Photon vs. Proton Radiotherapy in the Definitive Treatment of Nasopharyngeal Cancer: Single Institution Experience

PURPOSE/OBJECTIVE(S)

Definitive therapy for nasopharyngeal cancer includes chemotherapy and radiation (RT). Common toxicities such as xerostomia, mucositis, and hearing loss are correlated with the RT dose delivered to associated organs at risk. We hypothesized that compared to our historical experience with IMRT, the implementation of proton therapy (PT) would reduce radiation dose to organs at risks without compromising oncologic outcomes.

MATERIALS/METHODS

A retrospective review of all non-metastatic stage II-IV nasopharyngeal carcinoma (SCC, lymphoepithelioma, undifferentiated carcinomas) treated with definitive therapy at our institution from 2012-2022. Disease parameters and the mean dose to organs at risk were evaluated. Statistical comparison was made with the chi square test for categorical and Wilcoxon rank sum test for continuous variables. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS), using a log-rank test to compare IMRT and PT. PFS was defined as the time from the start of treatment to the first of either disease progression, relapse or death from any cause. PT was delivered with pencil-beam scanning in all patients. IMRT included multi-field treatment and volumetric-modulated arc therapy.

RESULTS

A total of 80 patients were included in analyses: 48 treated with IMRT and 32 with PT. Comparing IMRT to PT cohorts, there was no difference in the median age of patients (51 vs 55 years, p = 0.73), nor the distribution by T stage (p = 0.57) or N stage (p = 0.34) or in the percentage of patients with ECOG 2/3 performance status at presentation (p = 0.11). All but one patient received concurrent systemic therapy and there was no difference in the use of concurrent cisplatin between cohorts (83% vs 78%, p = 0.57). The most common non-cisplatin concurrent regimen was weekly carboplatin and paclitaxel. Induction chemotherapy was more commonly used in patients treated with PT (10.4% vs 25%, p = 0.04) while there was no difference in the use of adjuvant chemotherapy (10.4% vs 9.4%, p = 0.88). Among 42 cases initiating treatment since the opening of our proton center, 32 (76%) have received PT. Comparing IMRT and PT dosimetry, patients treated with PT received significantly lower mean dose to the better spared parotid gland (32.8 vs 25.7 Gy, p = 0.001), lesser spared parotid gland (35.5 vs 31.1 Gy, p = 0.047), better spared cochlea (31.5 vs 25.5 Gy, p = 0.004), lesser spared cochlea (41.8 vs 33.2 Gy, p = 0.004), larynx (44.5 vs 21.7 Gy, p<0.001), and oral cavity (42.6 vs 17.0 Gy, p<0.001). After a median follow-up time of 30 months (45 mos IMRT, 23 mos PT) the estimated 2-year PFS was 63.9% with IMRT and 90.3% with PT (p = 0.047). The estimate of 2-year overall survival was 86.8% with IMRT and 96.8% with PT (p = 0.17).

CONCLUSION

Comparing patients by radiation treatment modality, PT was associated with a statistically significant reduction in mean radiation dose to the parotid glands, cochlea, larynx, and oral cavity with excellent initial oncologic outcomes.

Effects of yeast culture supplementation on lactation performance and rumen fermentation profile and microbial abundance in mid-lactation Holstein dairy cows

The continuous trend for a narrowing margin between feed cost and milk prices across dairy farms in the United States highlights the need to improve and maintain feed efficiency. Yeast culture products are alternative supplements that have been evaluated in terms of milk performance and feed efficiency; however, less is known about their potential effects on altering rumen microbial populations and consequently rumen fermentation. Therefore, the objective of this study was to evaluate the effect of yeast culture supplementation on lactation performance, rumen fermentation profile, and abundance of major species of ruminal bacteria in lactating dairy cows. Forty mid-lactation Holstein dairy cows (121 ± 43 days in milk; mean ± standard deviation; 32 multiparous and 8 primiparous) were used in a randomized complete block design with a 7-d adaptation period followed by a 60-d treatment period. Cows were blocked by parity, days in milk, and previous lactation milk yield and assigned to a basal total mixed ration (TMR; 1.6 Mcal/kg of dry matter, 14.6% crude protein, 21.5% starch, and 38.4% neutral detergent fiber) plus 114 g/d of ground corn (CON; n = 20) or basal TMR plus 100 g/d of ground corn and 14 g/d of yeast culture (YC; n = 20; Culture Classic HD, Cellerate Yeast Solutions, Phibro Animal Health Corp.). Treatments were top-dressed over the TMR once a day. Cows were individually fed 1 × /d throughout the trial. Blood and rumen fluid samples were collected in a subset of cows (n = 10/treatment) at 0, 30, and 60 d of the treatment period. Rumen fluid sampled via esophageal tubing was analyzed for ammonia-N, volatile fatty acids (VFA), and ruminal bacteria populations via quantitative PCR amplification of 16S ribosomal DNA genes. Milk yield was not affected by treatment effects. Energy balance was lower in YC cows than CON, which was partially explain by the trend for lower dry matter intake as % body weight in YC cows than CON. Cows fed YC had greater overall ruminal pH and greater total VFA (mM) at 60 d of treatment period. There was a contrasting greater molar proportion of isovalerate and lower acetate proportion in YC-fed cows compared with CON cows. Although the ruminal abundance of specific fiber-digesting bacteria, including Eubacterium ruminantium and Ruminococcus flavefaciens, was increased in YC cows, others such as Fibrobacter succinogenes were decreased. The abundance of amylolytic bacteria such as Ruminobacter amylophilus and Succinimonas amylolytica were decreased in YC cows than CON. Our results indicate that the yeast culture supplementation seems to promote some specific fiber-digesting bacteria while decreasing amylolytic bacteria, which might have partially promoted more neutral rumen pH, greater total VFA, and isovalerate.

Effects of peripartal yeast culture supplementation on lactation performance, blood biomarkers, rumen fermentation, and rumen bacteria species in dairy cows

Feeding yeast culture fermentation products has been associated with improved feed intake and milk yield in transition dairy cows. These improvements in performance have been further described in terms of rumen characteristics, metabolic profile, and immune response. The objective of this study was to evaluate the effects of a commercial yeast culture product (YC; Culture Classic HD, Phibro Animal Health) on performance, blood biomarkers, rumen fermentation, and rumen bacterial population in dairy cows from -30 to 50 d in milk (DIM). Forty Holstein dairy cows were enrolled in a randomized complete block design from -30 to 50 DIM and blocked according to expected calving day, parity, previous milk yield, and genetic merit. At -30 DIM, cows were assigned to either a basal diet plus 114 g/d of ground corn (control; n = 20) or a basal diet plus 100 g/d of ground corn and 14 g/d of YC (n = 20), fed as a top-dress. Cows received the same close-up diet from 30 d prepartum until calving [1.39 Mcal/kg of dry matter (DM) and 12.3% crude protein (CP)] and lactation diet from calving to 50 DIM (1.60 Mcal/kg of DM and 15.6% CP). Blood samples and rumen fluid were collected at various time points from -30 to 50 d relative to calving. Cows fed YC compared with control showed a trend for increased energy-corrected milk (+3.2 kg/d). Lower somatic cell counts were observed in YC cows than in control. We detected a treatment × time interaction in nonesterified fatty acids (NEFA) that could be attributed to a trend for greater NEFA in YC cows than control at 7 DIM, followed by lower NEFA in YC cows than control at 14 and 30 DIM. In the rumen, YC contributed to mild changes in rumen fermentation, mainly increasing postpartal valerate while decreasing prepartal isovalerate. This was accompanied by alterations in rumen microbiota, including a greater abundance of cellulolytic (Fibrobacter succinogenes) and lactate-utilizing bacteria (Megasphaera elsdenii). These results describe the potential benefits of supplementing yeast culture during the late pregnancy through early lactation, at least in terms of rumen environment and performance.

Symposium review: Strategies to improve the efficiency and profitability of heifer raising

Regional Research Project NC-2042 has a main objective to study calf and heifer nutrition. Within this objective, feeding the postweaned heifer is considered a major priority to improve the profitability and sustainability of US dairy farms. Through optimizing nutrient utilization by precision feeding, using alternative feeds, high-fiber diets, and feed additives, this research group has worked to enhance dairy heifer nutrition. Research has focused on precision feeding heifers and incorporating high- and low-fiber diets into this system of feeding. This is accomplished by meeting the nutrient needs of the heifer for a desired rate of growth while enhancing total-tract nutrient digestibility, reducing waste and improving profitability. High-fiber forages have been studied as a means of controlling ad libitum dry matter intakes and thus weight gain in heifers. These results provide producers with a means of feeding heifers while reducing costs. Similarly, utilizing alternative feedstuffs in heifer diets has also been a major research area for this group including comprehensive research on distillers co-products, and new protein sources such as camelina and carinata meals. Results indicated that these products can be satisfactorily incorporated into heifer diets. Studying feed additives has also been a function of the research group. Research with Ascophyllum nodosum and cinnamaldehyde indicated that calves find these additives unpalatable and that supplementing cinnamaldehyde to postweaned heifers showed no benefit. However, sodium butyrate and yeast supplementation proved to be beneficial in the growth and feed efficiency of heifers. Research from this group has an effect on heifer feeding, resulting in new information that can aid in the sustainability of dairy farms. This review will focus on the area of postweaned heifer nutrition.

Altered rumen fermentation patterns in lactating dairy cows supplemented with phytochemicals improve milk production and efficiency

Tannins and other phytochemicals are known to improve RUP in the diet by binding protein and then limiting ruminal degradation, which may improve milk yield and milk protein synthesis. The objective of this study was to evaluate the effects of dietary phytochemicals (tannins and Capsicum species) as rumen modifiers on production parameters and milk efficiency in dairy cows. Twenty-four multiparous Holstein cows (96 ± 16 d in milk; mean ± standard deviation) were used in a replicated 3 × 3 Latin square design balanced to measure carryover effects. Cows were blocked according to days in milk, milk production, and body weight and randomly assigned to 1 of 3 groups (n = 8/group). Each group was assigned to a unique treatment sequence across the 3 periods in the Latin square. The experiment consisted of a 14-d covariate period and three 30-d treatment periods. Cows received a basal diet supplemented with soybean meal pellets (SB) as the control diet, phytochemicals (RUM; Rumiviv, CCPA, Janzé, France) pelleted with soybean meal, or expeller soybean meal (ESBM; SoyPlus, West Central Soy, Ralston, IA). Milk production and dry matter intake during the last 4 d of each period were used for statistical analysis. Blood and rumen fluid samples were collected on d 27 of each period. Rumen fluid was analyzed for ammonia N and volatile fatty acids as well as ruminal bacteria via quantitative PCR amplification of 16S ribosomal DNA genes. Greater milk yield (37.9 vs. 36 kg/d), energy-corrected milk (39.7 vs 37.1 kg/d), and protein yield (1.15 vs. 1.08 kg/d) were observed in RUM compared with SB, but these parameters were similar between RUM and ESBM. Concentrations of total volatile fatty acids (118.1 vs. 101.5 mM) were greater in RUM in comparison to SB and ESBM diets. Cows fed RUM had greater β-hydroxybutyrate (0.49 vs. 0.42 mmol/L) than SB and ESBM. Selenomonas ruminantium, Succinimonas amylolytica, and Streptococcus bovis in rumen fluid were lower in RUM fed cows in comparison to SB and ESBM. Increased total volatile fatty acids and lower ruminal abundance of bacteria associated with low feed efficiency in RUM cows can partially explain the improvements observed in milk yield and milk efficiency. Overall, these data suggest that feeding a combination of tannin mixture and Capsicum can significantly affect rumen fermentation characteristics via partial manipulation of rumen microbiota, and these effects were reflected in improved milk production and efficiency.

Symposium review: Colostrum management and calf nutrition for profitable and sustainable dairy farms

Multistate dairy management research project NC-2042, which is part of the National Institute of Food and Agriculture, has devoted an ongoing objective to calf and heifer nutrition and management. Within this objective, colostrum research has been a priority due to continued opportunities to improve this area on US dairy farms. Research has focused on heating colostrum to reduce bacterial populations and pathogens while increasing IgG absorption. Research also identified other proteins that are reduced when heating colostrum. Studies indicated an apparent upper limit to IgG absorption from colostrum fed to calves. Additional studies have shed light on absorption of IgG from colostrum replacers and evaluated the use of lactoferrin and sodium bicarbonate in both maternal colostrum and colostrum replacers. Milk replacer formulation, feeding strategies, and the effect of calfhood nutrition on future performance have also been researched. Finally, water quality and its effect on calves and heifers have been studied. This review focuses on research done by multistate research project NC-2042 member states in the area of colostrum and calf nutrition and management.

P1536Does free thyroxine (fT4) predict risk of atherosclerotic cardiovascular disease (ASCVD)?

Background

Thyroid hormones are associated with arrhythmic risk, but their relationship to ASCVD is unclear. The Rotterdam Study* reported associations of higher fT4 and lower thyroid stimulating hormone (TSH) levels with ASCVD, including within the euthyroid range. Free T3 (fT3) was not assessed.

Methods

We tested whether fT4, fT3, and TSH levels were associated with ASCVD in Intermountain Healthcare. All patients >18 y old with an fT4 level in the electronic medical record database were included. The hormone reference ranges were divided into quartiles (Q), and associations with prevalent and incident ASCVD were assessed by multivariable regression and trend tests.

Results

A total of 212,202 patients (age = 64.4±11.2 y; 66.6% women) were included and followed for 6.1±4.4 y. Of these, 8.3%, 86.6%, and 5.1% had fT4 levels below, within, and above the reference range. CAD was prevalent in 18.9% of fT4 Q1 patients. The adjusted odds ratio (OR) for coronary artery disease (CAD) increased through (Q4/Q1 OR=1.36) and beyond (High/Q1 OR=1.71) the normal range, p-trend<0.001 (Table). Smaller incremental risks were noted for fT3 (Q4/Q1 OR=1.13; High/Q1 OR=1.25). The frequencies of incident MI (Q1=2.5%) and stroke (Q1=5.4%) were low and did not show a concentration-related risk gradient. Incident all-cause death (Q1=24.3%) increased slightly for Q4 and high fT4 (OR=1.05, 1.06) but not fT3; death also increased with low fT4 (OR=1.28). TSH showed no consistent gradient within the normal range for prevalent or incident events; however, mortality increased with both high and low TSH.

Thyroid Hormone Levels and Prevalent CAD Prevalent CAD (adjusted OR) Low Normal Q1 Normal Q2 Normal Q3 Normal Q4 High fT4 (n=212,202) OR=1.08, p=0.02 OR=1.00 referent OR=1.11, p<0.001 OR=1.21, p<0.001 OR=1.36, p<0.001 OR=1.71, p<0.001 fT3 (n=30,200) OR=1.12, p<0.001 OR=1.00 referent OR=0.98, p=0.61 OR=1.02, p=0.53 OR=1.13, p<0.001 OR=1.25, p<0.001 TSH (n=183,227) OR=1.39, p<0.001 OR=1.00 referent OR=0.93, p=0.42 OR=0.88, p=0.15 OR=0.92, p=0.35 OR=1.73, p<0.001 Reference Q 1–4 are: fT4: 0.75–0.90; 0.91–1.01; 2.02–1.14; 1.15–1.50 ng/dL; TSH: 0.54–1.30; 1.31–2.04; 2.05–3.68; 3.69–6.80 uIU/mL; fT3: 2.40–2.60; 2.70–2.80; 2.90–3.10; 3.20–4.20 pg/dL.

Conclusions

Consistent with the Rotterdam Study, we found an increase in prevalent CAD with increasing fT4 levels within and beyond the normal range and, uniquely, a more modest relationship with fT3. We could not confirm a normal-range relationship between hormone levels and incident events or between TSH and prevalent disease. The relationship of fT4 levels to ASCVD is intriguing, is deserving of further study, and may have important implications for ASCVD prevention.

*A Bano, et-al. Circ Res 2017; 121:1397–1400

Growth performance, nutrient utilization, and health of dairy calves supplemented with condensed whey solubles

Our objective was to evaluate growth performance, nutrient utilization, and health of calves supplemented with condensed whey solubles (CWS). Twenty-four Holstein calves (2 d old) in hutches were used in a 12-wk randomized complete block design study. Calves were blocked by birth date and sex. Treatments were (1) control (CON) with no supplement and (2) 50 g/d of CWS. Preweaning CWS was fed with milk and postweaning CWS was top-dressed on starter pellets. Calves were fed 2.83 L of pasteurized milk 2×/d during wk 1 to 5, 1×/d in wk 6, and weaned at d 42. Calves had ad libitum access to starter pellets and water. Individual intakes of milk and starter pellets were measured daily. Fecal scores (0 = firm, 3 = watery) and respiratory scores (healthy ≤3, sick ≥5), calculated from the sum of scores for rectal temperature, cough, ocular, and nasal discharge, were recorded daily. Body weights (BW), frame growth, and jugular blood samples were taken once every week at 3 h after the morning feeding. Fecal grab samples were collected in wk 12 for analysis of apparent total-tract digestibility. Data were analyzed using MIXED procedures of SAS 9.4 (SAS Institute Inc., Cary, NC) with repeated measures. Total dry matter intake was greater in calves fed CWS compared with CON. Calves fed CWS tended to have greater BW during the postweaning period. Gain:feed, average daily gains, withers heights, and concentrations of plasma urea nitrogen were not different. Concentrations of plasma β-hydroxybutyrate were greater in calves fed CWS compared with CON. Serum glucose concentrations were greater in calves fed CON during the preweaning stage, but similar concentrations were found between treatments during the postweaning stage. Rumen pH, ammonia-N, and total volatile fatty acids were similar between treatments. The acetate:propionate ratio was greater in calves fed CWS. The apparent total-tract digestion of nutrients was similar; however, CON tended to have greater digestion of neutral detergent fiber. Fecal scores were not different, but a treatment by week interaction was observed. Supplementing CWS improved starter intake, postweaning BW, β-hydroxybutyrate, fecal scores, and maintained frame growth.

Musculoskeletal injuries in real tennis

Introduction: Real tennis is a growing, unique, and well-established sport. To date, there has been no epidemiological data on real tennis injuries. The primary aim of this retrospective study is to record the incidence and document any trends in real tennis musculoskeletal injuries, so as to improve injury awareness of common and possibly preventable injuries.

Methods: A surveillance questionnaire e-mailed to 2,036 Tennis & Rackets Association members to retrospectively capture injuries sustained by amateur and professional real tennis players over their playing careers.

Results: A total of 485 (438 males and 47 females) questionnaires were fully completed over 4 weeks. A total of 662 musculoskeletal injuries were recorded with a mean of 1.4 injuries per player (range 0–7). The incidence of sustaining an acute real tennis musculoskeletal injury is 0.4/1000 hrs. The three main anatomical locations reported injured were elbow 15.6% (103/662), knee 11.6% (77/662), and face 10.0% (66/662). The most common structures reported injured were muscle 24% (161/661), tendon 23.4% (155/661), ligament 7.0% (46/661), soft tissue bruising 6.5% (43/661), and eye 6.2% (41/661). The majority of the upper limb injuries were gradual onset (64.7%, 143/221), and the lower limb injuries were sudden onset (72.0%, 188/261).

Conclusion: This study uniquely provides valuable preliminary data on the incidence and patterns of musculoskeletal injuries in real tennis players. In addition, it highlights a number of reported eye injuries. The study is also a benchmark for future prospective studies on academy and professional real tennis players.

Growth performance and health of dairy calves given water treated with a reverse osmosis system compared with municipal city water

Our objective was to determine effects of drinking reverse osmosis water (RW) versus municipal city water (MW) on growth, nutrient utilization, and health scores of calves. Twenty-four Holstein calves (14 females, 10 males; 2 d old; 44.6 ± 6.10 kg of body weight), housed in individual hutches, were used in a 10-wk randomized complete block design study. Calves were blocked by birthdate and sex. Treatments were RW (Culligan Water Filtration System, Brookings, SD) versus MW (Brookings Municipal Utilities, Brookings, SD) that contained 13 and 387 mg/L of total dissolved solids, respectively. Milk replacer (28% crude protein; 18% fat) was fed twice daily during wk 1 through 5 and then once daily during wk 6. At each feeding, 0.45 kg of dry milk replacer was mixed with 2.83 L of the respective water type according to treatment. Calves were fed water, respective to treatment, and calf starter pellets ad libitum throughout the study. All intakes were recorded daily. Daily total respiratory scores (healthy ≤3, sick ≥5) were calculated from the sum of scores for rectal temperature, cough, and ocular and nasal discharges. Fecal consistency scores (0 = firm, 3 = watery) were also recorded daily. Body weights and frame growth were measured 2 d every 2 wk and jugular blood samples were collected 1 d every 2 wk at 3 h after the morning feeding. Fecal grab samples were collected 5 times per day for 3 d during wk 10 for analysis of apparent total-tract digestibility of nutrients. We found treatment by week interactions for dry matter intake and gain-to-feed ratio, and total dry matter intake increased more during the study for RW than MW. Gain-to-feed ratio was greater during the first few weeks of the feeding period for RW compared with MW and then comparable during the rest of study. Water intake was less in RW than MW, potentially indicating more efficient water use by calves. Frame growth, body weight, average daily gain, serum glucose, plasma urea nitrogen, β-hydroxybutyrate, total-tract digestibility of dry matter, and crude protein were similar. Fecal scores tended to be lower (firmer) in calves on RW, with an interaction by time. Respiratory scores decreased during the weaning period when calves drank RW. Results demonstrated calves drinking RW had similar growth and improved health scores with treatment by time interactions compared with MW.

Evaluation of carinata meal as a feedstuff for growing dairy heifers: Effects on growth performance, rumen fermentation, and total-tract digestibility of nutrients

Our objective was to determine the effects of feeding carinata meal (CRM) compared with distillers dried grains with solubles (DDGS) on growth performance, rumen fermentation, and nutrient utilization in peripubertal dairy heifers. A 16-wk randomized block design experiment with 24 Holstein heifers [6.6 ± 0.7 mo and 218 ± 27 kg of body weight (BW)] was conducted. Treatments diets were (1) 10% cold-pressed CRM and (2) 10% DDGS on a dry matter (DM) basis. The remainder of the diets consisted of grass hay, ground corn, soybean meal, and mineral mix. Diets were formulated to be isonitrogenous and isocaloric. Heifers were individually fed using a Calan gate feeding system, and the rations were limit-fed at 2.65% of BW on a DM basis to target a 0.8 kg/d of average daily gain. Heifers were weighed every 2 wk and the ration amount offered was adjusted accordingly. Frame sizes, BW, and body condition scores were measured 2 d every 2 wk throughout the study. During wk 12 and 16, rumen fluid samples were collected via esophageal tubing for pH, ammonia N, and volatile fatty acid analyses. In wk 16, fecal grab samples were collected for apparent total-tract digestibility estimation. Heifer DM intake, BW, average daily gain, and gain:feed were similar between treatments. No differences were observed between treatments in frame measurements or body condition scores. Rumen pH tended to be greater in CRM compared with DDGS. Rumen ammonia N and total volatile fatty acid concentration were not different between treatments. Apparent total-tract digestibility of DM, neutral detergent fiber, and acid detergent fiber were decreased in CRM compared with DDGS. A tendency was detected for reduced organic matter digestibility in CRM. No difference was observed between treatments for crude protein total-tract digestibility. However, these differences in total-tract nutrient digestibility were not large enough to influence growth performance. Overall, results demonstrated that growing heifers can be limit-fed diets with 10% CRM and maintain growth performance compared with a control diet containing 10% DDGS.

Growth performance, rumen fermentation, nutrient utilization, and metabolic profile of dairy heifers limit-fed distillers dried grains with ad libitum forage

The objective of this study was to determine the effects of feeding a corn- and soybean-product-based concentrate mix or distillers dried grains with solubles concentrate mix with ad libitum grass hay to dairy heifers. A 16-wk randomized complete block design study was conducted using 24 heifers [18 Holstein and 6 Brown Swiss; 219 ± 2 d of age (±standard deviation); 230 ± 4 kg of body weight] to evaluate the effect of diet on dry matter intake (DMI), growth performance, rumen fermentation, metabolic profile, and nutrient digestibility. Treatments were (1) corn and soybean product concentrate mix, and (2) distillers-dried-grains-with-solubles-based concentrate mix (DDG). Both concentrate mixes were limit-fed at 0.8% of body weight and grass hay was offered ad libitum. Heifers were individually fed using Calan gates and orts were recorded daily at feeding. Heifers were weighed every 2 wk and ration concentrate mix offered was adjusted accordingly. Frame measurements and body condition score were recorded every 2 wk. Rumen fluid was collected via esophageal tubing during wk 12 and 16 for pH, ammonia N, and volatile fatty acid analysis. Jugular blood samples were collected every 4 wk for metabolite and metabolic hormone analysis. Total-tract digestibility of nutrients was evaluated during wk 16 by fecal grab sampling. No treatment by week interactions were observed for any of the growth measurements and growth measurements and DMI did not differ between treatments. A treatment by time interaction was observed for rumen butyrate percentage with heifers fed DDG having a greater percentage. Total volatile fatty acid concentration, acetate molar percentage, and acetate:propionate decreased with the DDG treatment, whereas propionate molar percentage increased. No treatment by week interactions were observed for any of the metabolites or metabolic hormones measured. A tendency was observed for glucose and plasma urea nitrogen concentration to decrease with DDG. Plasma cholesterol and insulin increased with DDG. Results demonstrated that limit-feeding heifers DDG at 0.8% of body weight with ad libitum grass hay maintained growth performance, average daily gain, DMI, and gain:feed, with shifts in the metabolic profile compared with the corn and soybean product concentrate mix.

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Pharmacogenetics-Guided Warfarin Dosing: 2017 Update

This document is an update to the 2011 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2C9 and VKORC1 genotypes and warfarin dosing. Evidence from the published literature is presented for CYP2C9, VKORC1, CYP4F2, and rs12777823 genotype-guided warfarin dosing to achieve a target international normalized ratio of 2-3 when clinical genotype results are available. In addition, this updated guideline incorporates recommendations for adult and pediatric patients that are specific to continental ancestry.

Both initial red cell distribution width (RDW) and change in RDW during heart failure hospitalization are associated with length of hospital stay and 30-day outcomes

INTRODUCTION

We examined the predictive ability of red cell distribution width (RDW) and the change in RDW during hospitalization (ΔRDW) for length of stay (LOS) and 30-day outcomes after heart failure (HF) inpatient stay.

METHODS

Electronic query of Intermountain Healthcare medical records identified patients (N = 6414) with a primary diagnosis of HF who were discharged between 2004 and 2013, had RDW measured within 24 h after admission, and had RDW tested at least once more during the same hospitalization. ΔRDW was defined as the last RDW within 24 h prior to discharge minus the first RDW.

RESULTS

Median LOS by initial RDW quartiles was Q1: 3.0, Q2: 3.1, Q3: 3.7, and Q4: 4.0 days (P-trend<0.001), and by ΔRDW quartiles was Q1: 4.1, Q2: 3.4, Q3: 3.6, and Q4: 4.7 days (P-trend<0.001). Both initial RDW (16.8 ± 2.8% vs. 16.3 ± 2.7%, P < 0.001) and ΔRDW (0.21 ± 1.09% vs. 0.14 ± 1.04%, P = 0.039) predicted 30-day readmission vs. no readmit. For 30-day decedents vs. survivors, initial RDW was 17.3 ± 3.0% vs. 16.3 ± 2.6% (P < 0.001), while ΔRDW was +0.20 ± 1.14% vs. +0.14 ± 1.04% (P = 0.15).

CONCLUSIONS

Greater initial RDW and ΔRDW during HF hospitalization were associated with 30-day mortality, longer LOS, and 30-day all-cause readmission, suggesting both ΔRDW and initial RDW may aid in personalizing prognosis and treatment.

Feeding distillers dried grains in replacement of forage in limit-fed dairy heifer rations: Effects on metabolic profile and onset of puberty

The objective of this study was to determine the effect of increasing the inclusion rate of distillers dried grains (DDGS) in replacement of forage in limit-fed diets on the metabolic profile and onset of puberty in dairy heifers. A 16-wk randomized complete block design study was conducted using 48 Holstein heifers (199 ± 2 d of age) with 3 treatments. Treatments were (1) 30% DDGS (30DG), (2) 40% DDGS (40DG), and (3) 50% DDGS (50DG), with the remainder of the diet consisting of grass hay and 1.5% mineral mix. Heifers were housed in groups of 6 and individually limit-fed using Calan gates at 2.65, 2.50, and 2.35% of body weight (BW) on a dry matter (DM) basis for 30DG, 40DG, and 50DG, respectively. Jugular blood samples were collected during wk 0, 4, 8, 12, and 16 for metabolite and metabolic hormone analysis. Additional samples were taken during wk 16 for plasma fatty acid analysis. When heifers weighed 200 kg, coccygeal vein blood samples were taken twice per week for progesterone analysis to estimate onset of puberty. Blood samples continued until cycling was confirmed via ultrasound for the presence of a corpus luteum. A quadratic response and a linear tendency in the proportion of total fatty acids as linoleic acid were observed. Linear and quadratic responses for plasma concentrations of linoleic acid and arachidonic acid occurred. Overall results for fatty acid analysis demonstrated that total fatty acid and polyunsaturated fatty acids concentration in the blood were linearly increased, with a quadratic response for polyunsaturated fatty acids with 30DG and 50DG having the greatest concentrations. No interactions of treatment by week were observed for any of the metabolites and metabolic hormones measured. Glucose, insulin, insulin-like growth factor-1, leptin, and triglycerides were similar across treatments. A linear response of plasma urea nitrogen and a quadratic response tendency for cholesterol concentration were observed. Age and BW at puberty were similar across treatments. Limit-feeding heifers with greater inclusion rates of DDGS maintained energy status without the accumulation of excess adipose tissue as indicated by leptin. Treatments had no detrimental effects on age or BW at puberty.