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Camporota L, Meadows C, Ledot S, Scott I, Harvey C, Garcia M, Vuylsteke A. Consensus on the referral and admission of patients with severe respiratory failure to the NHS ECMO service. Lancet Respir Med 2021; 9:e16-e17. [PMID: 33428874 PMCID: PMC7832224 DOI: 10.1016/s2213-2600(20)30581-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London SE1 7EH, UK.
| | - Christopher Meadows
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
| | - Stephane Ledot
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian Scott
- Department of Critical Care, Aberdeen Royal Infirmary NHS Grampian, Aberdeen, Scotland
| | - Christopher Harvey
- Department of Critical Care, Glenfield Hospital, University Hospital Leicester, Leicester, UK
| | - Miguel Garcia
- Department of Critical Care, Wythenshaw Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alain Vuylsteke
- Department of Critical Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Zhang J, Whebell SF, Sanderson B, Retter A, Daly K, Paul R, Barrett N, Agarwal S, Lams BE, Meadows C, Terblanche M, Camporota L. Phenotypes of severe COVID-19 ARDS receiving extracorporeal membrane oxygenation. Br J Anaesth 2020; 126:e130-e132. [PMID: 33487454 PMCID: PMC7836959 DOI: 10.1016/j.bja.2020.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joe Zhang
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK.
| | - Stephen F Whebell
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Barney Sanderson
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Andrew Retter
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Kathleen Daly
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Richard Paul
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Barrett
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Sangita Agarwal
- Department of Rheumatology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Boris E Lams
- Department of Respiratory Medicine, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Christopher Meadows
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Marius Terblanche
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Grobman WA, Sandoval G, Reddy UM, Tita AT, Silver RM, Mallett G, Hill K, Rice MM, El-Sayed YY, Wapner RJ, Rouse DJ, Saade GR, Thorp JM, Chauhan SP, Iams JD, Chien EK, Casey BM, Gibbs RS, Srinivas SK, Swamy GK, Simhan HN, Macones GA, Peaceman A, Plunkett B, Paycheck K, Dinsmoor M, Harris S, Sheppard J, Biggio J, Harper L, Longo S, Servay C, Varner M, Sowles A, Coleman K, Atkinson D, Stratford J, Dellermann S, Meadows C, Esplin S, Martin C, Peterson K, Stradling S, Willson C, Lyell D, Girsen A, Knapp R, Gyamfi C, Bousleiman S, Perez-Delboy A, Talucci M, Carmona V, Plante L, Tocci C, Leopanto B, Hoffman M, Dill-Grant L, Palomares K, Otarola S, Skupski D, Chan R, Allard D, Gelsomino T, Rousseau J, Beati L, Milano J, Werner E, Salazar A, Costantine M, Chiossi G, Pacheco L, Saad A, Munn M, Jain S, Clark S, Clark K, Boggess K, Timlin S, Eichelberger K, Moore A, Beamon C, Byers H, Ortiz F, Garcia L, Sibai B, Bartholomew A, Buhimschi C, Landon M, Johnson F, Webb L, McKenna D, Fennig K, Snow K, Habli M, McClellan M, Lindeman C, Dalton W, Hackney D, Cozart H, Mayle A, Mercer B, Moseley L, Gerald J, Fay-Randall L, Garcia M, Sias A, Price J, Hale K, Phipers J, Heyborne K, Craig J, Parry S, Sehdev H, Bishop T, Ferrara J, Bickus M, Caritis S, Thom E, Doherty L, de Voest J. Health resource utilization of labor induction versus expectant management. Am J Obstet Gynecol 2020; 222:369.e1-369.e11. [PMID: 31930993 DOI: 10.1016/j.ajog.2020.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/26/2019] [Accepted: 01/06/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization. OBJECTIVE The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum. STUDY DESIGN This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum. RESULTS Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all). CONCLUSION Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.
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Abstract
Despite timely intervention, there exists a small subgroup of patients with septic shock who develop progressive multi-organ failure. Seemingly refractory to conventional therapy, they exhibit a very high mortality. Such patients are often poorly represented in large clinical trials. Consequently, good evidence for effective treatment strategies is lacking. In this article, we describe a pragmatic, multi-faceted approach to managing patients with refractory septic shock based on our experience of toxin-mediated sepsis in a specialist referral centre. Many components of this strategy are inexpensive and widely accessible, and so may offer an opportunity to improve outcomes in these critically ill patients.
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Affiliation(s)
- Prashanth Nandhabalan
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK.
| | - Nicholas Ioannou
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
| | - Christopher Meadows
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
| | - Duncan Wyncoll
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
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Camporota L, Nicoletti E, Malafronte M, De Neef M, Mongelli V, Calderazzo MA, Caricola E, Glover G, Meadows C, Langrish C, Ioannou N, Wyncoll D, Beale R, Shankar-Hari M, Barrett N. International survey on the management of mechanical ventilation during ECMO in adults with severe respiratory failure. Minerva Anestesiol 2015; 81:1170-1183. [PMID: 26125687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND No consensus exists on the optimal settings of mechanical ventilation during veno-venous extracorporeal membrane oxygenation (ECMO). Our aim was to describe how mechanical ventilation and related interventions are managed by adult ECMO centres. METHODS A cross-sectional, multi-centre, international survey of 173 adult respiratory ECMO centres. The survey was generated through an iterative process and assessed for clarity, content and face validity. RESULTS One hundred thirty-three centres responded (76.8%). Pressure control was the most commonly used mechanical ventilation mode (64.4%). Although the median PEEP was 10 cmH2O, 22.6% set PEEP <10 cmH2O and 15.5% used 15-20 cmH2O. In 63% of centres PEEP was fixed and not titrated. Recruitment maneuvres, were never used in 34.1% of centres, or used daily in 13.2%. Centres reported using either a "lung rest" (45.7%), or an "open lung" strategy (44.2%). Only 24.8% used chest CT to guide mechanical ventilation. Adjunctive treatments were never or occasionally used. Only 10% of centres extubated patients on ECMO, mainly in more experienced centres. 71.3% of centres performed tracheostomy on ECMO, with large variability in timing (most frequent on days 6-10). Only 27.1% of ECMO centres had a protocol for mechanical ventilation on ECMO. CONCLUSION We found large variability in ventilatory practices during ECMO. The clinicians' training background and the centres' experience had no influence on the approach to ventilation. This survey shows that well conducted studies are necessary to determine the best practice of mechanical ventilation during ECMO and its impact on patient outcome.
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Affiliation(s)
- L Camporota
- Division of Asthma, Allergy and Lung Biology, King's College London and Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK -
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Lloyd D, Bomford J, Barry M, Berry W, Barrett N, Camporota L, Ioannou N, Lams B, Langrish C, Meadows C, Retter A, Wyncoll D, Glover G. Endobronchial streptokinase for airway thrombus: a case series. Crit Care 2015. [PMCID: PMC4472801 DOI: 10.1186/cc14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kovacs A, Assabiny A, Lakatos B, Apor A, Nagy A, Kutyifa V, Merkely B, Ulbrich S, Sveric K, Rady M, Strasser R, Ebner B, Lervik Nilsen LC, Brekke B, Missant C, Ortega A, Haemers P, Tong L, Sutherland G, D'hooge J, Stoylen A, Gurzun MM, Ionescu A, Santoro A, Federico Alvino F, Carlo Gaetano Sassi C, Giovanni Antonelli G, Sergio Mondillo S, Chumarnaya T, Alueva Y, Kochmasheva V, Mikhailov S, Ostern O, Solovyova O, Revishvili A, Markhasin V, Rodriguez Munoz D, Carbonell Sanroman A, Moya Mur J, Fernandez Santos S, Lazaro Rivera C, Valverde Gomez M, Casas Rojo E, Garcia Martin A, Fernandez-Golfin C, Zamorano Gomez J, Kanda T, Fujita M, Masuda M, Iida O, Okamoto S, Ishihara T, Nanto K, Shiraki T, Takahara M, Uematsu M, Kolesnyk MY, Victor K, Lux D, Carr-White G, Barrett N, Glover G, Langrish C, Meadows C, Ioannou N, Castaldi B, Vida V, Argiolas A, Maschietto N, Cerutti A, Biffanti R, Reffo E, Padalino M, Stellin G, Milanesi O, Simova I, Katova T, Galderisi M, Lalov I, Onciul S, Alexandrescu A, Petre I, Zamfir D, Onut R, Tautu O, Dorobantu M, Caldas A, Ladeia A, D'almeida J, Guimaraes A, Ball C, Abdelmoneim Mohamed S, Huang R, Zysek V, Mantovani F, Scott C, Mccully R, Mulvagh S, Lee JH, Cho G, Mihaila S, Muraru D, Aruta P, Piasentini E, Cavalli G, Ucci L, Peluso D, Vinereanu D, Iliceto S, Badano L, Ozawa K, Funabashi N, Takaoka H, Kamata T, Nomura F, Kobayashi Y, Ovsianas J, Valuckiene Z, Mizariene V, Jurkevicius R, Reskovic Luksic V, Dosen D, Cekovic S, Separovic Hanzevacki J, Simova I, Katova T, Santoro C, Galderisi M, Kalcik M, Cakal B, Gursoy M, Astarcioglu M, Yesin M, Gunduz S, Karakoyun S, Cersit S, Toprak C, Ozkan M. Club 35 Poster session 3: Friday 5 December 2014, 08:30-18:00 * Location: Poster area. Eur Heart J Cardiovasc Imaging 2014. [DOI: 10.1093/ehjci/jeu263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Starsmore L, Lams B, Agarwal S, Nair A, Preston R, Barrett N, Glover G, Ioannou N, Langrish C, Wyncoll D, Meadows C. S9 Acute Inflammatory Presentation Associates With Survival In Interstitial Lung Disease And Extracorporeal Membrane Oxygenation-requiring Severe Respiratory Failure: A Single Centre Case Series. Thorax 2014. [DOI: 10.1136/thoraxjnl-2014-206260.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Simpson T, Ling C, Glover G, Barrett N, Ioannou N, Lams B, Langrish C, Meadows C, Agarwal N, D'Cruz D. P278 Extra-corporeal Membrane Oxygenation And Diffuse Alveolar Haemorrhage - A Single Centre Case Series And Analysis Of The Elso Database. Thorax 2014. [DOI: 10.1136/thoraxjnl-2014-206260.396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vimalanathan C, Barrett N, Ioannou N, Langrish C, Meadows C, Salt G, Glover G. Potential use of veno-arterial extracorporeal membrane oxygenation for cardiogenic shock refractory to mechanical assist devices: baseline physiology and mortality data. Crit Care 2014. [PMCID: PMC4068265 DOI: 10.1186/cc13357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Meadows C, Bastin A, Kaul S, Finney S. Family satisfaction on the intensive care unit. Crit Care 2010. [PMCID: PMC2934070 DOI: 10.1186/cc8829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Meadows C, Creagh-Brown B, Nia T, Bonnici K, Finney S. Definition of catheter-related bloodstream infection as a quality improvement measure in intensive care. Crit Care 2009. [PMCID: PMC4084077 DOI: 10.1186/cc7355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Affiliation(s)
- C Meadows
- Bristol Royal Hospital for Children, Bristol, UK
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Affiliation(s)
- J Gauntlett-Gilbert
- Pain Management Unit, Royal National Hospital for Rheumatic Diseases and The University of Bath, Bath, UK
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Murphy JE, Marsh AE, Reed SM, Meadows C, Bolten K, Saville WJA. Development and evaluation of a Sarcocystis neurona-specific IgM capture enzyme-linked immunosorbent assay. J Vet Intern Med 2006; 20:322-8. [PMID: 16594589 DOI: 10.1892/0891-6640(2006)20[322:daeoas]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Equine protozoal myeloencephalitis (EPM) is a serious neurologic disease of horses caused primarily by the protozoal parasite Sarcocystis neurona. Currently available antemortem diagnostic testing has low specificity. The hypothesis of this study was that serum and cerebrospinal fluid (CSF) of horses experimentally challenged with S neurona would have an increased S neurona-specific IgM (Sn-IgM) concentration after infection, as determined by an IgM capture enzyme linked immunoassay (ELISA). The ELISA was based on the S neurona low molecular weight protein SNUCD-1 antigen and the monoclonal antibody 2G5 labeled with horseradish peroxidase. The test was evaluated using serum and CSF from 12 horses experimentally infected with 1.5 million S neurona sporocysts and 16 horses experimentally infected with varying doses (100 to 100,000) of S neurona sporocysts, for which results of histopathologic examination of the central nervous system were available. For horses challenged with 1.5 million sporocysts, there was a significant increase in serum Sn-IgM concentrations compared with values before infection at weeks 2-6 after inoculation (P < .0001). For horses inoculated with lower doses of S neurona, there were significant increases in serum Sn-IgM concentration at various points in time after inoculation, depending on the challenge dose (P < .01). In addition, there was a significant increase between the CSF Sn-IgM concentrations before and after inoculation (P < .0001). These results support further evaluation of the assay as a diagnostic test during the acute phase of EPM.
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Affiliation(s)
- J E Murphy
- Department of' Clinical Sciences, The Ohio State University, Columbus, USA
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Murphy J, Marsh A, Reed S, Meadows C, Bolten K, Saville W. Development and Evaluation of aSarcocystis neurona-Specific IgM Capture Enzyme-Linked Immunosorbent Assay. J Vet Intern Med 2006. [DOI: 10.1111/j.1939-1676.2006.tb02863.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Meadows C, Rajala-Schultz PJ, Frazer GS. A Spreadsheet-Based Model Demonstrating the Nonuniform Economic Effects of Varying Reproductive Performance in Ohio Dairy Herds. J Dairy Sci 2005; 88:1244-54. [PMID: 15738258 DOI: 10.3168/jds.s0022-0302(05)72791-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A spreadsheet-based model was developed to estimate the economic effect of varying reproductive performance in dairy herds. Scenarios were created to model an average cow with respect to production, herd lifetime, and reproductive events. Average milk yield per day of life as well as lifetime calf and replacement heifer production were examined. Additional inputs representing milk, feed, semen, calf, and salvage prices were used to calculate net cash flow for each day of herd life for the average cow in a scenario. Economic comparison of different scenarios was accomplished using an equivalent annual cash flow (annuity) methodology.Herd performance measures and prices representative of Ohio dairy herds were used to establish a baseline average cow that had a 160-d calving-to-conception interval [days open (DO)]. Alternative scenarios that differed from baseline in DO, annual culling rate, and feed and milk prices were created to characterize the effects of changes. Under scenario inputs representative of typical Ohio dairy herds, the model indicated that a lower annual culling rate (25%) was preferable to higher annual culling rates (34 or 45%). The model estimated maximum average milk yield per day of life to occur at 110 DO. At 34% annual culling rate, calves and replacement heifers produced per lifetime declined as DO increased; beyond 150 DO, the modeled cow produced less than 1 replacement heifer per lifetime. The model also estimated a loss of $1.37 per cow per year for a 1-d increase in DO beyond 160 d. At 20% higher feed and milk prices, the model estimated a loss of $1.52 per cow per year; at 20% lower feed and milk prices, the model estimated a loss of $1.23 per cow per year. Furthermore, the model suggested that the loss associated with a 1-d increase in DO changed as DO changed. Using baseline inputs, the model calculated losses for a 1-d increase of $0.44 per cow per year at 130 DO and $1.71 per cow per year at 190 DO. The nonuniform nature of the cost of additional DO is important to veterinarians and producers. The implication is that inefficient reproduction becomes marginally more costly to producers as performance declines and warrants increased attention. Conversely, marginal benefits of improved reproduction decrease as performance improves. Herds with strong reproductive performance have less opportunity to capture economic benefits of improvement.
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Affiliation(s)
- C Meadows
- Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH 43210, USA.
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Abstract
A survey was conducted to collect information on nutrient management practices on dairy farms in south-central Pennsylvania. Of the 994 responding farms, the average farm consisted of 64 lactating cows, 10 dry cows, 41 heifers, and 17 calves with 69.7 ha of tillable land. Manure from lactating cows was mainly collected on a daily basis (84% of the farms) and stored as slurry or liquid (73%), while dry cow and heifer manure was collected weekly or less frequently (69 and 85% of the farms) and stored as solid stack or bedded pack (67 and 82%). Manure utilization featured consistent use of on-farm spreading, with limited incorporation, to corn or small grain fields before planting. Spreading on perennial forages or pasture was also common. Irrigation or injection of manure occurred on less than 5% of the farms. Only 20% of the farms reported manure nutrient testing, contrasting to over 90% for soil testing. Farm advisors and their services can be of vital importance in helping producers make conscientious management decisions for enhanced nutrient utilization. For example, ration balancing involved the services of feed and mineral sales representatives (85% of the farms), independent consultants (12%), and veterinarians (5%). Manure nutrient crediting to determine manure application rates was made by fertilizer dealers (40%), crop advisors and independent consultants (31%), and others. Nutrient management strategies and efforts must address the specific needs of farms with different animal densities and nutrient balances in order to be effective and applicable on the majority of farms.
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Affiliation(s)
- Z Dou
- University of Pennsylvania, School of Veterinary Medicine Center for Animal Health and Productivity, Kennett Square 19348, USA.
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Meadows C. Mental health. Keep taking the tablets. Nurs Times 1990; 86:69-70. [PMID: 2362867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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