Subacute ruminal acidosis phenotypes in periparturient dairy cows differ in ruminal and salivary bacteria and in the in vitro fermentative activity of their ruminal microbiota.

Both ruminal microbial structure and functionality might play a role in inter-individual variation in susceptibility for subacute rumen acidosis (SARA) observed in dairy cows. The aims of this study were to determine whether differences between cows with distinct SARA susceptibility were reflected in distinct (1) ruminal microbial communities, (2) salivary bacterial communities, and (3) fermentative capacity of ruminal microbiota assessed in vitro. To test this hypothesis, rumen samples were collected via an esophageal tube on 21 d postpartum from 38 multiparous Holstein cows, which were classified into 4 groups differing in median and mean time of reticular pH below 6 as well as area under the curve of pH below 6.0. During the 21 d postpartum, all cows within a group fulfilled following criteria: susceptible (S, n = 10; mean or median ≥180 min/d), moderately susceptible (MS, n = 7; 60 min/d < mean time of pH below 6 < 180 min/d, and median time of pH below 6 <180 min/d), moderately unsusceptible (MU, n = 11; 10 min/d < mean < 60 min/d, and median time of pH below 6 ≤30 min/d), or unsusceptible (U, n = 10; median = 0 min/d, and mean <10 min/d). Groups did not differ in total daily dry matter intake nor in total, roughage, or concentrate intake during daily 6-h time intervals. Rumen bacterial α-diversity did not differ among groups, but ß-diversity varied and bacterial 16S rRNA gene copy numbers were lower in S compared with U cows. The relative abundance of genera Streptococcus, Sharpea, Prevotellaceae_YAB2003, Succinivibrionaceae_UCG-001, Ruminococcus, and Ruminococcaceae_UCG-001 were higher in S compared with U cows. In contrast, Lachnospiraceae_ND3007 and Oscillospiraceae_V9D2013 were more abundant in U cows. Although pH-associated, inter-animal differences were also observed in the salivary bacteria, common differences in ruminal and salivary bacterial genera were limited. The functionality of the rumen microbiota was evaluated in vitro through exposure of the microbial inoculum of S and U cows to an anaerobic buffer at pH 5.8 and 6.8, in the presence of sterile supernatant of their own and of dry cows' rumen fluid (2 × 2 design). Generally, the S inoculum produced more volatile fatty acids, except at low pH with dry cows' supernatant, where volatile fatty acid production was completely impaired and lactate accumulation was highest. Compared with the microbes of U cows, microbes of S cows showed less fermentative activity in situations with 2 stress factors (low pH and an unfamiliar environment, i.e., rumen fluid supernatant of dry cows).

Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service team.

BACKGROUND: The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex created a designated critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers. METHODS: Retrospective review of air critical care transfer service set up and case review of first 50 transfers. RESULTS: We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. 94% of the transfer missions were conducted by road. The mean age of these patients was 58 years (29-83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 min (range 149-440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 min (31-158). The mean transfer transit time between referring and receiving units was 72 min (9-182). CONCLUSION: Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air transfer, can be achieved safely with specific planning, protocols and precautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.

Distinct blood and milk 18-carbon fatty acid proportions and buccal bacterial populations in dairy cows differing in reticulorumen pH response to dietary supplementation of rapidly fermentable carbohydrates.

Nine Holstein dairy cows were fed diets with increasing proportions of rapidly fermentable carbohydrates (RFCH) to investigate the effect on reticular pH, milk fat content (MFC), 18-carbon fatty acid proportions in blood plasma and milk, and bacterial community in buccal swab samples. Inter-animal variation was expected in terms of reticular pH response upon higher RFCH proportions, which would be reflected in the occurrence or not of milk fat depression (MFD). Moreover, this variation in occurrence of MFD was hypothesized to be related to differences in blood and milk fatty acid proportions and in the bacterial community in buccal samples. Cows were fed a total mixed ration throughout the experiment, which consisted of 4 periods: adaptation (d 0-4) and low (d 5-18), increasing (d 19-24), and high RFCH (d 25-28). During the increasing RFCH period, the standard concentrate (211 g of starch/kg of dry matter) was gradually and partly replaced by a concentrate high in RFCH (486 g of starch/kg of dry matter). The reticular pH was measured using a bolus and the time below pH 6.00 was calculated on a daily basis. On d 13, 14, 25, 27, and 28, plasma and milk samples were collected and analyzed for 18-carbon fatty acid proportions, and buccal swabs were collected for bacterial community analysis based on 16S rRNA gene amplicon sequencing. Inter-animal variation was observed in terms of reticular pH, which allowed us to divide the cows into 2 groups: tolerant (time below pH 6.00 ≤ 0.1 h/d) and susceptible cows (time below pH 6.00 ≥ 1.26 h/d). The lower reticular pH of susceptible cows was accompanied by lower MFC. Both groups already differed in reticular pH and MFC during the low-RFCH period. Furthermore, higher RFCH amounts did not decrease the reticular pH in either of the 2 groups. Nevertheless, MFD was observed in both groups during the high-RFCH period compared with the low-RFCH period. Lower MFC in animals with lower reticular pH or during the high-RFCH period was associated with a shift in 18-carbon fatty acids toward trans-10 at the expense of trans-11 intermediates, which was observed in plasma as well as in milk samples. Moreover, lower MFC was accompanied by shifts in the relative abundance of specific bacteria in buccal samples. Genera Dialister, Sharpea, Carnobacterium, Acidaminococcus, and uncultured genera belonging to the Betaproteobacteria were more abundant in situations with greater trans-10 proportions.

Out-of-hospital cardiac arrest following trauma: What does a helicopter emergency medical service offer?

INTRODUCTION: Helicopter emergency medical services (HEMS) are often dispatched to patients in traumatic cardiac arrest (TCA) as they can provide treatments and advanced interventions in the pre-hospital environment that have the potential to contribute to an increased survival. This study, aimed to investigate the added value of HEMS in the treatment of TCA. METHODS: We performed a retrospective cohort study of all patients with a pre-hospital TCA who were attended by a non-urban HEMS (Kent, Surrey and Sussex Air Ambulance trust) between July 1st 2013 and May 1st 2018. We investigated how many patients got return of spontaneous circulation (ROSC) at scene, which HEMS specific advanced interventions were performed in these patients, and how these interventions were related to ROSC. RESULTS: During the study period 263 patients with a TCA were attended by HEMS with an average response time of 30 min [range 13-109]. 51 patients (20%) regained ROSC at scene (28 before- and 23 after arrival of HEMS). The HEMS specific interventions of blood product administration (OR 8.54 [2.84-25.72]), and RSI (2.95 [1.32-6.58]) were positively associated with ROSC. Most patients who had a ROSC had one or more HEMS specific interventions being performed - RSI (n = 19, 37%), blood product administration (n = 32, 62%), thoracostomies (n = 36, 71%) and thoracotomy (n = 1, 2%). HEMS also delivered other important interventions to these patients as IV/IO access (n = 20, 39.2%) and endotracheal intubation without drugs (n = 9, 17.6%). CONCLUSION: HEMS teams should be involved in the treatment of patients with a TCA, even in non-urban areas with prolonged response times, as they provide knowledge and skills that contribute to regaining and maintaining a sustained ROSC in this critically ill and injured cohort of patients.

Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid.

BACKGROUND: Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid. METHODS: A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets. RESULTS: The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19-1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32-1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07). CONCLUSION: In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.

Polyunsaturated fatty acids are less effective to reduce methanogenesis in rumen inoculum from calves exposed to a similar treatment early in life.

The aim of this study was to evaluate the dose response on in vitro methane (CH) production of PUFA to which the inoculum donor animals had been exposed early in life. Sixteen Holstein calves (160 ± 3 and 365 ± 2 kg BW) at 6 and 12 mo of age were used as inoculum donors. Half of the calves were given increasing amounts of extruded linseed from birth (22 g/d) until 4 mo of age (578 g/d) first mixed with milk and then included in their concentrate. Linseed oil (LSO) was supplemented in vitro at 5 different doses (0, 0.6, 1.2, 2.4, and 4.8 mg/mL). Supplementation of LSO in the rumen inocula at both ages linearly decreased ( < 0.05) the in vitro CH production. Total in vitro VFA production was not affected by LSO supplementation. Inhibition of CH was smaller when using the rumen inoculum from calves that had received a similar treatment early in life ( < 0.05). Differences in response to in vitro supplementation of a type of fatty acids similar to those applied during early life suggest some "changes" in the functioning of the rumen microbial community.

Screening of bacterial direct-fed microbials for their antimethanogenic potential in vitro and assessment of their effect on ruminal fermentation and microbial profiles in sheep.

Direct-fed microbials (DFM) are used to modulate ruminal function and induce beneficial effects on ruminants. The objectives of this work were to 1) screen bacterial strains for their antimethanogenic potential in vitro and 2) assess the effect of 3 selected DFM on ruminal methane (CH) emissions, fermentation parameters, and microbial profiles in sheep. Forty-five bacterial strains were preselected based on their metabolism and fermentation characteristics. These bacteria were screened for their ability to reduce ruminal methanogenesis using 24-h batch incubations and an inoculum of 10 cfu/mL of medium. The addition of bacterial strains stimulated ruminal fermentation with increases in total gas production for 41 strains ( < 0.05) without a concomitant increase in CH production (only 9 strains had higher CH than the controls without DFM; < 0.05). 53-W, D31, and D1 had the greatest difference between total gas and CH production and were selected for further in vivo testing. Twelve rumen-cannulated Texel wethers were divided into 3 groups and were treated daily for 4 wk with 6 × 10 cfu/animal for and and 3 × 10 cfu/animal for . Measures of enteric CH, ruminal fermentation, and ruminal microbial traits were performed before, at 2 and 4 wk during the treatment period, and at 2 wk after the DFM treatment stopped. Methane production was reduced by 13% ( < 0.05) with after 2 wk of DFM administration, and this effect was maintained throughout the treatment and posttreatment periods. In contrast, had no effect on CH production, and increased it by 16% ( < 0.05) after 4 wk of DFM administration. There was no effect on other fermentation parameters or on the bacterial, archaeal, and protozoal numbers monitored by quantitative PCR. However, denaturing gradient gel electrophoresis profiles indicated changes in bacterial and archaeal diversity in the and groups. Although added bacteria were unable to permanently colonize the rumen, had a greater 24-h survival rate than the others, implying that the persistence of DFM may be important for modulating ruminal traits of interest. These results suggest that bacterial DFM used in this trial were able to modify CH emissions, although correlated changes in other ruminal parameters studied were minor.

Effect of adsorbants on in vitro biohydrogenation of 22:6n-3 by mixed cultures of rumen microorganisms.

Studies on microbial biohydrogenation of fatty acids in the rumen are of importance as this process lowers the availability of nutritionally beneficial unsaturated fatty acids for incorporation into meat and milk but also might result in the accumulation of biologically active intermediates. The impact was studied of adsorption of 22:6n-3 (DHA) to particulate material on its disappearance during 24 h in vitro batch incubations with rumen inoculum. Four adsorbants were used in two doses (1 and 5 mg/ml of mucin, gum arabic, bentonite or silicic acid). In addition, the distribution of 22:6n-3 in the pellet and supernatant of diluted rumen fluid was measured. Bentonite and silicic acid did not alter the distribution of 22:6n-3 between pellet and supernatant nor increased the disappearance of 22:6n-3 during the incubation. Both mucin and gum arabic increased the recovery of 22:6n-3 in the supernatant, indicating that these compounds lowered the adsorption of the fatty acid to ruminal particles. This was associated with an increased disappearance of 22:6n-3, when initial 22:6n-3 was 0.06 or 0.10 mg/ml, and an increased formation of 22:0, when initial 22:6n-3 was 0.02 mg/ml, during the 24 h batch culture experiment. Addition of gum arabic to pure cultures of Butyrivibrio fibrisolvens or Butyrivibrio proteoclasticus did not negate the inhibitory effect of 22:6n-3 on growth. As both mucin and gum arabic provide fermentable substrate for ruminal bacteria, an additional experiment was performed in which mucin and gum arabic were replaced by equal amounts of starch, cellulose or xylan. No differences in disappearance of 22:6n-3 were observed, suggesting that the stimulatory effect of mucin and gum arabic on disappearance of 22:6n-3 most probably is not due to provision of an alternative site of adsorption but related to stimulation of bacterial growth. A relatively high proportion of 22:6n-3 can be reduced to 22:0 provided the initial concentration is low.

The use of direct-fed microbials for mitigation of ruminant methane emissions: a review.

Concerns about the environmental effect and the economic burden of methane (CH4) emissions from ruminants are driving the search for ways to mitigate rumen methanogenesis. The use of direct-fed microbials (DFM) is one possible option to decrease CH4 emission from ruminants. Direct-fed microbials are already used in ruminants mainly to increase productivity and to improve health, and are readily accepted by producers and consumers alike. However, studies on the use of DFM as rumen CH4 mitigants are scarce. A few studies using Saccharomyces cerevisiae have shown a CH4-decreasing effect but, to date, there has not been a systematic exploration of DFM as modulators of rumen methanogenesis. In this review, we explored biochemical pathways competing with methanogenesis that, potentially, could be modulated by the use of DFM. Pathways involving the redirection of H2 away from methanogenesis and pathways producing less H2 during feed fermentation are the preferred options. Propionate formation is an example of the latter option that in addition to decrease CH4 formation increases the retention of energy from the diet. Homoacetogenesis is a pathway using H2 to produce acetate, however up to now no acetogen has been shown to efficiently compete with methanogens in the rumen. Nitrate and sulphate reduction are pathways competing with methanogenesis, but the availability of these substances in the rumen is limited. Although there were studies using nitrate and sulphate as chemical additives, use of DFM for improving these processes and decrease the accumulation of toxic metabolites needs to be explored more. There are some other pathways such as methanotrophy and capnophily or modes of action such as inhibition of methanogens that theoretically could be provided by DFM and affect methanogenesis. We conclude that DFM is a promising alternative for rumen methane mitigation that should be further explored for their practical usage.

A comparison of performance between Teflon and polyurethane safety cannulae at extremes of operating temperatures.

OBJECTIVES: In the United Kingdom, approximately eight million peripheral cannulations are performed each year. Intravenous cannulae are made from either polytetrafluoroethylene (Teflon) or polyurethane. Polyurethane has a lower incidence of thrombophlebitis, however the physical characteristics of polyurethane may make the cannulae difficult to use at higher ambient temperatures. This effect maybe of importance to those involved in cannulation in extreme environments and especially for military doctors deployed in current theatres of operations. METHODS: In a randomised single blinded study we investigated the different characteristics of Teflon and polyurethane cannulae (Vasofix Safety Cannulae, B Braun) at three different temperatures (-10 degrees C, 21 degrees C and 40 degrees C). RESULTS: There is no statistically significant difference in the ease or speed of cannulation of either polyurethane or Teflon safety cannulae in extremes of temperature. CONCLUSIONS: This study provides evidence that performance of polyurethane safety cannulae are not impaired by temperature extremes.

A survey of primary health care provision at a Forward Operating Base in Afghanistan during operation HERRICK 10.

OBJECTIVES: To record and discuss patient morbidity treated in a Forward Operating Base in Afghanistan and explore who delivers the care. METHODS: Prospective case series of all patients presenting to the Regimental Aid Post during a summer tour of Afghanistan. RESULTS: 1903 episodes of care were delivered over a 6-month period in 2009. Afghan patients represented 32.8% of all cases seen. The majority of cases were related to primary care. The most common types of presentations were dermatological, other general medical conditions, other injuries and disorders of the digestive tract. Combat Medical Technicians (CMT) were able to deal with 47% of all cases using the CMT protocols. CONCLUSIONS: Primary care in forward areas involves patients from a spectrum of backgrounds with multiple morbidities and diagnoses. Consideration should be given for further research into the area of the consultation at the front line to aid patient care. Combat Medical Technicians were able to treat nearly 50% of all cases by themselves but this left a significant number where the assistance of a Medical Officer was required. Consideration should be given for further research into preparation of Combat Medical Technicians for autonomous working at the front line.