Short communication: Temporal profiles of colostrum and milk haptoglobin and substance P in early lactation multiparous Holstein cows

Milk markers have the potential to aid in the detection of cow disease in early lactation if the automation of milk analysis becomes commonplace. Characterising temporal profiles of milk markers in dairy cows will improve the understanding of basal concentrations in clinically healthy cows. The objective of this observational study was to characterise the variation and temporal profiles of colostrum and milk haptoglobin (Hp) and substance P concentrations within 21 days postcalving in clinically healthy multiparous Holstein dairy cows. Ninety Holstein dairy cows from a commercial dairy herd were included. Milk samples were collected on the day of calving (day 0), and on days 1 to 4, 7, 14, and 21 postcalving and concentrations of Hp and substance P in colostrum (days 0 to 3) and milk (days 4, 7, 14, and 21) were determined using Enzyme Linked Immunosorbent assay. Haptoglobin and substance P concentrations were, on average (raw means ± SD), 0.40 ± 0.26 µg/ml and 56.2 ± 38.7 pg/ml in colostrum, respectively, and 0.23 ± 0.23 µg/ml and 37.1 ± 27.8 pg/ml in milk, respectively. Haptoglobin and substance P were elevated and greatest 1 day postcalving (least squares mean ± SE of the mean; 0.53 ± 0.05 µg/ml and 46.5 ± 3.64 pg/ml, respectively) and substance P varied widely within 21 days postcalving. The presence of substance P in dairy cow colostrum was not documented previously. Elevated concentrations of Hp and substance P immediately postcalving may be due to physiological roles these inflammatory markers have in the dairy cow or neonate or may simply represent an accumulation in colostrum before the first milk is removed.

The development and validation of a nationwide dataset of water distribution zones in Aotearoa New Zealand: A cross-sectional geospatial study

The reliable supply of safe drinking water is vital for the health of human populations. Despite this, there is no consistent nationwide spatial dataset of water distribution zones (WDZ) for Aotearoa New Zealand (A-NZ). The purpose of this data article is to describe the development and validation of a consistent nationwide dataset of WDZ across A-NZ. We obtained spatial data from all 67 district and city councils through: 1) information requests between 2021 and 2023; 2) the Ministry of Health and; 3) the Institute of Environmental Science and Research. Data were modified to improve the spatial accuracy of the WDZ using auxiliary data on the building footprints (Land Information New Zealand) and the drinking water reticulation (WSP & councils). We estimated the population served by each WDZ through spatial linking to meshblock-level data provided by Statistics New Zealand (meshblocks are the smallest administrative geographic unit in A-NZ). The dataset will be useful to provide insights into the extent of the publicly-owned drinking water assets in A-NZ and is essential for the accurate exposure assessment in epidemiological research investigating the impact of drinking water quality on human health.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Diagnosis, differential diagnosis and misdiagnosis of Susac syndrome

Background and purpose

Susac syndrome (SuS) is an inflammatory condition of the brain, eye and ear. Diagnosis can be challenging, and misdiagnosis is common.

Methods

This is a retrospective review of the medical records of 32 adult patients from an Australasian cohort of SuS patients.

Results

An alternative diagnosis prior to SuS was made in 30 patients (94%) with seven patients receiving two or more diagnoses. The median time to diagnosis of SuS was 3 months (range 0.5–100 months). The commonest misdiagnoses were migraine in 10 patients (31%), cerebral vasculitis in six (19%), multiple sclerosis in five (16%) and stroke in five (16%). Twenty‐two patients were treated for alternative diagnoses, 10 of whom had further clinical manifestations prior to SuS diagnosis. At presentation seven patients (22%) met criteria for definite SuS, 19 (59%) for probable SuS and six (19%) for possible SuS. Six patients (19%) presented with brain–eye–ear involvement, 14 with brain–ear (44%), six with brain–eye (19%) and six (19%) with only brain involvement. In patients with the complete triad of symptoms the median delay to diagnosis was 3 months (range 1–9 months) compared to 5.25 months (range 0.5–100 months) for patients with encephalopathy and ocular symptoms at presentation.

Conclusions

Susac syndrome patients are frequently misdiagnosed at initial presentation, despite many having symptoms or radiological features that are red flags for the diagnosis. Delayed diagnosis can lead to patient morbidity. The varied ways in which SuS can present, and clinician failure to consider or recognize SuS, appear to be the main factors leading to misdiagnosis.

What Is the "Optimal" Target Mismatch Criteria for Acute Ischemic Stroke?

We aimed to compare Perfusion Imaging Mismatch (PIM) and Clinical Core Mismatch (CCM) criteria in ischemic stroke patients to identify the effect of these criteria on selected patient population characteristics and clinical outcomes. Patients from the INternational Stroke Perfusion Imaging REgistry (INSPIRE) who received reperfusion therapy, had pre-treatment multimodal CT, 24-h imaging, and 3 month outcomes were analyzed. Patients were divided into 3 cohorts: endovascular thrombectomy (EVT), intravenous thrombolysis alone with large vessel occlusion (IVT-LVO), and intravenous thrombolysis alone without LVO (IVT-nonLVO). Patients were classified using 6 separate mismatch criteria: PIM-using 3 different measures to define the perfusion deficit (Delay Time, Tmax, or Mean Transit Time); or CCM-mismatch between age-adjusted National Institutes of Health Stroke Scale and CT Perfusion core, defined as relative cerebral blood flow <30% within the perfusion deficit defined in three ways (as above). We assessed the eligibility rate for each mismatch criterion and its ability to identify patients likely to respond to treatment. There were 994 patients eligible for this study. PIM with delay time (PIM-DT) had the highest inclusion rate for both EVT (82.7%) and IVT-LVO (79.5%) cohorts. In PIM positive patients who received EVT, recanalization was strongly associated with achieving an excellent outcome at 90-days (e.g., PIM-DT: mRS 0-1, adjusted OR 4.27, P = 0.005), whereas there was no such association between reperfusion and an excellent outcome with any of the CCM criteria (all p > 0.05). Notably, in IVT-LVO cohort, 58.2% of the PIM-DT positive patients achieved an excellent outcome compared with 31.0% in non-mismatch patients following successful recanalization (P = 0.006).

Conclusion: PIM-DT was the optimal mismatch criterion in large vessel occlusion patients, combining a high eligibility rate with better clinical response to reperfusion. No mismatch criterion was useful to identify patients who are most likely response to reperfusion in non-large vessel occlusion patients.

Tenecteplase vs Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

OBJECTIVE

To investigate the efficacy of tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, prior to endovascular thrombectomy (EVT) in patients with basilar artery occlusion (BAO).

METHODS

To determine whether TNK is associated with better reperfusion rates than alteplase prior to EVT in BAO, clinical and procedural data of consecutive patients with BAO from the Basilar Artery Treatment and Management (BATMAN) registry and the Tenecteplase vs Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial were retrospectively analyzed. Reperfusion >50% or absence of retrievable thrombus at the time of the initial angiogram was evaluated.

RESULTS

We included 110 patients with BAO treated with IV thrombolysis prior to EVT (mean age 69 [SD 14] years; median NIH Stroke Scale score 16 [interquartile range (IQR) 7-32]). Nineteen patients were thrombolysed with TNK (0.25 mg/kg or 0.40 mg/kg) and 91 with alteplase (0.9 mg/kg). Reperfusion >50% occurred in 26% (n = 5/19) of patients thrombolysed with TNK vs 7% (n = 6/91) thrombolysed with alteplase (risk ratio 4.0, 95% confidence interval 1.3-12; p = 0.02), despite shorter thrombolysis to arterial puncture time in the TNK-treated patients (48 [IQR 40-71] minutes) vs alteplase-treated patients (110 [IQR 51-185] minutes; p = 0.004). No difference in symptomatic intracranial hemorrhage was observed (0/19 [0%] TNK, 1/91 [1%] alteplase; p = 0.9).

CONCLUSIONS

TNK may be associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare TNK with alteplase in patients with BAO are warranted.

CLINICALTRIALSGOV IDENTIFIERS

NCT02388061 and NCT03340493.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that TNK leads to higher reperfusion rates in comparison with alteplase prior to EVT in patients with BAO.

Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial)

There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg^-1 based on factor IX) or fresh frozen plasma (15 ml.kg^-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α₂ -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.

BSc nursing & midwifery students experiences of guided group reflection in fostering personal and professional development. Part 2

Reflective practice is a learning strategy supporting preregistration nursing and midwifery students in meeting everyday clinical practice challenges. This paper reports on a development and innovation evaluation using a qualitative approach exploring students' experiences of guided group reflection organised during fourth year undergraduate internship. Data were collected through student feedback and interviews using a descriptive approach. Three categories emerged from the findings; beginnings for reflective learning, engaging in reflective learning and being a reflective practitioner. Students reported that guided group reflection provided positive opportunities for enhancing confidence. Students demonstrated understanding of reflection and valued reflective time within the closed group structure, which fostered personal and professional development. Findings support the benefits of the established collaborative guided group reflection structures. Guided group reflection is described as a valuable learning strategy on the journey of becoming a nurse in an ever-demanding health care practice world.

Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network

Background and Purpose: Telestroke aims to increase access to endovascular clot retrieval (ECR) for rural areas. There is limited information on transfer workflow for ECR in rural settings. We sought to describe the transfer metrics for ECR in a rural telestroke network with respect to decision making.

Methods: A retrospective cohort study was employed on consecutive patients transferred to the comprehensive stroke center (CSC) for ECR in a rural hub-and-spoke telestroke network between April 2013 and October 2019, by road or air. Key time-based metrics were analyzed.

Results: Sixty-two patients were included. Mean age was 66 years [standard deviation (SD), 14] and median National Institutes of Health Stroke Scale 13 [interquartile range (IQR), 8–18]. Median rural-hospital-door-to-CSC-door (D2D) was 308 min (IQR, 254–351), of which 68% was spent at rural hospitals [door-in-door-out (DIDO); 214 min; IQR, 171–247]. DIDO was longer for air transfers than road (P = 0.004), primarily because of a median 87 min greater decision-to-departure time (Decision-DO, P < 0.001). In multiple linear regression analysis, intubation but not thrombolysis was associated with significantly longer DIDO. The distance at which the extra speed of an aircraft made up for the delays involved in booking an aircraft was 299 km from the CSC.

Conclusions: DIDO is longer for air retrievals compared with road. Decision-DO represents the most important component of DIDO, being longer for air transfers. Systems for rapid transportation of rural ECR candidates need optimization for best patient outcomes, with decision support seen as a potential tool to achieve this.

No Evidence of the "Weekend Effect" in the Northern New South Wales Telestroke Network

Background: Admission outside normal business hours has been associated with prolonged door-to-treatment times and poorer patient outcomes, the so called "weekend effect. " This is the first examination of the weekend effect in a telestroke service that uses multi-modal computed tomography. Aims: To examine differences in workflow and triage between in-hours and out-of-hours calls to a telestroke service. Methods: All patients assessed using the Northern New South Wales (N-NSW) telestroke service from April 2013 to January 2019 were eligible for inclusion (674 in total; 539 with complete data). The primary outcomes measured were differences between in-hours and out-of-hours in door-to-call-to-decision-to-needle times, differences in the proportion of patients confirmed to have strokes or of patients selected for reperfusion therapies or patients with a modified Rankin Score (mRS ≤ 2) at 90 days. Results: There were no significant differences between in-hours and out-of-hours in any of the measured times, nor in the proportions of patients confirmed to have strokes (67.6 and 69.6%, respectively, p = 0.93); selected for reperfusion therapies (22.7 and 22.6%, respectively, p = 0.56); or independent at 3 months (34.8 and 33.6%, respectively, p = 0.770). There were significant differences in times between individual hospitals, and patient presentation more than 4.5 h after symptom onset was associated with slower times (21 minute delay in door-to-call, p = 0.002 and 22 min delay in door-to-image, p = 0.001). Conclusions: The weekend effect is not evident in the Northern NSW telestroke network experience, though this study did identify some opportunities for improvement in the delivery of acute stroke therapies.

Validation of an ear tag-based accelerometer system for detecting grazing behavior of dairy cows

The objective of the study was to develop a grazing algorithm for an ear tag-based accelerometer system (Smartbow GmbH, Weibern, Austria) and to validate the grazing algorithm with data from a noseband sensor. The ear tag has an acceleration sensor, a radio chip, and temperature sensor for calibration and it can monitor rumination and detect estrus and localization. To validate the ear tag, a noseband sensor (RumiWatch, Itin and Hoch GmbH, Liestal, Switzerland) was used. The noseband sensor detects pressure and acceleration patterns, and, with a software program specific to the noseband, pressure and acceleration patterns are used to classify data into eating, ruminating, drinking, and other activities. The study was conducted at the University of Minnesota West Central Research and Outreach Center (Morris, MN) and at Teagasc Animal and Grassland Research and Innovation Centre (Moorepark, Fermoy, Co. Cork, Ireland). During May and June 2017, observational data from Minnesota and Ireland were used to develop the grazing algorithm. During September 2018, data were collected by the ear tag and noseband sensor from 12 crossbred cows in Minnesota for a total of 248 h and from 9 Holstein-Friesian cows in Ireland for a total of 248 h. A 2-sided t-test was used to compare the percentage of grazing and nongrazing time recorded by the ear tag and the noseband sensor. Pearson correlations and concordance correlation coefficients (CCC) were used to evaluate associations between the ear tag and noseband sensor. The percentage of total grazing time recorded by the ear tag and by the noseband sensor was 37.0% [95% confidence interval (CI): 32.1 to 42.0] and 40.5% (95% CI: 35.5 to 45.6), respectively, in Minnesota, and 35.4% (95% CI: 30.6 to 40.2) and 36.9% (95% CI: 32.1 to 41.8), respectively, in Ireland. The ear tag and noseband sensor agreed strongly for monitoring grazing in Minnesota (r = 0.96; 95% CI: 0.94 to 0.97, CCC = 0.95) and in Ireland (r = 0.92; 95% CI: 0.90 to 0.94, CCC = 0.92). The results suggest that there is potential for the ear tag to be used on pasture-based dairy farms to support management decision-making.

Menstrual Suppression in Pediatric and Adolescent Patients with Disabilities Ranging from Developmental to Acquired Conditions: A Population Study in an Australian Quaternary Pediatric and Adolescent Gynecology Service from January 2005 to December 2015

STUDY OBJECTIVE

The aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent. DESIGN, SETTINGS, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression.

RESULTS

Of the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment.

CONCLUSION

Medical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression.

An examination of the effects of labor efficiency on the profitability of grass-based, seasonal-calving dairy farms

The seasonality of grass-based, seasonal-calving dairy systems results in disproportionately higher labor demands during the spring, when cows are calving, than in the remaining seasons. This study aimed to (1) examine the relationship between labor efficiency and profitability; (2) investigate strategies to reduce the hours worked per day by the farmer, family, and farm staff in the spring by having certain tasks outsourced; and (3) quantify the economic implications of those strategies. Data from an existing labor efficiency study on Irish dairy farms were used in conjunction with economic performance data from the farms. Tasks that required the highest level of farm labor per day in the spring were identified and hypothetical strategies to reduce the farm hours worked per day were examined. A stochastic budgetary simulation model was then used to examine the economic implications of employing these strategies and the effects of their use in conjunction with a proportionate increase in cow numbers that would leave the hours worked per day unchanged. The strategies were to use contractors to perform calf rearing, machinery work, or milking. Contracting out milking resulted in the greatest reduction in hours worked per day (5.6 h/d) followed by calf rearing (2.7 h/d) and machinery work (2 h/d). Reducing the hours worked per day by removing those tasks had slight (i.e., <5%) negative effects on profitability; however, maintaining the farm hours worked per day while utilizing the same strategies and increasing herd sizes resulted in profitable options. The most profitable scenario was for farms to increase herd size while contracting out milking.

Intravenous Thrombolysis May Not Improve Clinical Outcome of Acute Ischemic Stroke Patients Without a Baseline Vessel Occlusion

Background and Purpose: The benefit of thrombolysis in ischemic stroke patients without a visible vessel occlusion still requires investigation. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase. Methods: We utilized a prospectively collected registry of ischemic stroke patients [the International Stroke Perfusion Imaging Registry (INSPIRE)] who had baseline computed tomographic perfusion and computed tomographic angiography. The rates of patients achieving modified Rankin Scale (mRS) 0-1 were compared between alteplase treated and untreated patients using logistic regression to generate odds ratios. Results: Of 1569 patients in the INSPIRE registry, 1,277 were eligible for inclusion. Of these, 306 (24%) had no identifiable occlusion and were eligible for alteplase, with 141 (46%) of these patients receiving thrombolysis. The treated and untreated groups had significantly different median baseline National Institutes of Health Stroke Scale (NIHSS) [alteplase 8, interquartile range (IQR) 5-10, untreated 6, IQR 4-8, P < 0.001] and median volume of baseline perfusion lesion [alteplase 5.6 mL, IQR 1.3-17.7 mL, untreated 2.6 mL, IQR 0-6.7 mL, P < 0.001]. After propensity analysis, alteplase treated patients without a vessel occlusion were less likely to have an excellent outcome (mRS 0-1; 56%) than untreated (78.8%, OR, 0.42, 95% confidence interval, 0.24-0.75, P = 0.003). Conclusions: In this non-randomized comparison, alteplase treatment in patients without an identifiable vessel occlusion did not result in higher rates of favorable outcome compared to untreated. However, treated patients displayed less favorable baseline prognostic factors than the untreated group. Further studies may be required to confirm this data.

Daily and seasonal trends of electricity and water use on pasture-based automatic milking dairy farms

The objective of this study was to identify the major electricity and water-consuming components of a pasture-based automatic milking (AM) system and to establish the daily and seasonal consumption trends. Electricity and water meters were installed on 7 seasonal calving pasture-based AM farms across Ireland. Electricity-consuming processes and equipment that were metered for consumption included milk cooling components, air compressors, AM unit(s), auxiliary water heaters, water pumps, lights, sockets, automatic manure scrapers, and so on. On-farm direct water-consuming processes and equipment were metered and included AM unit(s), auxiliary water heaters, tubular coolers, wash-down water pumps, livestock drinking water supply, and miscellaneous water taps. Data were collected and analyzed for the 12-mo period of 2015. The average AM farm examined had 114 cows, milking with 1.85 robots, performing a total of 105 milkings/AM unit per day. Total electricity consumption and costs were 62.6 Wh/L of milk produced and 0.91 cents/L, respectively. Milking (vacuum and milk pumping, within-AM unit water heating) had the largest electrical consumption at 33%, followed by air compressing (26%), milk cooling (18%), auxiliary water heating (8%), water pumping (4%), and other electricity-consuming processes (11%). Electricity costs followed a similar trend to that of consumption, with the milking process and water pumping accounting for the highest and lowest cost, respectively. The pattern of daily electricity consumption was similar across the lactation periods, with peak consumption occurring at 0100, 0800, and between 1300 and 1600 h. The trends in seasonal electricity consumption followed the seasonal milk production curve. Total water consumption was 3.7 L of water/L of milk produced. Water consumption associated with the dairy herd at the milking shed represented 42% of total water consumed on the farm. Daily water consumption trends indicated consumption to be lowest in the early morning period (0300-0600 h), followed by spikes in consumption between 1100 and 1400 h. Seasonal water trends followed the seasonal milk production curve, except for the month of May, when water consumption was reduced due to above-average rainfall. This study provides a useful insight into the consumption of electricity and water on a pasture-based AM farms, while also facilitating the development of future strategies and technologies likely to increase the sustainability of AM systems.

Evaluation of the RumiWatchSystem for measuring grazing behaviour of cows

Feeding behaviour is an important parameter of animal performance, health and welfare, as well as reflecting levels and quality of feed available. Previously, sensors were only used for measuring animal feeding behaviour in indoor housing systems. However, sensors such as the RumiWatchSystem can also monitor such behaviour continuously in pasture-based environments. Therefore, the aim of this study was to validate the RumiWatchSystem to record cow activity and feeding behaviour in a pasture-based system. The RumiWatchSystem was evaluated against visual observation across two different experiments. The time duration per hour at grazing, rumination, walking, standing and lying recorded by the RumiWatchSystem was compared to the visual observation data in Experiment 1. Concordance Correlation Coefficient (CCC) values of CCC=0.96 for grazing, CCC=0.99 for rumination, CCC=1.00 for standing and lying and CCC=0.92 for walking were obtained. The number of grazing and rumination bouts within one hour were also analysed resulting in Cohen's Kappa (κ)=0.62 and κ=0.86 for grazing and rumination bouts, respectively. Experiment 2 focused on the validation of grazing bites and rumination chews. The accordance between visual observation and automated measurement by the RumiWatchSystem was high with CCC=0.78 and CCC=0.94 for grazing bites and rumination chews, respectively. These results indicate that the RumiWatchSystem is a reliable sensor technology for observing cow activity and feeding behaviour in a pasture based milk production system, and may be used for research purposes in a grazing environment.

Renal nerve stimulation for treatment of neurocardiogenic syncope: a review from perspective of commercialization potential

A strong evidence of outcomes for vasovagal syncope is not easily identified. It would seem reasonable that the proposed Mayo Clinic technology would be reserved for cases with severe recurrent or refractory syncope. However, recurrence levels are relatively low, and while some predictive methods have been proposed, recurrence is also influenced by the interaction that occurs during screening and examinations, i.e. recurrence diminishes once an initial diagnosis has been made. Finally, a key factor in being able to identify suitable patients relates to understanding the relative significance of the vasodepression and cardioinhibitory components-the therapy is best suited to patients that have a significant level of both components. It is probably not needed in patients with mainly cardioinhibitory involvement-data from ISSUE 2 and ISSUE 3 studies suggest that this is a relatively large proportion, particularly with asystolic involvement. The challenge remains in having suitable screening tests to identify the best patients. Tilt table testing has questions concerning its ability to replicate clinical syncope-implantable loop recorders (ILRs) may provide more accurate data but their usage is not yet widely accepted given the costs and invasive nature of the monitor.

Perfusion computed tomography in patients with stroke thrombolysis

See Saver (doi:10.1093/awx020) for a scientific commentary on this article.

Stroke shortens an individual’s disability-free life. We aimed to assess the relative prognostic influence of pre- and post-treatment perfusion computed tomography imaging variables (e.g. ischaemic core and penumbral volumes) compared to standard clinical predictors (such as onset-to-treatment time) on long-term stroke disability in patients undergoing thrombolysis. We used data from a prospectively collected international, multicentre, observational registry of acute ischaemic stroke patients who had perfusion computed tomography and computed tomography angiography before treatment with intravenous alteplase. Baseline perfusion computed tomography and follow-up magnetic resonance imaging were analysed to derive the baseline penumbra volume, baseline ischaemic core volume, and penumbra salvaged from infarction. The primary outcome measure was the effect of imaging and clinical variables on Disability-Adjusted Life Year. Clinical variables were age, sex, National Institutes of Health Stroke Scale score, and onset-to-treatment time. Age, sex, country, and 3-month modified Rankin Scale were extracted from the registry to calculate disability-adjusted life-year due to stroke, such that 1 year of disability-adjusted life-year equates to 1 year of healthy life lost due to stroke. There were 772 patients receiving alteplase therapy. The number of disability-adjusted life-year days lost per 1 ml of baseline ischaemic core volume was 17.5 (95% confidence interval, 13.2–21.9 days, P < 0.001). For every millilitre of penumbra salvaged, 7.2 days of disability-adjusted life-year days were saved (β = −7.2, 95% confidence interval, −10.4 to −4.1 days, P < 0.001). Each minute of earlier onset-to-treatment time resulted in a saving of 4.4 disability-free days after stroke (1.3–7.5 days, P = 0.006). However, after adjustment for imaging variables, onset-to-treatment time was not significantly associated with savings in disability-adjusted life-year days. Pretreatment perfusion computed tomography can (independently of clinical variables) predict significant gains, or loss, of disability-free life in patients undergoing reperfusion therapy for stroke. The effect of earlier treatment on disability-free life appears explained by salvage of penumbra, particularly when the ischaemic core is not too large.

Validating a Predictive Model of Acute Advanced Imaging Biomarkers in Ischemic Stroke

BACKGROUND AND PURPOSE

Advanced imaging to identify tissue pathophysiology may provide more accurate prognostication than the clinical measures used currently in stroke. This study aimed to derive and validate a predictive model for functional outcome based on acute clinical and advanced imaging measures.

METHODS

A database of prospectively collected sub-4.5 hour patients with ischemic stroke being assessed for thrombolysis from 5 centers who had computed tomographic perfusion and computed tomographic angiography before a treatment decision was assessed. Individual variable cut points were derived from a classification and regression tree analysis. The optimal cut points for each assessment variable were then used in a backward logic regression to predict modified Rankin scale (mRS) score of 0 to 1 and 5 to 6. The variables remaining in the models were then assessed using a receiver operating characteristic curve analysis.

RESULTS

Overall, 1519 patients were included in the study, 635 in the derivation cohort and 884 in the validation cohort. The model was highly accurate at predicting mRS score of 0 to 1 in all patients considered for thrombolysis therapy (area under the curve [AUC] 0.91), those who were treated (AUC 0.88) and those with recanalization (AUC 0.89). Next, the model was highly accurate at predicting mRS score of 5 to 6 in all patients considered for thrombolysis therapy (AUC 0.91), those who were treated (0.89) and those with recanalization (AUC 0.91). The odds ratio of thrombolysed patients who met the model criteria achieving mRS score of 0 to 1 was 17.89 (4.59-36.35, P<0.001) and for mRS score of 5 to 6 was 8.23 (2.57-26.97, P<0.001).

CONCLUSIONS

This study has derived and validated a highly accurate model at predicting patient outcome after ischemic stroke.

Too good to treat? ischemic stroke patients with small computed tomography perfusion lesions may not benefit from thrombolysis

OBJECTIVE

Although commonly used in clinical practice, there remains much uncertainty about whether perfusion computed tomography (CTP) should be used to select stroke patients for acute reperfusion therapy. In this study, we tested the hypothesis that a small acute perfusion lesion predicts good clinical outcome regardless of thrombolysis administration.

METHODS

We used a prospectively collected cohort of acute ischemic stroke patients being assessed for treatment with IV-alteplase, who had CTP before a treatment decision. Volumetric CTP was retrospectively analyded to identify patients with a small perfusion lesion (<15ml in volume). The primary analysis was excellent 3-month outcome in patients with a small perfusion lesion who were treated with alteplase compared to those who were not treated.

RESULTS

Of 1526 patients, 366 had a perfusion lesion <15ml and were clinically eligible for alteplase (212 being treated and 154 not treated). Median acute National Institutes of Health Stroke Scale score was 8 in each group. Of the 366 patients with a small perfusion lesion, 227 (62%) were modified Rankin Scale (mRS) 0 to 1 at day 90. Alteplase-treated patients were less likely to achieve 90-day mRS 0 to 1 (57%) than untreated patients (69%; relative risk [RR] = 0.83; 95% confidence interval [CI], 0.71-0.97; p = 0.022) and did not have different rates of mRS 0 to 2 (72% treated patients vs 77% untreated; RR, 0.93; 95% CI, 0.82-1.95; p = 0.23).

INTERPRETATION

This large observational cohort suggests that a portion of ischemic stroke patients clinically eligible for alteplase therapy with a small perfusion lesion have a good natural history and may not benefit from treatment. Ann Neurol 2016;80:286-293.

Global White Matter Hypoperfusion on CT Predicts Larger Infarcts and Hemorrhagic Transformation after Acute Ischemia

INTRODUCTION

Presence of white matter hyperintensity (WMH) on MRI is a marker of cerebral small vessel disease and is associated with increased small vessel stroke and increased risk of hemorrhagic transformation (HT) after thrombolysis.

AIM

We sought to determine whether white matter hypoperfusion (WMHP) on perfusion CT (CTP) was related to WMH, and if WMHP predisposed to acute lacunar stroke subtype and HT after thrombolysis.

METHODS

Acute ischemic stroke patients within 12 h of symptom onset at 2 centers were prospectively recruited between 2011 and 2013 for the International Stroke Perfusion Imaging Registry. Participants routinely underwent baseline CT imaging, including CTP, and follow-up imaging with MRI at 24 h.

RESULTS

Of 229 ischemic stroke patients, 108 were Caucasians and 121 Chinese. In the contralateral white matter, patients with acute lacunar stroke had lower cerebral blood flow (CBF) and cerebral blood volume (CBV), compared to those with other stroke subtypes (P = 0.041). There were 46 patients with HT, and WMHP was associated with increased risk of HT (R(2) = 0.417, P = 0.002). Compared to previously reported predictors of HT, WMHP performed better than infarct core volume (R(2) = 0.341, P = 0.034), very low CBV volume (R(2) = 0.249, P = 0.026), and severely delayed perfusion (Tmax>14 second R(2) = 0.372, P = 0.011). Patients with WMHP also had larger acute infarcts and increased infarct growth compared to those without WMHP (mean 28 mL vs. 13 mL P < 0.001).

CONCLUSION

White matter hypoperfusion remote to the acutely ischemic region on CTP is a marker of small vessel disease and was associated with increased HT, larger acute infarct cores, and greater infarct growth.

Seasonal trends in milk quality in Ireland between 2007 and 2011

The objectives of this study were to evaluate annual and seasonal trends in bulk tank somatic cell count (SCC), total bacterial count (TBC), and laboratory pasteurization count (LPC) in Ireland between 2007 and 2011 (inclusive), and to compare trends based on herd type and herd size. The unadjusted median SCC and TBC of all records were 266,000 and 17,000 cfu/mL, respectively. Data were transformed to log values and analyzed using a mixed model. Fixed effects included milk processor, year, month, and total monthly milk volume; milk producer was fitted as a random variable. After analysis, means were back transformed for interpretation. Annual SCC increased slightly from 259,000 cells/mL in 2007 to a peak of 272,647 cells/mL in 2009 and then declined slightly thereafter. Although statistically significant changes in annual TBC are probably not biologically relevant, values ranged between 23,922 and 26,290 cfu/mL. Annual LPC peaked in 2008 (265 cfu/mL), declined in 2009, and increased thereafter. Monthly mean SCC of all records increased from April onward, with the greatest increases seen from October to December, when the majority of cows entered late lactation. Monthly mean TBC exhibited a seasonal trend, whereby TBC was greatest at the beginning and end of the year, coinciding with winter housing. Seasonal milk production herds (n=8,002 herds) calve all cows in spring (February to April), whereas split-calving herds (n=1,829 herds) calve cows in the spring and autumn. From February to September, monthly SCC was lower for seasonal herds than for split-calving herds, whereas SCC was lower for split-calving herds for the remaining months. During winter (October to March), split-calving herds had lower monthly TBC than seasonal herds, most likely because of stricter regulations imposed upon them. Herd size was approximated using total annual milk production figures. Across all months, larger herds had lower SCC and TBC compared with smaller herds. No obvious improvements in milk quality were seen between 2007 and 2011. Farmers have the opportunity to improve milk quality by reducing bulk tank SCC in late lactation and by imposing stricter hygiene practices at the beginning and end of the year to overcome the seasonal variation of bulk tank TBC.

Development and adoption of new technologies to increase the efficiency and sustainability of pasture-based systems

New technologies that can allow measurement and exploitation of biological variation to improve resource efficiency are rapidly becoming available. Some of these technologies can be applied to improve the efficiency of pasture-based systems. There will be significant innovation in technology for capturing variation in dairy-cow productivity and welfare, as the potential market globally is very large; however, the market potential for technology for pasture-based grazing systems is much smaller and will require public funding to stimulate innovation in technology, to capture and exploit the variation in pasture production and utilisation. Current research in Teagasc Moorepark is focussed on developing and adapting technology to capture both the inter-paddock and intra-paddock variation in pasture production that will potentially allow more specific and efficient nutrient use and higher total herbage production. The second focus of the current research is in the development of technologies to capture and manage the variation in grass utilisation by real-time monitoring and collating the data on herd output and post-grazing residual and controlling individual-animal pasture allocation through individual GPS-location identification and control with virtual fencing.

Investigation of the migration of triclabendazole residues to milk products manufactured from bovine milk, and stability therein, following lactating cow treatment

Triclabendazole (TCB) is a flukicide used in the treatment of liver fluke in cattle; however, its use is currently prohibited in lactating dairy cows. In this study, following administration of 10% Fasinex (triclabendazole, Novartis Animal Health UK Ltd., Camberley, UK) the milk of 6 animals was used to manufacture dairy products, to ascertain if TCB residues in milk migrate into dairy products. The detection limit of the ultra-high-performance liquid chromatography-tandem mass spectrometry method used was 0.67 μg/kg. The highest concentrations of TCB residue measured, within the individual cow milk yield, was 1,529 ± 244 µg/kg (n=6), on d 2 posttreatment. Days 2 and 23 posttreatment represented high and low residue concentrations, respectively. At each of these 2 time points, the milk was pooled into 2 independent aliquots and refrigerated. Milk products, including cheese, butter, and skim milk powder were manufactured using pasteurized and unpasteurized milk from each aliquot. The results for high residue milks demonstrated that TCB residues concentrated in the cheese by a factor of 5 (5,372 vs. 918 µg/kg for cheese vs. milk) compared with the starting milk. Residue concentrations are the sum of TCB and its metabolites, expressed as keto-TCB. Residues were concentrated in the butter by a factor of 9 (9,177 vs. 1,082 μg/kg for butter vs. milk) compared with the starting milk. For milk, which was separated to skim milk and cream fractions, the residues were concentrated in the cream. Once skim milk powder was manufactured from the skim milk fraction, the residue in powder was concentrated 15-fold compared with the starting skim milk (7,252 vs. 423 µg/kg for powder vs. skim milk), despite the high temperature (185 °C) required during powder manufacture. For products manufactured from milk with low residue concentrations at d 23 posttreatment, TCB residues were detected in butter, cheese, and skim milk powder, even though there was no detectable residue in the milk used to manufacture these products. Triclabendazole residues were concentrated in some milk products (despite manufacturing treatments), exceeding residue levels in the starting milk and, depending on the storage conditions, may be relatively stable over time.

The haemodynamic response to pre-hospital RSI in injured patients

BACKGROUND

Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting.

METHODS

We performed a retrospective analysis of 115 consecutive pre-hospital RSI's performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation.

RESULTS

Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common.

CONCLUSIONS

Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.

Estimating the effect of mastitis on the profitability of Irish dairy farms

The objective of this paper was to estimate the effect of the costs of mastitis on the profitability of Irish dairy farms as indicated by various ranges of bulk milk somatic cell count (BMSCC). Data were collected from 4 sources and included milk production losses, cases treated, and on-farm practices around mastitis management. The Moorepark Dairy Systems Model, which simulates dairying systems inside the farm gate, was used to carry out the analysis. The cost components of mastitis that affect farm profitability and that were included in the model were milk losses, culling, diagnostic testing, treatment, veterinary attention, discarded milk, and penalties. Farms were grouped by 5 BMSCC thresholds of ≤ 100,000, 100,001-200,000, 200,001-300,000, 300,001-400,000, and > 400,000 cells/mL. The ≤ 100,000 cells/mL threshold was taken as the baseline and the other 4 thresholds were compared relative to this baseline. For a 40-ha farm, the analysis found that as BMSCC increased, milk receipts decreased from €148,843 at a BMSCC <100,000 cells/mL to €138,573 at a BMSCC > 400,000 cells/mL. In addition, as BMSCC increased, livestock receipts increased by 17%, from €43,304 at a BMSCC <100,000 cells/mL to €50,519 at a BMSCC > 400,000 cells/mL. This reflected the higher replacement rates as BMSCC increased and the associated cull cow value. Total farm receipts decreased from €192,147 at the baseline (< 100,000 cells/mL) to €189,091 at a BMSCC > 400,000 cells/mL. Total farm costs increased as BMSCC increased, reflecting treatment, veterinary, diagnostic testing, and replacement heifer costs. At the baseline, total farm costs were €161,085, increasing to €177,343 at a BMSCC > 400,000 cells/mL. Net farm profit decreased as BMSCC increased, from €31,252/yr at the baseline to €11,748/yr at a BMSCC > 400,000 cells/mL. This analysis highlights the impact that mastitis has on the profitability of Irish dairy farms. The analysis presented here can be used to develop a "cost of mastitis" tool for use on Irish dairy farms to motivate farmers to acknowledge the scale of the problem, realize the value of improving mastitis control, and implement effective mastitis control practices.

Childhood obesity: parents fail to recognise, general practitioners fail to act

General Practitioners (GPs) have an important role to play in recognition of and intervention against childhood obesity in Ireland. Data were collected prospectively on a cohort of children aged 4-14 and their parents (n = 101 pairs) who attended consecutively to a semi-rural group general practice. Parents estimated their child's weight status. Actual weight status was determined for both parent and child using the United States Centres' for Disease Control's BMI-for-age references. 15 (14.9%) of the children and 49 (51.6%) of the parents were overweight or obese. While 71 (95.5%) of normal weight status children were correctly identified, parents showed poor concordance in identifying their children as overweight 2 (18.2%) or obese 0 (0%). BMI was only evidently recorded in the clinical records of 1 out of 15 cases of overweight children identified. With parents failing to recognise childhood obesity, GPs have a responsibility in tackling this problem at a family level.