Effects of a coccidiosis challenge on dietary methionine recommendations in broilers.

Broilers are commonly exposed to coccidiosis infections, and the use of dietary strategies to reduce losses in growth performance has practical implications for the poultry industry. Methionine (Met) is typically the first limiting amino acid for broilers and is involved in metabolic and immunological pathways; however, literature is conflicting on how dietary Met requirements are affected by environmental stressors. Our objective was to assess how the Met requirement changes during coccidiosis based on results of growth performance, carcass traits, and health outcomes. Two trials were conducted using 780 male Ross 308 broiler chicks in floor pens randomly assigned to 1 of 12 experimental treatments. All birds received common starter (d 0-10) and finisher (d 24-35, Trial 2 only) diets, and only differed based on their assigned experimental grower diet (d 10-24). Trial 1 experimental grower diets ranged from 2.61 to 6.21 g/kg digestible Met. Trial 2 experimental grower diets were formulated to contain 15% below, at, or 15% above the Met requirement determined in Trial 1. Birds were exposed to a coccidiosis challenge on d 11, with blood and tissue collection (1 bird/pen) on d 18 and carcass processing on d 35 (2 birds/pen) in Trial 2. Data were analyzed using a 1- or 2-way ANOVA. A non-linear regression analysis was conducted in Trial 1 to determine the Met requirement of 4.32 g of digestible Met/kg of diet using BW gain. Coccidiosis infection reduced (P < 0.05) growth performance during the experimental grower and overall study periods in Trial 2. Increasing dietary Met from below requirement to meeting requirement during the grower period improved (P < 0.001) BW gain and feed conversion ratio (FCR), but this effect was only significant between treatments below and above the requirement for the overall study period. There was an interactive effect (P = 0.038) on FCR for the overall study period. These findings provide evidence that the Met requirement is likely increased during coccidiosis based on growth performance outcomes.

Defining optimal dietary starch, oil, and amino acid inclusion levels for broilers experiencing a coccidiosis challenge.

Alternative methods to alleviate coccidiosis in broilers are of interest to producers, including dietary strategies to minimize disruptions in growth rate and efficiency when faced with health challenges. Our objective was to determine optimal combinations of dietary starch, amino acids (AA), and oil to benefit productivity of broilers experiencing Eimeria-induced immune activation. Two trials were conducted using 1,536 male Ross 308 broiler chicks in floor pens randomly assigned to 1 of 17 experimental treatments. All birds received common starter (d 0-10) and finisher (d 24-35) diets, and only differed based on their assigned experimental grower diet (d 10-24). Trial 1 experimental grower diets ranged from 2,700 to 3,300 kcal/kg AME. Trial 2 included 10 experimental grower diets following a simplex lattice design consisting of 3 basal lots formulated to have the highest starch (45.4%), oil (10.2%), or AA density (120, 1.33% digestible Lys) and mixed in 4 equally spaced levels for each component (0, 0.33, 0.67, 1). These mixtures enabled varying densities of AA (80-120% of recommendation), starch:oil (4:1-20:1), and AME (2,940-3,450 kcal/kg). Bird and feeder weights were collected on d 0, 10, 24, and 35, and birds were exposed to an Eimeria challenge on d 11 or 12. In trial 2, excreta samples were collected for AME determination and carcasses were processed on d 36. Data were analyzed using ANOVA, t test, or regression. In Trial 1, BW gain and feed conversion were improved (P < 0.05) by increasing dietary AME. In Trial 2, birds receiving diets containing AA at 93 to 107% of recommendations and higher oil exhibited improved (P < 0.05) performance, but increased starch at the expense of oil reduced performance (P < 0.05). Relative breast and fat pad weights were not influenced by diet in Trial 2. We determined that broilers mildly challenged with Eimeria would exhibit highest BW gain when receiving diets containing 35.8% starch, 8.9% oil, and 101.3% of AA recommendations, which can be utilized by producers to maintain productivity under health-challenged conditions.

Rise of extremity fractures and sport accidents in children at 8-12 years and increase of admittance via the resuscitation room over a decade.

INTRODUCTION: In an emergency department, the majority of pediatric trauma patients present because of minor injuries. The aim of this study was to evaluate temporal changes in age-related injury pattern, trauma mechanism, and surgeries in pediatric patients. METHODS: This retrospective study included patients < 18 years of age following trauma from 01/2009 to 12/2018 at a level I trauma center. They were divided into two groups: group A (A: 01/2009 to 12/2013) and group B (B: 01/2014 to 12/2018). Injury mechanism, injury pattern, and surgeries were analyzed. As major injuries fractures, dislocations, and organ injuries and as minor injuries contusions and superficial wounds were defined. RESULTS: 23,582 patients were included (58% male, median age 8.2 years). There was a slight increase in patients comparing A (n = 11,557) and B (n = 12,025) with no difference concerning demographic characteristics. Significant more patients (A: 1.9%; B: 2.4%) were admitted to resuscitation room, though the number of multiple injured patients was not significantly different. In A (25.5%), major injuries occurred significantly less frequently than in B (27.0%), minor injuries occurred equally. Extremity fractures were significantly more frequent in B (21.5%) than in A (20.2%), peaking at 8-12 years. Most trauma mechanisms of both groups were constant, with a rising of sport injuries at 8-12 years. CONCLUSION: Although number of patients increases only slightly over a decade, there was a clear increase in major injuries, particularly extremity fractures, peaking at 8-12 years. At this age also sport accidents significantly increased. At least, admittance to resuscitation room rose but without an increase of multiple injured patients.

Correction of Motion Artifacts Using a Multiscale Fully Convolutional Neural Network.

BACKGROUND AND PURPOSE: Motion artifacts are a frequent source of image degradation in the clinical application of MR imaging (MRI). Here we implement and validate an MRI motion-artifact correction method using a multiscale fully convolutional neural network. MATERIALS AND METHODS: The network was trained to identify motion artifacts in axial T2-weighted spin-echo images of the brain. Using an extensive data augmentation scheme and a motion artifact simulation pipeline, we created a synthetic training dataset of 93,600 images based on only 16 artifact-free clinical MRI cases. A blinded reader study using a unique test dataset of 28 additional clinical MRI cases with real patient motion was conducted to evaluate the performance of the network. RESULTS: Application of the network resulted in notably improved image quality without the loss of morphologic information. For synthetic test data, the average reduction in mean squared error was 41.84%. The blinded reader study on the real-world test data resulted in significant reduction in mean artifact scores across all cases (P < .03). CONCLUSIONS: Retrospective correction of motion artifacts using a multiscale fully convolutional network is promising and may mitigate the substantial motion-related problems in the clinical MRI workflow.

[Actively living a medical safety (error) culture-what does urology need to learn?] / Gelebte Sicherheits(fehler)kultur ­ was muss die Urologie lernen?

Patient safety is the basic quality of every medical treatment. Scientifically sound knowledge on the necessary structures of a safety management system and experience from effectively implementing those are aplenty. Yet, even 30 years after the first successful steps, it is still difficult for healthcare to implement a comprehensive, system-wide approach. Cultural changes at the level of attitudes and the consistent creation of the necessary structures might accelerate this transformation process.

A simulation platform using 3D printed neurovascular phantoms for clinical utility evaluation of new imaging technologies.

Modern 3D printing technology allows rapid prototyping of vascular phantoms based on an actual human patient with a high degree of precision. Using this technology, we present a platform to accurately simulate clinical views of neuro-endovascular interventions and devices. The neuro-endovascular interventional phantom has a 3D printed cerebrovasculature model derived from a patient CT angiogram and embedded inside a human skull providing bone attenuation. Acrylic layers were placed underneath and on top of the skull, simulating entrance and exit tissue attenuation and also simulating forward scatter. The 3D model was connected to a pulsatile flow loop for simulating interventions using clinical devices such as catheters and stents. To validate the x-ray attenuation and establish clinical accuracy, the automatic exposure selection by a clinical c-arm system for the phantom was compared with that for a commercial anthropomorphic head phantom (SK-150, Phantom Labs). The percentage difference between automatic exposure selection for the neuro-intervention phantom and the SK-150 phantom was under 10%. By changing 3D printed models, various patient diseased anatomies can be simulated accurately with the necessary x-ray attenuation. Using this platform various interventional procedures were performed using new imaging technologies such as a high-resolution x-ray fluoroscope and a dose-reduced region-of-interest attenuator and differential temporally filtered display for enhanced interventional imaging. Simulated clinical views from such phantom-based procedures were used to evaluate the potential clinical performance of such new technologies.

[Mediocarpal instability of the wrist]. / Mediokarpale Instabilitäten der Handwurzel.

Typical lesions of the carpal ligaments are mostly found after a fall on the wrist in hyperextension or as complex injuries after severe trauma, e. g. after a fall from a significant height, motorcycle accident or as accompanying lesions in multiple trauma. The typical mechanisms, patterns and diagnostic algorithms are well known for the common ligamentous injuries (e.g. scapholunate, lunotriquetral and perilunate); therefore, consistent diagnostic procedures and adequate therapy are increasingly performed after such lesions, e. g. by early ligament repair or by ligament reconstruction through augmentation. Within appropriate operative treatment, accompanying fractures are also treated and instabilities are addressed by transfixation of joints by Kirschner wires. If followed by immobilization with a cast or stable brace, healing can be achieved in most cases; however, more problems occur if ligamentous lesions or instabilities are not clearly due to a trauma mechanism and more the result of laxity or hypermobile situations due to a congenital predisposition. In such cases, wrist pain is often described and misdiagnosed as the result of overload or tenovaginitis.

Clinical outcome after alternative treatment of scaphoid fractures and nonunions.

PURPOSE: Achieving stable fixation of scaphoid fractures and nonunions continues to be a challenge. Compression screw fixation has been the current standard surgical procedure. However, in some cases, bone healing cannot be achieved and requires further revision. Recent series reintroduced volar plating as valid option for stable fixation. The aim of the study was to review clinical outcome of alternative scaphoid treatment. METHODS: From 2011 to 2014, nine patients with scaphoid fracture were treated by Headless Compression Screw (HCS) and seven patients with scaphoid nonunion by HCS or volar mini condylar plate with bone graft. The average age was 34.4 years and the average time to follow-up was 19.3 months. From 1996 to 1998, 38 patients with scaphoid nonunion were treated using compression screw (S-group) or volar mini condylar plate (P-group) with bone graft. The average age was 39.6 years and the average time to follow-up was 26.2 months. RESULTS: The union rate was 100%. For scaphoid fractures, the mean Modified Mayo Wrist Score (MMWS) was 94.1 and the DASH score 7.4. From 2011 to 2014, the MMWS was 87.9 and the DASH score 7 in scaphoid nonunions. In the period between 1996 and 1998, the MMWS was 67.2 in the P-group and 58.6 in the S-group, and the DASH score 16.8 and 28.2. CONCLUSIONS: Our study demonstrated that appropriate application of the HCS was able to produce very satisfactory results in scaphoid fractures and nonunions. In our opinion, however, the method of scaphoid plate osteosynthesis can achieve a higher degree of stability, particularly rotational stability, in case of multifragmentary avascular scaphoid nonunions.

Towards predicting the encoding capability of MR fingerprinting sequences.

Sequence optimization and appropriate sequence selection is still an unmet need in magnetic resonance fingerprinting (MRF). The main challenge in MRF sequence design is the lack of an appropriate measure of the sequence's encoding capability. To find such a measure, three different candidates for judging the encoding capability have been investigated: local and global dot-product-based measures judging dictionary entry similarity as well as a Monte Carlo method that evaluates the noise propagation properties of an MRF sequence. Consistency of these measures for different sequence lengths as well as the capability to predict actual sequence performance in both phantom and in vivo measurements was analyzed. While the dot-product-based measures yielded inconsistent results for different sequence lengths, the Monte Carlo method was in a good agreement with phantom experiments. In particular, the Monte Carlo method could accurately predict the performance of different flip angle patterns in actual measurements. The proposed Monte Carlo method provides an appropriate measure of MRF sequence encoding capability and may be used for sequence optimization.

Acute adrenal insufficiency: an aide-memoire of the critical importance of its recognition and prevention.

Adrenal crisis is a life-threatening emergency that causes significant excess mortality in patients with adrenal insufficiency. Delayed recognition by medical staff of an impending adrenal crisis and failure to give timely hydrocortisone therapy within the emergency department continue to be commonly encountered, even in metropolitan teaching hospitals. Within the authors' institutions, several cases of poorly handled adrenal crises have occurred over the last 2 years. Anecdotal accounts from members of the Addison's support group suggest that these issues are common in Australia. This manuscript is a timely reminder for clinical staff on the critical importance of the recognition, treatment and prevention of adrenal crisis. The manuscript: (i) outlines a case and the clinical outcome of sub-optimally managed adrenal crisis, (ii) summarises the clinical features and acute management of adrenal crisis, (iii) provides recommendations on the prevention of adrenal crisis and (iv) provides guidance on the management of 'sick days' in patients with adrenal insufficiency.

[Process design in high-reliability organizations]. / Prozessgestaltung in Hochzuverlässigkeitsorganisationen.

Modern medicine is a highly complex service industry in which individual care providers are linked in a complicated network. The complexity and interlinkedness is associated with risks concerning patient safety. Other highly complex industries like commercial aviation have succeeded in maintaining or even increasing its safety levels despite rapidly increasing passenger figures. Standard operating procedures (SOPs), crew resource management (CRM), as well as operational risk evaluation (ORE) are historically developed and trusted parts of a comprehensive and systemic safety program. If medicine wants to follow this quantum leap towards increased patient safety, it must intensively evaluate the results of other high-reliability industries and seek step-by-step implementation after a critical assessment.

[Error prevention through management of complications in urology: standard operating procedures from commercial aviation as a model]. / Fehlervermeidung durch Komplikationsmanagement in der Urologie: "Standard operating procedures" aus der Luftfahrt als Vorbild.

Patient safety and risk/complication management rank among the current megatrends in modern medicine, which has undoubtedly become more complex. In time-critical, error-prone and difficult situations, which often occur repeatedly in everyday clinical practice, guidelines are inappropriate for acting rapidly and intelligently. With the establishment and consistent use of standard operating procedures like in commercial aviation, a possible strategic approach is available. These medical aids to decision-making - quick reference cards - are short, optimized instructions that enable a standardized procedure in case of medical claims.

[Learning from errors: applying aviation safety concepts to medicine]. / Aus Fehlern lernen : Sicherheitskonzepte der Luftfahrt in der Medizin anwenden.

Health care safety levels range below other complex industries. Civil aviation has throughout its history developed methods and concepts that have made the airplane into one of the safest means of mass transport. Key elements are accident investigations that focus on cause instead of blame, human-centered design of machinery and processes, continuous training of all personnel and a shared safety culture. These methods and concepts can basically be applied to medicine which has successfully been achieved in certain areas, however, a comprehensive implementation remains to be completed. This applies particularly to including the topic of safety into relevant curricula. Physicians are obliged by the oath"primum nil nocere" to act, but economic as well as political pressure will eventually confine professional freedom if initiative is not taken soon.

[Skeletal tuberculosis of the distal radius during pregnancy]. / Ossäre Tuberkulose am distalen Radius in der Schwangerschaft.

We present a case of a pregnant woman (32nd gestational week) that suffered from a chronic non-healing wound at the distal radius. Skeletal tuberculosis was finally diagnosed and treated successfully with staged surgical therapy combined with appropriate medication. One year after surgical treatment, the outcome of the mother was excellent and the baby did not suffer from any disease related to operative procedures or pharmacotherapy. Operative treatment of skeletal tuberculosis (especially osteoarticular and vertebral tuberculosis) in combination with tuberculostatic therapy during pregnancy and lactation seem to be the appropriate treatment with minimal risk for the child and excellent outcome for the mother.

[Orbital and intracranial complications of acute sinusitis. Diagnostics and therapy in children and adolescents]. / Orbitale und intrakranielle Komplikationen akuter Sinusitiden. Diagnostik und Therapie bei Kindern und Jugendlichen.

Orbital and intracranial complications of acute sinusitis occur more frequently in the pediatric population compared to adults due to anatomic differences. Since the introduction of antibiotics the frequency of such complications has been dramatically reduced. Nevertheless, even in the era of modern antibiotics these complications continue to occur and it is therefore of utmost importance not only to know about these complications but also to include them in the differential diagnosis. Appropriate diagnosis mainly based on CT scanning or magnetic resonance tomography is the basis for a rapid and sufficient and if necessary interdisciplinary treatment. In this CME article the diagnostic and therapeutic interventions in four young patients suffering from orbital or intracranial complications due to acute sinusitis are described and discussed in the context of the current literature and a clinical algorithm is introduced.

Restoration of the tumor suppressor p53 by downregulating cyclin B1 in human papillomavirus 16/18-infected cancer cells.

Abrogation of functional p53 is responsible for malignant cell transformation and the maintenance of malignant state of human papillomavirus-infected cancer cells. Thus, restoration of p53 has been regarded as an important strategy for molecular intervention combating papillomavirus-associated malignancies. We show here that depleting cyclin B1 stabilizes and reactivates p53 in papillomavirus-infected cervical cancer cell lines HeLa and CaSki. HeLa cells depleted of cyclin B1 exhibit mitotic defects in spindle formation and chromosome alignment. Downregulation of cyclin B1 increases p14 alternative reading frame of p16, the positive regulator of p53, and decreases phosphorylation of Ser315 in p53. Whereas RO-3306, a selective inhibitor of cyclin-dependent kinase 1 (Cdk1), suppresses this phosphorylation at Ser315 of p53, ZM447439, targeting Aurora A/B kinases, shows no effect. Further analyses in HeLa cells and HCT116 p53(-/-) cells suggest that the Ser315 phosphorylation by Cdk1 regulates negatively the protein stability and the function of p53. Moreover, increased p53 in HeLa cells is functional by showing its increased downstream effectors p21, mouse double minute 2 and Bax. Restoration of p53 and silencing cyclin B1 render cervical carcinoma cells more susceptible to DNA damage agent camptothecin. Taken together, targeting cyclin B1 might be an attractive strategy for preventing and treating papillomavirus-associated cancer by reactivating p53 and by reducing the Cdk1 activity.

Oxidative stress markers in young hemodialysis patients - a pilot study.

AIMS: Studies in young hemodialysis patients without significant comorbidities might increase the understanding of incipient vascular pathology in uremia. We investigated whether a specific pattern of oxidative stress markers with potential prognostic significance could be identified in this population. MATERIAL AND METHODS: We performed a cross-sectional matched case control study of 25 young hemodialysis patients (age 18 - 40 years) without known comorbidity factors. Patients were matched pairwise to healthy controls, and markers of oxidative stress were analyzed for associations with surrogate parameters of vascular structure and function. RESULTS: Oxidized low-density lipoproteins (OxLDL) were similar in patients and controls whereas conjugated dienes were increased in the very low-density lipoproteins (VLDL) fraction (20 +/- 6 vs. 12 +/- 5 micromol/l, p < 0.0001), but not in the low-density lipoproteins (LDL) fraction (16 +/- 6 vs. 18 +/- 6 micromol/l). Superoxide dismutase (SOD) activity was diminished in patients (1,117 +/- 151 vs. 1,299 +/- 88 U/g Hb, p < 0.0001), but there was no difference in glutathione peroxidase (GPx) activity. Oxidative stress expressed as the ratio of oxidized and reduced glutathione (GSSG/GSH) was increased in patients (0.25 +/- 0.18 vs. 0.13 +/- 0.04, p = 0.0048). Intima-media thickness (IMT) of the common carotid artery (0.70 +/- 0.12 vs. 0.62 +/- 0.08 mm, p = 0.0007) was significantly increased, and postischemic peak flow (PIPF) by venous occlusion plethysmography was severely diminished in patients (632 +/- 319 vs. 1,057 +/- 543% of basal flow, p < 0.0001). None of the markers of oxidative stress was independently associated with IMT or PIPF or a significant discriminator between patients and controls by multivariate regression. CONCLUSIONS: In this pilot study of exclusively young patients on hemodialysis, oxidative stress markers were of limited clinical value in identifying young patients at risk for vascular complications.

[A dural fistula as a rare cause for a pulse-synchronized tinnitus aurium]. / Arteriovenöse Durafistel als seltene Ursache für einen pulssynchronen Tinnitus.

Pulse-synchronized tinnitus aurium is commonly caused by vascular processes within the area of the temporal bone. With a microphone or a stethoscope in the external ear or on the mastoid perceptible noises can be heard by the physician. The most important differential diagnoses of an objective tinnitus are paraganglioma of the glomus jugulare or the glomus tympanicum, vascular stenosis, arteriovenouse malformations, aneurysms and atypic findings of the bulbus venae jugularis interna of the temporal bone. In case of a pulse-synchronized tinnitus purposeful use of neuroradiological diagnostic can lead to a correct diagnosis. The indication for invasive intervention of dural fistulas depends on the number and the hemodynamic relevance of these fistulas and on individual suffering of the patient. Even if it does not succeed, all to embolize AV-short-circuits, it is possible to reduce the intensity of the tinnitus in order to continue with conservative therapy.