method (SCS, 1985). Results for a representative dairy as well as the entire 10 dairy data set are presented. Fecal coliform concentrations demonstrate high variability both within and between loading units. Fecal coliform concentrations for pastures range from 206 to 2,288,888 cfu/100 ml and for lots from 1,933 to 166,105,000 cfu/100 ml. Mean concentrations for pastures and lots are 121,298 (SE = 62,222) and 3,155,584 (SE = 1,902,713) cfu/100 ml, respectively. Fecal coliform load from units of concentrated animals and manure are significantly more than units such as pastures while storm flow amounts were significantly less. Compared with results from earlier tributary scale studies in the watershed, this systems approach has generated water quality data that is beneficial for management decisions because of its scale and representation of current management activities. These results are facilitating on-farm changes through the cooperative efforts of dairy managers, regulatory agency staff, and sources of technical and financial assistance.

[The posttraumatic carpal collapse--long-term results after midcarpal fusion]. / Der posttraumatische karpale Kollaps--Längerfristiger Verlauf nach mediokarpaler Teilarthrodese.

PURPOSE: Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid. METHOD AND MATERIAL: 37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically. RESULTS: The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain. CONCLUSION: Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

[Functional outcome and quality of life after ray amputation versus amputation through the proximal phalanx of the index finger]. / Funktion und Patientenzufriedenheit nach Strahlamputation versus subkapitaler Grundgliedamputation des Zeigefingers1.

Little data is available about the long-term functional outcome and quality of life after ray amputation or amputation at the level of the proximal phalanx of the index finger. The purpose of this study was to evaluate the functional outcome and postoperative quality of life after ray amputation or amputation through the proximal phalanx to create a database which is helpful in the decision whether to amputate a digital ray or to preserve a stump.58 patients with amputation of the second ray and 12 patients with amputation through the proximal phalanx of the index finger between 1987 and 1996 were included in the study and examined with respect to hand strength, sensibility, range of motion, pain, and aesthetic result of the hand. Subjective functional outcome was evaluated using the DASH-questionnaire. The majority of patients were male (78 % with ray amputation/83 % with amputation through the proximal phalanx). In 55 %/58 % the operation was performed on the dominant hand. Average age was 45 years and average follow-up was 44.2 months after ray resection and 22.1 months after amputation through the proximal phalanx. Patients lost an average of 10.7 weeks of work after ray amputation and 8.1 weeks after digital amputation. There was no significant loss of grip strength after ray amputation (29 % to 34 % loss of grip strength, 32 % loss of pinch grip) compared with patients after amputation through the proximal phalanx (21 % to 28 % loss of grip strength, 17 % to 35 % loss of pinch grip). DASH-score was 31.3 after ray amputation and 21.7 after digital amputation. Patients with amputation through the proximal phalanx reached a significantly better result in part B of the DASH-questionnaire. 65.5 % of the patients after ray amputation and 91.7 % after digital amputation complained of postoperative pain in the operated hand. Decreased sensibility was found in 55.2 % after ray resection and in 33.3 % after digital amputation. All patients after amputation through the proximal phalanx but only 82.8 % after ray amputation showed a free range of motion of the operated hand. The aesthetic appearance of the operated hand was rated higher after ray amputation. The results show that there is no significant loss of strength after ray amputation compared to amputation through the proximal phalanx as mentioned in the literature. Patients with amputation through the proximal phalanx demonstrate a better functional outcome, while the aesthetic appearance was rated higher after ray amputation. A significant difference was only found in part B of the DASH-questionnaire. This should be considered when the indication for ray amputation is pending.

Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study.

Transfer of the extensor indicis proprius is the gold standard for reconstruction of the extensor pollicis longus tendon to restore thumb extension. Twenty patients were included to a prospective randomized trial to assess whether an early dynamic motion protocol yields a better outcome than immobilization. Evaluation included postoperative range of motion, grip strength, duration of treatment, and time off work. Ten patients of each group had the thumb immobilized in an extension thumb spica cast for 3 weeks after surgery or underwent an early dynamic motion protocol. Follow-up examinations were performed 3, 4, 6, and 8 weeks after surgery. At 3 weeks total range of motion of the interphalangeal joint was almost twice as good (59 degrees ) in the dynamic motion group compared with immobilized patients (31 degrees ). At 6 weeks no significant differences between the groups were found. A similar pattern for grip strength and pinch grip was found after 3 weeks, when patients undergoing the motion protocol had significantly better results than the immobilized group. Although the dynamic motion group still had better results after 4 weeks, hand function was similar in both groups after 6 and 8 weeks. Patients with early dynamic motion recovered their hand function more rapidly than immobilized patients, shortening total rehabilitation time and making dynamic motion treatment highly cost-effective.

[Reconstruction of defects of the anterior abdominal wall]. / Die Rekonstruktion von Defekten der ventralen Bauchwand.

Reconstruction of the abdominal wall is of importance in many clinical situations, but may require the entire spectrum of plastic and reconstructive surgery. Indications for particular procedures depend on the clinical situation and the patient's individual profile. One has to differentiate between life-saving primary measures and secondary corrections to improve form or function. The article outlines current actual concepts of plastic surgical defect reconstruction with which the general/visceral surgeon should be acquainted, in order to integrate these concepts into a multi-disciplinary approach in pertinent clinical situations.