Genome-wide association study of age at puberty and its (co)variances with fertility and stature in growing and lactating Holstein-Friesian dairy cattle

Reproductive performance is a key determinant of cow longevity in a pasture-based, seasonal dairy system. Unfortunately, direct fertility phenotypes such as intercalving interval or pregnancy rate tend to have low heritabilities and occur relatively late in an animal's life. In contrast, age at puberty (AGEP) is a moderately heritable, early-in-life trait that may be estimated using an animal's age at first measured elevation in blood plasma progesterone (AGEP4) concentrations. Understanding the genetic architecture of AGEP4 in addition to genetic relationships between AGEP4 and fertility traits in lactating cows is important, as is its relationship with body size in the growing animal. Thus, the objectives of this research were 3-fold. First, to estimate the genetic and phenotypic (co)variances between AGEP4 and subsequent fertility during first and second lactations. Second, to quantify the associations between AGEP4 and height, length, and BW measured when animals were approximately 11 mo old (standard deviation = 0.5). Third, to identify genomic regions that are likely to be associated with variation in AGEP4. We measured AGEP4, height, length, and BW in approximately 5,000 Holstein-Friesian or Holstein-Friesian × Jersey crossbred yearling heifers across 54 pasture-based herds managed in seasonal calving farm systems. We also obtained calving rate (CR42, success or failure to calve within the first 42 d of the seasonal calving period), breeding rate (PB21, success or failure to be presented for breeding within the first 21 d of the seasonal breeding period) and pregnancy rate (PR42, success or failure to become pregnant within the first 42 d of the seasonal breeding period) phenotypes from their first and second lactations. The animals were genotyped using the Weatherby's Versa 50K SNP array (Illumina, San Diego, CA). The estimated heritabilities of AGEP4, height, length, and BW were 0.34 (90% credibility interval [CRI]: 0.30, 0.37), 0.28 (90% CRI: 0.25, 0.31), 0.21 (90% CRI: 0.18, 0.23), and 0.33 (90% CRI: 0.30, 0.36), respectively. In contrast, the heritabilities of CR42, PB21 and PR42 were all <0.05 in both first and second lactations. The genetic correlations between AGEP4 and these fertility traits were generally moderate, ranging from 0.11 to 0.60, whereas genetic correlations between AGEP4 and yearling body-conformation traits ranged from 0.02 to 0.28. Our GWAS highlighted a genomic window on chromosome 5 that was strongly associated with variation in AGEP4. We also identified 4 regions, located on chromosomes 14, 6, 1, and 11 (in order of decreasing importance), that exhibited suggestive associations with AGEP4. Our results show that AGEP4 is a reasonable predictor of estimated breeding values for fertility traits in lactating cows. Although the GWAS provided insights into genetic mechanisms underpinning AGEP4, further work is required to test genomic predictions of fertility that use this information.

Angiogenic Gene Therapy for Refractory Angina: Results of the EXACT Phase 2 Trial

BACKGROUND

XC001 is a novel adenoviral-5 vector designed to express multiple isoforms of VEGF (vascular endothelial growth factor) and more safely and potently induce angiogenesis. The EXACT trial (Epicardial Delivery of XC001 Gene Therapy for Refractory Angina Coronary Treatment) assessed the safety and preliminary efficacy of XC001 in patients with no option refractory angina.

METHODS

In this single-arm, multicenter, open-label trial, 32 patients with no option refractory angina received a single treatment of XC001 (1×1011 viral particles) via transepicardial delivery.

RESULTS

There were no severe adverse events attributed to the study drug. Twenty expected severe adverse events in 13 patients were related to the surgical procedure. Total exercise duration increased from a mean±SD of 359.9±105.55 seconds at baseline to 448.2±168.45 (3 months), 449.2±175.9 (6 months), and 477.6±174.7 (12 months; +88.3 [95% CI, 37.1-139.5], +84.5 [95% CI, 34.1-134.9], and +115.5 [95% CI, 59.1-171.9]). Total myocardial perfusion deficit on positron emission tomography imaging decreased by 10.2% (95% CI, -3.1% to 23.5%), 14.3% (95% CI, 2.8%-25.7%), and 10.2% (95% CI, -0.8% to -21.2%). Angina frequency decreased from a mean±SD 12.2±12.5 episodes to 5.2±7.2 (3 months), 5.1±7.8 (6 months), and 2.7±4.8 (12 months), with an average decrease of 7.7 (95% CI, 4.1-11.3), 6.6 (95% CI, 3.5-9.7), and 8.8 (4.6-13.0) episodes at 3, 6, and 12 months. Angina class improved in 81% of participants at 6 months.

CONCLUSIONS

XC001 administered via transepicardial delivery is safe and generally well tolerated. Exploratory improvements in total exercise duration, ischemic burden, and subjective measures support a biologic effect sustained to 12 months, warranting further investigation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04125732.

Dissemination and implementation analysis of the Ross procedure in adults: time to update the guidelines?

Background

The science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure's historical context on its D&I.

Methods

A contextual baseline of the Ross procedure was defined from the procedure's original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants.

Results

Each of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure's varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation.

Conclusions

The D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness.

Natural History of the Distal Aorta Following Elective Root Replacement in Patients with Marfan Syndrome

OBJECTIVE

It is unclear if the addition of a prophylactic arch operation is beneficial at the time of root replacement in patients with Marfan Syndrome (MFS). This project aims to understand the fate of the distal aorta following elective root replacement in MFS patients.

METHODS

Between 2000 and 2019, 124 adult patients with MFS were identified as having undergone elective aortic root replacement with a clamped distal aortic anastomosis during their lifetime. Serial axial imaging was analyzed. The primary outcome was a composite of subsequent type B aortic dissection (TBAD), aneurysmal degeneration (>4cm), and aortic re-intervention. Secondary outcomes included subsequent TBAD and mortality.

RESULTS

Mean age at root replacement was 33.3 years. Median follow-up was 11.3 years. 31 patients (25%) experienced the primary outcome, with no survival difference (p=0.9). The cross clamp and aortic cannulation sites were stable (growth rate 0.33mm/yr), and 2 patients (1.6%) required re-intervention there. 23 patients (19.8%) suffered subsequent TBAD. Patients with TBAD had a higher rate of distal degeneration (p<0.001), but no significant change in survival (p=0.2). Pre-operative hypertension (OR 3.96, p<0.05) and younger age at root replacement (OR 1.05, p<0.05) increased the risk of TBAD, based on regression analysis.

CONCLUSIONS

The distal aorta (including the clamp and cannulation site) overall appears stable in MFS patients following elective root replacement without prophylactic arch operation. Development of TBAD seems to be the primary driver of distal degeneration. Factors associated with TBAD development included hypertension, underscoring the importance of strict blood pressure control in these patients.

Genome-wide association study of anogenital distance and its (co)variances with fertility in growing and lactating Holstein-Friesian dairy cattle

Anogenital distance (AGD) is a moderately heritable trait that can be measured at a young age that may provide an opportunity to indirectly select for improved fertility in dairy cattle. In this study, we characterized AGD and its genetic and phenotypic relationships with a range of body stature and fertility traits. We measured AGD, shoulder height, body length, and body weight in a population of 5,010 Holstein-Friesian and Holstein-Friesian × Jersey crossbred heifers at approximately 11 mo of age (AGD1). These animals were born in 2018 across 54 seasonal calving, pasture-based dairy herds. A second measure of AGD was collected in a subset of herds (n = 17; 1,956 animals) when the animals averaged 29 mo of age (AGD2). Fertility measures included age at puberty (AGEP), then time of calving, breeding, and pregnancy during the first and second lactations. We constructed binary traits reflecting the animal's ability to calve during the first 42 d of their herd's seasonal calving period (CR42), be presented for breeding during the first 21 d of the seasonal breeding period (PB21) and become pregnant during the first 42 d of the seasonal breeding period (PR42). The posterior mean of sampled heritabilities for AGD1 was 0.23, with 90% of samples falling within a credibility interval (90% CRI) of 0.20 to 0.26, whereas the heritability of AGD2 was 0.29 (90% CRI 0.24 to 0.34). The relationship between AGD1 and AGD2 was highly positive, with a genetic correlation of 0.89 (90% CRI 0.82 to 0.94). Using a GWAS analysis of 2,460 genomic windows based on 50k genotype data, we detected a region on chromosome 20 that was highly associated with variation in AGD1, and a second region on chromosome 13 that was moderately associated with variation in AGD1. We did not detect any genomic regions associated with AGD2 which was measured in fewer animals. The genetic correlation between AGD1 and AGEP was 0.10 (90% CRI 0.00 to 0.19), whereas the genetic correlation between AGD2 and AGEP was 0.30 (90% CRI 0.15 to 0.44). The timing of calving, breeding, and pregnancy (CR42, PB21, and PR42) during first or second lactations exhibited moderate genetic relationships with AGD1 (0.19 to 0.52) and AGD2 (0.46 to 0.63). Genetic correlations between AGD and body stature traits were weak (≤0.16). We conclude that AGD is a moderately heritable trait, which may have value as an early-in-life genetic predictor for reproductive success during lactation.

A multidisciplinary multistage complete mega aorta replacement and utilization of extracorporeal membrane oxygenation in thoracoabdominal aneurysm repair

A 49-year-old woman underwent a 11-month multistage complete replacement of a mega aorta. Replacement stages included ascending aorta and arch replacement in conjunction with a frozen elephant trunk thoracic endovascular aortic repair, extension of thoracic endovascular aortic repair to zone 5, and open repair of the thoracoabdominal aneurysm with the use of venoarterial extracorporeal membrane oxygenation for circulatory support. This case illustrates the complexity of repairing a mega aorta, the multidisciplinary care and staging needed for repair, and the use of peripheral venoarterial extracorporeal membrane oxygenation for circulatory perfusion during thoracoabdominal aneurysm repair.

Animal- and herd-level factors associated with onset of puberty in grazing dairy heifers

AIMS

To explore animal- and herd-level risk factors influencing age at puberty in predominantly Holstein-Friesian dairy heifers managed in seasonal, pasture-based systems.

METHODS

Heifers born in spring 2018 (n = 5,010) from 54 commercial dairy herds in New Zealand were visited on three occasions when the mean heifer age, within herd, was 10 (visit 1; V1), 11 (V2) and 12 (V3) months old. Blood samples were collected on each visit and liveweight, stature and anogenital distance (AGD) were measured at V2. Heifers were defined as having reached puberty at the first visit where blood progesterone was elevated (≥ 1 ng/mL). Animal-level response variables included pubertal status by V1, V2 and V3, and age at puberty (or age at V3 plus 31 days for those that had not attained puberty by V3). To explore herd-level management factors, farmers answered a questionnaire relating to animal location, land type, health, feeding, and management between weaning and mating. A partial least squares regression was undertaken to identify herd-level factors associated with the greatest influence on puberty rate within herd.

RESULTS

The mean age at puberty was 352 (SD 34.9) days. Heavier animals at a greater proportion of expected mature liveweight based on their breeding value for liveweight, or animals with a higher breed proportion of Jersey and lower breed proportion of Holstein, were associated with earlier puberty. Herd puberty rates varied widely among enrolled herds, and averaged 20%, 39% and 56% by V1, V2 and V3, respectively. Liveweight, followed by breed and land type, had the greatest influence on the herd puberty rate. Heifer herds with a greater mean liveweight (absolute and proportion of expected mature weight) or greater Jersey proportion had more animals that reached puberty at any visit, whereas herds located on steep land or with greater Holstein breed proportions had lower puberty rates. Management-related factors such as vaccinations, provision of feed supplements, and weighing frequency were also herd-level risk factors of puberty but had less influence.

CONCLUSIONS AND CLINICAL RELEVANCE

This study highlights the importance of having well-grown heifers for increasing the chances of earlier puberty onset and the effect of breed and youngstock management to achieve growth targets. These outcomes have important implications for the optimal management of heifers to achieve puberty before their maiden breeding and for the timing of measurements to potentially incorporate a puberty trait in genetic evaluations.

Does valve size impact hemodynamic, left ventricular mass regression, and prosthetic valve deterioration with a sutureless aortic valve?

OBJECTIVE

To assess the mid-term clinical outcomes, hemodynamics, left ventricular (LV) mass regression, and structural valve deterioration (SVD) in patients implanted with the Perceval aortic sutureless valve across valve sizes.

METHODS

Data were obtained from a multicenter European trial and a US Investigational Device Exemption trial. Echocardiography data were analyzed by an echocardiography core lab. A mixed-effects regression model was used to assess relationships between hemodynamic outcomes, time from the procedure, and valve sizes. The Valve Academic Research Consortium (VARC)-3 definition for bioprosthetic valve failure was applied.

RESULTS

A Perceval sutureless valve was implanted in 970 patients. The median patient age was 77.8 years, 57.2% were female, the median Society of Thoracic Surgeons predicated risk of mortality was 3.3% (range, 2.1%-6.2%), and 33.4% had a concomitant procedure. The median clinical follow-up was 45.7 months (range, 28.2-76.1 months). Small and medium valves were implanted more commonly in women than in men (16.9% vs 1.9% for small and 55.1% vs 19.5% for medium; P < .001). The mean aortic valve gradients decreased significantly postimplantation and remained stable across all valve sizes throughout the follow-up period. All patients were free from severe patient-prosthesis mismatch (with an effective orifice area/m2 of >0.8). Significant LV mass regression was documented regardless valve sizes, plateaued at -9.1% at 5 years. Freedom from SVD and reintervention were 95.2% and 96.3%, respectively, at 5 years and were independent of implanted valve size (P = .22). The VARC-3 stage 3 bioprosthetic valve failure rate was low, 2.8% at 5 years.

CONCLUSIONS

The Perceval valve demonstrated low and stable mean gradients, significant LV mass regression, and low SVD and reintervention rates across all valve sizes.

Effect of nonsteroidal anti-inflammatory drugs on the inflammatory response of bovine endometrial epithelial cells in vitro

Chronic postpartum uterine infection detrimentally affects subsequent fertility. Nonsteroidal anti-inflammatory drugs (NSAID) are used to alleviate pain and treat inflammatory conditions in transition dairy cows with varying success. To screen the efficacy of NSAID in the absence of animal experiments, we have established an in vitro model to study uterine inflammation. Inflammation was induced in cultured bovine endometrial epithelial cells by challenging cells with an inflammation cocktail: lipopolysaccharide and proinflammatory cytokines, interleukin-1β (IL1β) and tumor necrosis factor α (TNFα). Release of the inflammation markers, serum amyloid A (SAA) and α-1-acid glycoprotein (αAGP), was measured by ELISA. Concentration of these markers was used to indicate the effectiveness in dampening inflammation of 5 NSAID: meloxicam, flunixin meglumine, aspirin, ketoprofen, and tolfenamic acid. Three NSAID, meloxicam, flunixin meglumine, and tolfenamic acid, were successful at dampening the release of SAA and αAGP into cell-culture supernatant, and the corresponding treated cells were selected for down-stream mRNA expression analysis. Expression of 192 genes involved in regulation of inflammatory pathways were investigated using Nanostring. Of the genes investigated, 81 were above the mRNA expression-analysis threshold criteria and were included in expression analysis. All SAA genes investigated (SAA2, SAA3, M-SAA3.2) were upregulated in response to the inflammation cocktail, relative to mRNA expression in control cells; however, AGP mRNA expression was below the expression analysis threshold and was, therefore, excluded from analysis. Treatment with NSAID downregulated genes involved in regulating chemokine signaling (e.g., CXCL2, CXCR4, CXCL5, and CXCL16) and genes that regulate the eicosanoid pathway (e.g., LTA4H, PTGS2, PLA2G4A, and PTGDS). Of the 5 NSAID investigated, meloxicam, flunixin meglumine, and tolfenamic acid are recommended for further investigation into treatment of postpartum uterine inflammation. The results from this study confirm the immunomodulatory properties of the endometrial epithelium in response to inflammatory stimuli and suggest that NSAID may be beneficial in alleviating uterine inflammation.

The first week following insemination is the period of major pregnancy failure in pasture-grazed dairy cows

A 60% pregnancy success for inseminations is targeted to optimize production efficiency for dairy cows within a seasonal, pasture-grazed system. Routine measures of pregnancy success are widely available but are limited, in practice, to a gestation stage beyond the first 28 d. Although some historical data exist on embryonic mortality before this stage, productivity of dairy systems and genetics of the cows have advanced significantly in recent decades. Accordingly, the aim was to construct an updated estimate of pregnancy success at key developmental stages during the first 70 d after insemination. Blood samples were collected for progesterone concentrations on d 0 and 7. A temporal series of 4 groups spanning fertilization through d 70 were conducted on 4 seasonal, pasture-grazed dairy farms (n = 1,467 cows) during the first 21 d of the seasonal breeding period. Morphological examination was undertaken on embryos collected on d 7 (group E7) and 15 (group E15), and pregnancy was diagnosed via ultrasonography on approximately d 28 and 35 (group E35) as well as d 70 (group E70). Fertilization, embryo, and fetal evaluation for viability established a pregnancy success pattern. Additionally, cow and on-farm risk factor variables associated with pregnancy success were evaluated. We estimated pregnancy success rates of 70.9%, 59.1%, 63.8%, 62.3%, and 56.7% at d 7, 15, 28, 35, and 70, respectively. Fertilization failure (15.8%) and embryonic arrest before the morula stage (10.3%) were the major developmental events contributing to first-week pregnancy failures. Embryo elongation failure of 7% contributed to pregnancy failure during the second week. The risk factors for pregnancy success that were related to the cows included interval between calving and insemination, and d-7 plasma progesterone concentrations, whereas insemination sire was associated with pregnancy outcome. Most pregnancy failure occurs during the first week among seasonal-calving pasture-grazed dairy cows.

Is Porcine Small Intestinal Submucosal Extracellular Matrix (ECM) a Suitable Material for Right Ventricular Outflow Tract Reconstruction in Association With Pulmonary Valve Replacement?

Pulmonary valve replacement (PVR) with right ventricular outflow tract (RVOT) reconstruction is a common congenital cardiac operation. Porcine submucosal intestinal-derived extracellular matrix (ECM) patches have been used for RVOT reconstruction. We present 2 adult patients with Tetralogy of Fallot who underwent PVR with RVOT reconstruction utilizing ECM. Both cases required reoperation due to patch dehiscence causing a large paravalvular leak. One patient also had a pseudoaneurysm associated with ECM dehiscence. There may be a propensity for ECM dehiscence in this application and, based on these cases, we recommend avoidance of ECM in RVOT reconstruction with PVR. PVR patients repaired with ECM should be monitored for this complication.

Aortic valve repair for isolated right coronary leaflet prolapse

Objectives

Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented.

Methods

Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets.

Results

Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients.

Conclusions

The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.

Implementation of telemedicine in the care of patients with aortic dissection

Telemedicine uses telephone-based or any form of digital communication for remote clinical services. It has been a field of interest for the last century, with broader implementation of telemedicine technologies during the last 25 years. The COVID-19 pandemic was an impetus for the adoption of these technologies globally across all health care services, including patient care, surgical practice, and workflow. As part of the patient engagement work in the Aortic Dissection Collaborative, this topic was identified as an important patient-centered research topic. Telemedicine has been adopted increasingly in vascular surgery; however, there is little evidence on appropriate use of these technologies pertaining to treating patients with aortic dissection or aortopathy in general. This landscape review summarizes the uses of telemedicine applications pre and post pandemic in medicine and vascular surgery, with a particular focus on uses in aortopathy. Using common resource databases, we identified articles related to the history of telemedicine, its current utilization, and application to vascular surgery and/or aortopathy. We briefly review the history of telemedicine and illustrate a range of applications in medicine before the pandemic, along with its rapid uptake globally during the COVID-19 pandemic. The enablers and barriers to using telemedicine are explored, although as a whole there is satisfaction with its integration among patients and providers. To address these, we offer recommendations to address future research as it pertains to telemedicine technologies in aortic dissection.

Temporal profiles describing markers of inflammation and metabolism during the transition period of pasture-based, seasonal-calving dairy cows

The physiology of the dairy cow while transitioning from pregnancy to lactation is complex, with multifactorial processes studied extensively for the role they play in manifestation of disease along with associated economic losses and compromised animal welfare. Manuscripts outlining associations among nutrition, production, physiology, and genetics variables and transition cow disorders are common in literature, with blood analytes that are central to energy metabolism (e.g., nonesterified fatty acids; NEFA, β-hydroxybutyrate; BHB) often reported. Immunity and inflammation have increasingly been explored in the pathogenesis and persistence of disorders, with cytokines and acute phase proteins well documented. However, most of these studies have involved cows fed total mixed rations, which may not always reflect profiles of blood analytes and other physiological indicators of transition cow health in grazing cows consuming fresh pasture. Considering the comparatively lesser characterization of these analytes and markers in pasture-based, seasonal-calving dairy cows, we compiled a database consisting of 2,610 cow lactations that span 20 yr of transition cow research in New Zealand. Using this database, analyte profiles from approximately 28 d precalving to 35 d postcalving were identified in dairy cows with a range of genetics, milk production potentials, and pasture-based farm management systems. These profiles characterize changes in energy reserves and metabolism (NEFA, BHB, glucose, insulin, growth hormone, insulin-like growth factor-1, leptin, body condition score, body weight), liver function (globulin, aspartate aminotransferase, glutamate dehydrogenase, gamma-glutamyl transpeptidase, bilirubin, cholesterol, liver triacylglycerides), protein metabolism (albumin, total protein, albumin:globulin ratio, creatinine, urea, creatine kinase), mineral balance (calcium, magnesium, phosphate, potassium, sodium, chloride, bicarbonate), inflammation (IL-1β, IL-6, haptoglobin, reactive oxygen species, total antioxidant capacity), and uterine health (polymorphonuclear cells, macrophage cells, vaginal discharge score). Temporal changes are generally consistent with previously characterized homeorhetic changes experienced by the dairy cow during the transition from pregnancy to lactation in both pastoral and housed systems. Some of the profiles had not previously been presented for pastoral systems, or in some cases, presented for either system. Our results indicate that moderate-yielding dairy cows undergo similar homeorhetic changes to high-yielding housed cows; however, differences in diet composition result in greater BHB concentrations than expected, based on their milk production and NEFA concentrations. In addition, most cows were able to transition to a state of higher energy requirement following calving, albeit with an increased metabolic challenge in the liver, and only a small percentage of cows were classified with severe hepatic lipidosis or severe hyperketonemia. Increases in metabolic function of the liver were accompanied by changes in indicators of the immune system and changes in mineral balance that, combined, probably reflect the innate response to the transition from gestation to lactation.

The microenvironment of ovarian follicles in fertile dairy cows is associated with high oocyte quality

We hypothesised that heifers and cows with positive genetic merit for fertility would have a follicular microenvironment that resulted in better quality oocytes. To test this, we compared cumulus cell-oocyte complexes (COC) and follicular fluid from preovulatory follicles of 36 Holstein-Friesian nulliparous heifers and 50 primiparous lactating cows with either positive (POS, +5%) or negative (NEG, -5%) fertility breeding values (FertBV). Established gene markers of oocyte quality were measured in individual cumulus cell masses and oocytes, and concentrations of amino acids, steroids, and metabolites were quantified in corresponding follicular fluid and plasma. The timing of visually detectable oestrus in NEG FertBV heifers was inconsistent with their stage of COC maturation. Retrospective analyses of oestrous activity data indicated that NEG FertBV heifers were sampled earlier. Their recovered COC were morphologically less mature and exhibited differential expression of genes that are associated with follicular maturation (lower levels of BMPR2) and protein processing (higher levels of HSP90B1). Despite consistent sampling times being achieved in the lactating cows, lower concentrations of serine, proline, methionine, isoleucine, and non-esterified fatty acids were present in follicular fluid from POS FertBV cows. This was associated with higher expression of gene biomarkers of good oocyte quality (VCAN, PDE8A) in COC recovered from POS FertBV cows. This study supports our hypothesis that the follicular microenvironment in lactating dairy cows with high genetic merit leads to COC with higher metabolic rates and oocytes of superior quality. Moreover, an additional stressor such as lactation is required for this difference to be pronounced.

Changes in plasma electrolytes, minerals, and hepatic markers of health across the transition period in dairy cows divergent in genetic merit for fertility traits and postpartum anovulatory intervals

Peripartum metabolism and subsequent reproductive performance of dairy cows are linked, with maladaptation over the transition period associated with poor reproductive success. A herd of seasonal calving, grazing dairy cows was established that differed in their genetic merit for fertility traits. The heifers were produced by a customized mating program to achieve a 10-percentage point divergence in the New Zealand fertility breeding value (FertBV) as follows: +5 FertBV (POS) versus -5% FertBV (NEG), while also limiting divergence in other breeding values, including body weight, body condition score, and milk production. In this study, we aimed to characterize differences in metabolic, mineral, and metabolic stress marker profiles during their first postpartum transition period as primiparous heifers and to examine if animals with longer postpartum anestrous intervals (PPAI; more than 66 d compared with less than 35 d) had greater metabolic dysfunction. Blood was sampled at -21, -14, -7, 0, 4, 7, 10, 14, 17, 21, 28, and 35 d relative to calving in 455 primiparous cows and plasma analyzed. The NEG cows had lower concentrations of both plasma nonesterified fatty acids and β-hydroxybutyrate at d 7 compared with POS cows. Detailed temporal profiling of various metabolic, mineral, and metabolic stress markers was undertaken in a subset of cows (n = 70). Cows were selected retrospectively to create 4 groups in a 2 × 2 factorial design with either a POS or NEG FertBV and either a short (19-35 d) or long (66-131 d) PPAI. The NEG cows tended, on average, to have lower nonesterified fatty acids and β-hydroxybutyrate concentrations compared with POS cows across the transition period. Mean body weight and body condition score was greatest in NEG cows when compared with the POS cows and an interaction with day demonstrated this only occurred precalving. They also had indications of improved liver health precalving, with higher albumin-to-globulin ratios and lower bilirubin concentrations. Concentrations of aspartate aminotransferase were lower, and the Na-to-Cl ratio was greater in cows with a long versus a short PPAI at d 28 and d 35 after calving, potentially because of cows with a short PPAI (19-35 d) returning to estrous during this time. Magnesium concentrations were lower in NEG cows with a short PPAI from d 21 onwards, indicating NEG cows may metabolically respond to estrous differently than POS cows. The NEG-long PPAI cows had greater gamma-glutamyl transferase concentrations from calving until d 28 and lower bilirubin concentrations throughout the transition period. Together, the results demonstrate significant effects of FertBV on peripartum metabolic status. However, most of the markers tested returned to reference intervals within 4 d after calving or remained within those intervals for the whole transition period, indicating relatively minor biological effects of FertBV on transition period adaptation. The profound differences in reproductive performance among the groups was not explained by underlying differences in metabolic responses during the transition period.

Estrous activity in lactating cows with divergent genetic merit for fertility traits

This observational study aimed to determine the effect of genetic merit for fertility traits on estrous expression and estrous cycle duration in grazing dairy cows, as measured by an activity monitoring device. A secondary aim was to describe changes in expression of estrus that occur during successive estrous cycles postpartum. Neck-mounted, activity-monitoring devices (Heatime, SCR Engineers Ltd.) were fitted to nulliparous Holstein-Friesian heifers with positive (POS FertBV) or negative genetic merit for fertility traits (NEG FertBV) to capture activity data during their first and second lactations (POS FertBV: n = 242, n = 188; NEG FertBV: n = 159, n = 87 in lactation 1 and 2, respectively). An estrous event was identified when the activity change index exceeded 26 activity units (AU) for 4 h. A total of 1,254 and 892 estrous events were identified in lactation 1 and 2, respectively. Estrous duration was defined as the interval between when the threshold was first exceeded and when activity dropped below the threshold, with no new event starting within 24 h of the end of the previous event. This definition of estrus included cows in which activity crossed the threshold multiple times in a day and were classified as a single estrous event. A second measure, high activity duration, was defined as the total hours that activity exceeded the threshold. To characterize estrous activity, peak activity (above baseline) and total activity (area under the curve of activity above baseline) were measured. Compared with NEG FertBV cows, POS FertBV cows had more active, longer estrous events. In lactation 1, the POS FertBV group had a mean estrous duration and a high activity duration of 12.5 and 12.4 h compared with 11.4 and 11.3 h for the NEG FertBV group [standard error of the difference (SED) = 0.5 and 0.4 h, respectively]. This significant difference also occurred in lactation 2, with a mean estrous duration of 13.1 versus 11.8 h (SED = 0.5 h) and a high activity duration of 13.0 versus 11.8 h (SED = 0.4 h) in the POS and NEG FertBV groups, respectively. Total activity and peak activity were greater in the POS compared with the NEG FertBV group in lactation 1 (peak activity: 65.5 vs. 55.8 AU, SED = 2.4 AU; total activity: 588 vs. 494 AU, SED = 25 AU) and lactation 2 (peak activity: 72.5 vs. 61.2 AU, SED = 2.9 AU; total activity: 648 vs. 541 AU, SED = 30 AU). Estrous cycle duration did not differ between the POS and NEG FertBV groups (lactation 1: 20.4 vs. 20.6 d, SED = 0.25; lactation 2: 20.8 vs. 21.0 d, SED = 0.28). Less estrous activity of the cow was associated with the first postpartum estrus. In contrast, the number of previous estrous events did not consistently affect the duration of the subsequent estrous cycle. The outcomes of this study provide evidence that positive genetic merit for fertility traits is associated with more overt estrous expression. Selection for these traits may improve estrous expression and thus estrous detection in commercial herds.

Investigating anogenital distance and antral follicle count as novel markers of fertility within a herd of cows with positive or negative genetic merit for fertility traits

Using early-in-life markers of reproductive characteristics may enhance the speed and success of genetic improvement in fertility. We investigated 2 phenotypes that can be measured early in life and are moderately heritable to determine their association with traditional measures of reproductive success and genetic variation under a seasonal-calving, pasture-based system. Cows were bred to be divergent in the New Zealand Fertility Breeding Value, which estimates genetic merit for fertility. Cows consisted of 2 groups with an average positive (+5%) or negative (-5%) genetic merit for fertility traits and were expected to have large diversity in reproductive outcomes. Calves were genotyped at 41 ± 3.1 d of age (mean ± SD; n = 538), and antral follicle counts (AFC) were measured when they were postpubertal heifers before their first breeding (416 ± 15 d old; 92-d range; n = 520). The anogenital distance (AGD) was measured in 478 primiparous cows of this same population 50 to 60 d after the breeding start date when they were 881 ± 25 d old (145-d range). The AGD was shorter in animals with a positive genetic merit for fertility traits (based on parent averages). An indicator of herd reproductive success in a seasonal-calving system (recalving by 6 wk in lactation 2) was chosen for logistic regression with cross-validation, and if significant, a cut-off was calculated that categorized animals into groups. Both linear and quadratic regression was undertaken, and the model with the greatest sensitivity for detection of nonpregnant cows used. The AGD linear model was significant with a sensitivity of 64% and a specificity of 48%. This model resulted in a cut-off of 102 mm, which we used to classify cows as short (≤102 mm) or long (>102 mm) AGD animals. Primiparous cows with a short AGD were more likely to be pregnant within the first 3 and 6 wk of mating, and become pregnant as a primiparous cow, than those with a long AGD. The time from calving to conception was 20 d earlier in short AGD compared with long-AGD cows. None of the models tested for AFC were significant; therefore cows were categorized into 3 groups based on previous work in seasonal systems. However, associations between fertility phenotypes and AFC group were limited. Genomic regions of interest for AGD and AFC did not overlap, indicating phenotypes were genetically independent. Overall, AGD appears as a promising early marker of fertility in seasonal grazing systems.

Traumatic Suprahepatic inferior vena cava injury survival of a rare case

Traumatic supra-hepatic inferior vena cava (IVC) injury is rare and nearly universally fatal. We report an excellent outcome from a case involving severe injury of the suprahepatic and intra-pericardial IVC utilizing emergency cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest.

The goal of this case report is to outline key factors that facilitated the patient's survival of extensive IVC injury. We conclude that aggressive prehospital fluid resuscitation, facile transfer to the operating room, early detection of anatomy and pathology of the injury, an early decision to call for perfusion and cardiothoracic surgery, and prompt blood transfusion were the key factors that allowed for the patient to survive without deficits.

Development of an intrauterine infection model in the postpartum dairy cow

AIMS

To develop an intrauterine infection model for Trueperella pyogenes in postpartum dairy cows and to assess the effect of this infection on the degree of intrauterine inflammation and concentrations of progesterone in serum.

METHODS

The oestrous cycles of 36 healthy, non-pregnant, postpartum dairy cows were synchronised. They were then treated by intrauterine infusion of 0.5 g cephapirin before being blocked by age and randomly assigned to treatment with intrauterine infusion of saline (n = 18), 10⁷ (n = 9) or 10⁹ (n = 9) cfu of T. pyogenes, approximately 4 days after the expected time of ovulation (Day 0). Prior to intrauterine infusion on Day 0 and again on Days 3, 7, 10, and 15, cytobrush samples were collected from the uterus of each cow for microbiology and assessment of the percentage of polymorphonuclear neutrophils (PMN%). Blood samples were collected on the same days for measurement of concentrations of progesterone in serum, and uterine lumen diameter was assessed daily using transrectal ultrasonography.

RESULTS

Trueperella pyogenes was isolated from 5/18 (28%), 7/9 (78%) and 8/9 (89%) cows infused with saline, 10⁷ or 10⁹ cfu of T. pyogenes, respectively (p < 0.001). Mean PMN% in the control cows did not change over time (p > 0.05), whereas it was higher on Days 7 and 10 than Day 0 in the 10⁷ cfu group, and higher on Days 3 and 10 than Day 0 in the 10⁹ cfu group (p < 0.05). The percentage of observations with uterine lumen diameters >2 mm was higher in cows infused with 10⁷ (29.3 (95% CI = 14.5-44.2)%) or 10⁹ cfu (19.2 (95% CI = 7.0-31.5)%) than in control cows (3.1 (95% CI = 0.1-6.0)%) (p < 0.001). Mean concentrations of progesterone in serum were higher in cows infused with 10⁷ cfu (2.01 (SE 0.19) ng/mL) than cows infused with 10⁹ cfu (1.01 (SE 0.27) ng/mL), with the control group intermediate (1.41 (SE 0.19) ng/mL) (p = 0.03).

CONCLUSIONS

Infusion of 10⁷ or 10⁹ cfu of T. pyogenes resulted in the establishment of intrauterine infection in 83% of cows. Infection resulted in increased uterine lumen diameter, and an inflammatory response, i.e. elevated PMN%.

CLINICAL RELEVANCE

This intrauterine infection model may be useful for future research on, for example, the pathogenesis of intrauterine infection in postpartum dairy cows.

Aortic arch stenting: current strategies, new technologies and future directions

Operating on the aortic arch is a formidable challenge. Open operations remain the gold standard, but despite improvement in technique and outcomes, they are still associated with significant morbidity and mortality. The last 20 years have seen a remarkable reduction in the operative morbidity associated with treatment of the descending thoracic aorta using thoracic endovascular aneurysm repair (TEVAR). To improve outcomes following arch repair, new TEVAR devices, including both single-branched and multibranched designs, have come to clinical trial. This review discusses the modern state of open and hybrid repairs while introducing the reader to technology for endovascular therapy of the aortic arch. We describe important anatomical and operative considerations for the devices. Given these nuances, we believe the future of the aortic arch to be patient-individualised hybrid repairs, involving both open and endovascular options with a multidisciplinary 'thoracic aorta team' at the helm.

Positive genetic merit for fertility traits is associated with superior reproductive performance in pasture-based dairy cows with seasonal calving

New Zealand's Fertility Breeding Value (FertBV) is reported as the percentage of a sire's daughters that calve in the first 42 d of the seasonal calving period and is an estimate of genetic merit for fertility for dairy cattle. Reproductive physiology, milk production, and changes in body weight and body condition score of 2 groups of cows divergent in FertBV (+5.0%: POS; -5.1%: NEG) were characterized during their first 2 lactations. Cows grazed fresh pasture and were managed in a seasonal calving system; they were bred by artificial insemination on observed estrus for the entire breeding period (98 d in lactation 1 and 76 d in lactation 2). During lactation 1, all animals were primiparous and were randomly allocated to 1 of 2 herds, ensuring each herd was balanced for FertBV and expected calving date. During lactation 2, cows that became pregnant during lactation 1 were managed as 1 herd. Cows not inseminated in the first 42 d of the breeding season were examined for the presence of a corpus luteum and treated with an anestrus program. On average, the interval from calving to ovulation was 19 d longer in lactation 1 and 10 d longer in lactation 2 for NEG FertBV cows. The percent of cows submitted for artificial insemination after 21 d (i.e., submission rate) was 38 and 25 percentage points greater in the POS FertBV cows during lactations 1 and 2, respectively. Pregnancy rate from 42 d of breeding was 33 and 30 percentage points greater, respectively. There was no effect of FertBV on vaginal discharge score postcalving; however, POS FertBV cows had a 50% lower risk of having subclinical endometritis (polymorphonuclear leukocytes >7%) 42 d postcalving. Interactions between FertBV and month relative to calving identified that NEG FertBV cows were fatter (greater body condition score) in the month before calving, but thinner between 3 and 5 mo postcalving. There was no effect of FertBV on lactation length, estimated 270-d milk yields, or daily milk, fat, or protein yields, and only small effects on milk fat and protein percentage across the lactations. In summary, the POS FertBV cows had superior uterine health, a shorter calving to ovulation interval, a greater submission rate, and a greater pregnancy rate earlier in the breeding season when compared with the NEG FertBV cohort. Based on these results, these may be useful phenotypes to include in genetic selection indices.

Outcomes of Adults with Congenital Heart Disease Supported with Extracorporeal Life Support After Cardiac Surgery

Patients with adult congenital heart disease (ACHD) who undergo cardiac surgery may require extracorporeal life support (ECLS) for cardiopulmonary support, but outcomes after ECLS support have not been well described. This study aimed to identify risk factors for ECLS mortality in this population. We identified 368 ACHD patients who received ECLS after cardiac surgery between 1994 and 2016 in the Extracorporeal Life Support Organization (ELSO) database, a multicenter international registry of ECLS centers. Risk factors for mortality were assessed using multivariate logistic regression. Overall mortality was 61%. In a multivariate model using precannulation characteristics, Fontan physiology (odds ratio [OR]: 5.7; 95% CI: 1.6-20.0), weight over 100 kg (OR: 2.6; 95% CI: 1.3-5.4), female gender (OR: 1.6; 95% CI: 1.001-2.6), delayed ECLS cannulation (OR: 2.0; 95% CI: 1.2-3.2), and neuromuscular blockade (OR: 1.9; 95% CI: 1.1-3.3) were associated with increased mortality. Adding postcannulation characteristics to the model, renal complications (OR: 3.0; 95% CI: 1.7-5.2), neurologic complications (OR, 4.7; 95% CI: 1.5-15.2), and pulmonary hemorrhage (OR: 6.4; 95% CI: 1.3-33.2) were associated with increased mortality, whereas Fontan physiology was no longer associated, suggesting the association of Fontan physiology with mortality may be mediated by complications. Fontan physiology was also a risk factor for neurologic complications (OR: 8.2; 95% CI: 3.3-20.9). Given the rapid increase in ECLS use, understanding risk factors for ACHD patients receiving ECLS after cardiac surgery will aid clinicians in decision-making and preoperative planning.

Heifers with positive genetic merit for fertility traits reach puberty earlier and have a greater pregnancy rate than heifers with negative genetic merit for fertility traits

This study investigated the hypothesis that dairy heifers divergent in genetic merit for fertility traits differ in the age of puberty and reproductive performance. New Zealand's fertility breeding value (FertBV) is the proportion of a sire's daughters expected to calve in the first 42 d of the seasonal calving period. We used the New Zealand national dairy database to identify and select Holstein-Friesian dams with either positive (POS, +5 FertBV, n = 1,334) or negative FertBV (NEG, -5% FertBV, n = 1,662) for insemination with semen from POS or NEG FertBV sires, respectively. The resulting POS and NEG heifers were predicted to have a difference in average FertBV of 10 percentage points. We enrolled 640 heifer calves (POS, n = 324; NEG, n = 316) at 9 d ± 5.4 d (± standard deviation; SD) for the POS calves and 8 d ± 4.4 d old for the NEG calves. Of these, 275 POS and 248 NEG heifers were DNA parent verified and retained for further study. The average FertBV was +5.0% (SD = 0.74) and -5.1% (SD = 1.36) for POS and NEG groups, respectively. Heifers were reared at 2 successive facilities as follows: (1) calf rearing (enrollment to ∼13 wk of age) and (2) grazier, after 13 wk until 22 mo of age. All heifers wore a collar with an activity sensor to monitor estrus events starting at 8 mo of age, and we collected weekly blood samples when individual heifers reached 190 kg of body weight (BW) to measure plasma progesterone concentrations. Puberty was characterized by plasma progesterone concentrations >1 ng/mL in at least 2 of 3 successive weeks. Date of puberty was defined when the first of these samples was >1 ng/mL. Heifers were seasonally bred for 98 d starting at ∼14 mo of age. Transrectal ultrasound was used to confirm pregnancy and combined with activity data to estimate breeding and pregnancy dates. We measured BW every 2 wk, and body condition and stature at 6, 9, 12, and 15 mo of age. The significant FertBV by day interaction for BW was such that the NEG heifers had increasingly greater BW with age. This difference was mirrored with the significant FertBV by month interaction for average daily gain, with the NEG heifers having a greater average daily gain between 9 and 18 mo of age. There was no difference in heifer stature between the POS and NEG heifers. The POS heifers were younger and lighter at puberty, and were at a lesser mature BW, compared with the NEG heifers. As a result, 94 ± 1.6% of the POS and 82 ± 3.2% of the NEG heifers had reached puberty at the start of breeding. The POS heifers were 20% and 11% more likely to be pregnant after 21 d and 42 d of breeding than NEG heifers (relative risk = 1.20, 95% confidence interval of 1.03-1.34; relative risk = 1.11, 95% confidence interval of 1.01-1.16). Results from this experiment support an association between extremes in genetic merit for fertility base on cow traits and heifer reproduction. Our results indicate that heifer puberty and pregnancy rates are affected by genetic merit for fertility traits, and these may be useful phenotypes for genetic selection.

The use of extracorporeal membrane oxygenation in human immunodeficiency virus-positive patients: a review of a multicenter database

AIM

We chose to evaluate the survival of extracorporeal membrane oxygenation among patients with human immunodeficiency virus in a multicenter registry.

METHODS

Retrospective case review of the Extracorporeal Life Support Organization Registry respiratory failure of all patients with human immunodeficiency virus supported with extracorporeal membrane oxygenation.

RESULTS

A total of 126 patients were included. Survival to discharge was 36%. Eight infants were supported with extracorporeal membrane oxygenation and three (37.5%) survived to discharge. Respiratory extracorporeal membrane oxygenation was the primary indication (78%) with a 39% survival, while cardiac and extracorporeal cardiopulmonary resuscitation indications accounted for 16% and 6% of patients with survivals of 30% and 12.5%, respectively. These differences did not reach significance. There were no significant differences between survivors and non-survivors in demographic data, but non-survivors had significantly more non-human immunodeficiency virus pre-extracorporeal membrane oxygenation infections than survivors. There were no differences in other pre-extracorporeal membrane oxygenation supportive therapies, mechanical ventilator settings, or arterial blood gas results between survivors and non-survivors. The median duration of mechanical ventilation prior to cannulation was 52 (interquartile range: 13-140) hours, while the median duration of the extracorporeal membrane oxygenation exposure was 237 (interquartile range: 125-622) hours. Ventilator settings were significantly lower after 24 hours compared to pre-extracorporeal membrane oxygenation settings. Complications during extracorporeal membrane oxygenation exposure including receipt of renal replacement therapy, inotropic infusions, and cardiopulmonary resuscitation were more common among non-survivors compared to survivors. Central nervous system complications were rare.

CONCLUSION

Survival among patients with human immunodeficiency virus infection who receive extracorporeal membrane oxygenation was less than 40%. Infections before extracorporeal membrane oxygenation cannulation occurred more often in non-survivors. The receipt of renal replacement therapy, inotropic infusions, or cardiopulmonary resuscitation during extracorporeal membrane oxygenation was associated with worse outcome.

Applicability of the Zenith Inner Branched Arch Endograft

Purpose: To evaluate the clinical and anatomical features of patients with arch pathology to better understand the applicability of the Zenith inner branched arch endograft (IBAE). Materials and Methods: A retrospective review was performed of 60 consecutive patients (mean age 62.5 years; 42 men) who presented with nonruptured aortic arch pathology at a single institution between 2009 and 2016. Patients were stratified into standard (no previous cardiac surgery, <80 years old, and no significant medical comorbidity), high (previous cardiac surgery or significant comorbidity), or prohibitive risk (turned down for operative intervention) for operative intervention. Anatomical measurements of the aorta were obtained on computed tomography scans; anatomical suitability was based on the device's instructions for use. Results: Overall, 27 (45%) patients had anatomy amenable to treatment with the existing IBAE. Inadequate proximal seal length and large ascending aortic diameters were the primary reasons for anatomical unsuitability. Shortening the inner curve seal zone from 25 to 15 mm and increasing the proximal seal zone diameter from 38 to 42 mm increased anatomical suitability to include 49 (82%) patients. Of these, 31 were in the high-risk cohort and 7 were deemed prohibitive risk; therefore, IBAE would have been strongly considered in these 38 patients. Conclusion: Based on anatomical criteria alone, nearly half of patients with aortic arch pathology have anatomy suitable to the Zenith IBAE in its current design. Arch branch vessel anatomy was not a limitation of the device. From a clinical standpoint, if endovascular repair were reserved for those at high or prohibitive risk for open repair, approximately 30% of patients would likely benefit from the IBAE in its current form.

Prevalence of endometritis diagnosed by vaginal discharge scoring or uterine cytology in dairy cows and herds

Endometritis, diagnosed either by assessing the proportion of nucleated cells that are neutrophils (PMN%) following cytology of the endometrium or by assessing the degree of purulent material within the vagina (purulent vaginal discharge or PVD score), is prevalent among dairy cows. However, limited data exist as to the degree of variation among herds in the prevalence of endometritis diagnosed by these 2 methods. Thus, we undertook a study involving uterine cytological and vaginal sampling at a median of 41 d in milk of 1,807 cows from 100 seasonally breeding dairy herds in New Zealand. The optimal cut-point for PMN% was determined by receiver operator characteristic (ROC) curve analysis using conception to first artificial insemination (AI) as the outcome variable. The prevalence of disease was then calculated at the cow and herd levels, and an estimate of the effect of clustering of cow within a herd was calculated. Reproductive outcomes were collated and associations between endometritis and reproductive outcomes assessed using multivariable models. The optimal PMN% cut-point was ≥2%. The correlation of results for cows within a herd (the intraclass correlation) was 0.03, which was significant; hence, subsequent modeling accounted for this clustering. The cow-level prevalence of PMN% ≥2% was 27.0% [95% confidence interval (CI): 25.0 to 29.1%], whereas the mean within-herd prevalence of PMN% ≥2% was 27.1% (95% CI: 24.7 to 29.6%; range: 5.0 to 63.6%), and the prevalence among herds varied significantly. An elevated PMN% (≥2%) was significantly associated with a reduction in the proportion of cows conceiving to first AI (45.8 vs. 54.5%), a reduced proportion of cows submitted for AI in the first 3 wk of the seasonal breeding program (83.7 vs. 89.3%), and a lower proportion pregnant in the first 3 (44.4 vs. 55.4%) and 6 wk (67.5 vs. 76.4%) of the breeding program relative to cows with a low PMN% (i.e., <2%). A total of 24.6% of cows had a PVD score ≥2. The herd mean prevalence of PVD score ≥2 was 25.1% (95% CI: 22.5 to 27.7%; range: 5.0 to 65.0%) and varied significantly among herds. The level of agreement (kappa) between the PVD score and PMN% was low (16.8%) and nonsignificant. The effects of PVD score and PMN% on reproductive outcomes were independent. The within-herd median prevalence of endometritis based on combining both diagnostic tests and using a Bayesian latent class model was 22.9% (Bayesian 95% CI: 10.4 to 40.1%). We conclude that more than one-fifth of dairy cows have endometritis diagnosed either by PMN% or PVD in seasonal breeding herds when assessed at an average of 41 DIM, which was, on average, 30 d before the start of the seasonal breeding program. There is large and unexplained variation in prevalence of endometritis among herds. The 2 diagnostic methods were both associated with reproductive outcomes but have low levels of agreement between them and their effects appear to be independent.

Feeding synthetic zeolite to transition dairy cows alters neutrophil gene expression

Synthetic zeolites are used to control the availability of dietary minerals (e.g., Ca, Mg, and P) in dairy cows. Due to calcium demand increasing with lactation onset, most cows become hypocalcemic immediately postpartum, which likely contributes to poorer immune function because calcium is important for immune cell signaling. To overcome postpartum hypocalcemia, we fed transition cows synthetic zeolite A (sodium aluminosilicate) precalving and hypothesized that it would alter calcium and thus neutrophil function during the transition period. Multiparous Holstein-Friesian cows in late gestation were randomly allocated to an untreated control group (n = 10) or a treatment group in which each cow received 500 g of zeolite A daily (n = 10) for 14 d prior to the expected calving date (actual duration = 17 ± 3 d prepartum). The cows grazed pasture, and each was supplemented with 2 kg/d of maize silage (dry matter basis), with or without zeolite, until calving. Blood samples for neutrophil isolation and analysis of plasma indicators of mineral status, energy status, liver function, and inflammation were collected pretreatment (covariate; d -19); on d -14 and -7 precalving; on the day of calving (d 0); and on d 1, 4, 7, and 28 postcalving. Neutrophils were isolated and gene expression was analyzed using microfluidic gene expression arrays. Neutrophil respiratory burst was assessed using stimulation with phorbol 12-myristate 13-acetate and flow cytometry. Plasma calcium and phosphorus revealed a treatment by time interaction; cows offered zeolite had greater plasma calcium concentrations at d 0, 1, and 4 postcalving and plasma phosphorus concentrations were lower in zeolite-treated cows during the precalving period until d 1 postcalving compared with control animals. Zeolite treatment downregulated neutrophil gene expression of CXCR4 and S100A8 and tended to lower gene expression for other immune mediators (CXCR1, IFNG, S100A12, and S100A9) compared with the control. Zeolite treatment did not affect neutrophil respiratory burst or expression of the other genes investigated. Plasma concentrations of cytokine IL-6 were reduced with zeolite treatment, which was most evident immediately postcalving (d 0, 1, and 7). Overall, feeding zeolite precalving had few effects on neutrophil gene expression and function; however, the lower gene expression of neutrophil inflammatory mediators may be due to altered availability of dietary minerals prepartum and indicates that zeolite A may control inflammation during the transition period.

The Role of Thoracic Endovascular Repair in Chronic Type B Aortic Dissection

Continued device improvements along with refined implantation techniques have revolutionize the use of thoracic endovascular repair for both aortic dissections and aneurysms. This is now considered standard of care for acute, complicated type B aortic dissection in patients with appropriate anatomy. However, the treatment of chronic, uncomplicated type B dissection continues to present challenges for the aortic surgeon, as the long-held dogma of medical management and surveillance for aneurysm degeneration has recently come into questions. We present evidence for a more thoughtful approach to management and intervention with thoracic endovascular repair in select patients with chronic, type B dissection.

Venovenous extracorporeal life support in patients with HIV infection and Pneumocystis jirovecii pneumonia

AIM

As experience with extracorporeal life support (ECLS) increases, indications for its use have expanded to diverse patient populations, including those with HIV infection. Pneumocystis jirovecii pneumonia (PJP) is a particularly devastating complication of HIV infections. The objective of this study was to review ECLS use in HIV-positive patients, with particular emphasis on those with concomitant PJP infection.

METHODS

All patients were treated by the same ECLS team, consisting of an ECLS specialist intensivist, cardiothoracic surgeon and allied medical professionals at three healthcare institutions. The same ECLS protocol was utilized for all patients during the study period. A retrospective review was performed for all HIV-positive patients placed on ECLS from May 2011 to October 2014. Demographic, clinical, ECLS and complication data were reviewed to identify risk factors for death.

RESULTS

A total of 22 HIV-positive patients received ECLS therapy during the study period. All patients were supported with venovenous ECLS and overall survival to hospital discharge was 68%. Survival amongst the PJP positive cohort was 60%. Non-survivors were more likely to require inotropic medications on ECLS (100% non-survivors vs. 46.7% survivors, p=0.022) and had a longer total duration of ECLS (13 days non-survivors vs. 7 days survivors, p=0.011). No difference was observed between PJP-positive and PJP-negative patients with regard to demographic data, complication rates or survival.

CONCLUSION

ECLS is a viable treatment option in carefully selected HIV-positive patients, including those with severe disease as manifested by PJP infection.

Characterization of exosomes from body fluids of dairy cows

Exosomes are a specific subpopulation of extracellular vesicles that are widely released by cells of different origins with divergent functions that make their way into body fluids that can be conveniently sampled. In the current study, we isolated and evaluated exosomes from concurrently collected samples of milk, plasma, saliva, and urine from a group of 6 pregnant Holstein-Friesian dairy cows (aged 7 mo, 174 to 203 d of gestation). The cows had BCS of 3.5 to 5.25 (on a scale of 1 to 10), and the milk production for the season to the time of sampling ranged between 5,118 and 6,959 kg. The low levels of extracellular vesicles in saliva and urine (more than 86% fewer compared to the extracellular vesicles in milk and plasma) precluded further detailed evaluation since utility for diagnostics was deemed unlikely. In exosomes isolated from milk and plasma, size distribution, morphology, and the presence of exosome markers was confirmed by nanoparticle tracking analysis, electron microscopy, and Western blot. In addition, a targeted proteomic approach using the quadrupole ion trap mass spectrometer was also used in the study to screen for the exosome marker (e.g., Tumor susceptibility gene 101). Following confirmation of the presence of exosomes, the proteomic profiles of milk and plasma exosomes were evaluated using information-dependent acquisition-mediated liquid chromatography-tandem mass spectrometry (LC-MS/MS). The milk exosomes contain proteins that differed greatly from the plasma exosomes, with only 8 similar proteins harbored in both the milk and plasma exosomes. The milk and plasma exosomes were found to contain proteins (e.g., immunoglobulin J chain and α2 macroglobulin) associated with specific biological processes and molecular functions. Hence, the fluid of origin required for exosome analysis will be dependent on the specific information needed. In conclusion, isolated exosomes from milk and plasma samples collected at the same time point from the same dairy cows encapsulated different profiles of proteins associated with different biological processes and molecular functions.

Early Cardiac Catheterization Leads to Shortened Pediatric Extracorporeal Membrane Oxygenation Run Duration

OBJECTIVE

Cardiac catheterization in patients receiving extracorporeal life support (ECLS) has previously been shown to be safe and, in many cases, therapeutic. However, the influence of cardiac catheterization on clinical outcomes in this patient population has not been clearly defined.

METHODS

A single institution, retrospective review of all pediatric cardiac ECLS patients who underwent cardiac catheterization between January 2006 and September 2015 was performed.

RESULTS

Eighty-two interventional cardiac catheterization procedures were performed on 74 patients. Catheterization findings directly led to catheterization-based or surgical intervention in 54 (73%) patients. One (1.2%) catheterization-related complication occurred (pulmonary artery rupture), which ultimately resulted in death. Patients who underwent early catheterization (≤72 hours of ECLS initiation) required shorter total duration of ECLS than patients who underwent catheterization >72 hours after ECLS initiation (136 hours vs. 227 hours, P < 0.01). The groups experienced similar rates of interventions based on catheterization findings (72% early cath vs. 74% late cath, P = 0.81). Survival to hospital discharge was higher in the early catheterization group (74% vs. 51%, P = 0.04). In multivariate models adjusting for covariates, early catheterization was associated with a reduction in ECLS duration by approximately 150 hours (P < 0.01).

CONCLUSIONS

Cardiac catheterization is safe in pediatric ECLS patients and an earlier catheterization is associated with shorter duration of ECLS and improved hospital survival. Diagnostic cardiac catheterization should be considered in patients who remain dependent on ECLS after several days of support.

Pediatric extracorporeal cardiopulmonary resuscitation during nights and weekends

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) is a lifesaving rescue therapy for patients with refractory cardiac arrest. Previous studies suggest that maintaining a 24/7 in-house surgical team may reduce ECPR initiation time and improve survival in adult patients. However, an association between cardiac arrest occurring during off-hours and ECPR outcome has not been established in children.

METHODS

This is a single institution, retrospective review of all pediatric patients who received ECPR from December 2008 to August 2015.

RESULTS

During the study period, ECPR was performed 54 times in 53 patients (20 weekday, 34 night/weekend). Interval from ECPR activation to initiation of extracorporeal life support was significantly longer during night/weekends (49min night/weekend vs. 33min weekday, p<0.001) as was the interval from ECPR activation to incision for cannulation (26min night/weekend vs. 14min Weekday, p<0.001). Rate of central nervous system (CNS) injury was higher in the night/weekend group (43% night/weekend vs. 15% weekday, p=0.04), with associated 75% mortality prior to hospital discharge. Time of arrest did not impact survival to hospital discharge (44% night/weekend vs. 55% weekday, p=0.57), one-year survival (33% night/weekend vs. 44% weekday, p=0.44), or neurologic outcome (Pediatric Cerebral Performance Score at 1-year post-ECPR, 1.45 weekday vs. 1.50 night/weekend, p=0.82).

CONCLUSIONS

Cardiac arrest occurring at night or during weekend hours is associated with a longer ECPR initiation time and higher rates of CNS injury. However, prolonged pre-ECPR support associated with off-hours cardiac arrest does not appear to impact survival or functional outcome in pediatric patients.

Fertility and the transition dairy cow

The transition from pregnancy to lactation (i.e. the transition period) is a time of significant metabolic challenge, with a several-fold increase in a cow's requirement for energy, protein and minerals within days of calving. A successful transition involves the initiation and coordination of changes in multiple tissues that facilitate the provision of these nutrients to the cow and, more specifically, to the mammary gland, often at the considerable expense of other tissues. Failure to coordinate the necessary changes effectively results in transition period maladaptation, which can broadly be grouped into three categories: (1) negative energy balance and metabolic diseases associated with energy metabolism; (2) immune dysfunction and inflammation; and (3) metabolic diseases associated with mineral deficiency. Because reinitiation of ovarian activity, follicle recruitment, ovulation, fertilisation and, potentially, even maternal recognition of pregnancy and implantation occur against the backdrop of this metabolic and immunological disturbance in early lactation, the role of nutrition in ensuring a smooth transition between the pregnant and lactating state is important. In this paper we integrate recent research findings with previous knowledge of the interaction between transition cow metabolism and nutrition and reproductive outcomes, and offer new insights into key elements of successful cow management to avoid transition 'maladaptation' and improve pregnancy rates.

Prepartum body condition score and plane of nutrition affect the hepatic transcriptome during the transition period in grazing dairy cows

Background

A transcriptomic approach was used to evaluate potential interactions between prepartum body condition score (BCS) and feeding management in the weeks before calving on hepatic metabolism during the periparturient period.

Methods

Thirty-two mid-lactation grazing dairy cows of mixed age and breed were randomly allocated to one of four treatment groups in a 2 × 2 factorial arrangement: two prepartum BCS categories [4.0 (thin, BCS4) and 5.0 (optimal, BCS5); based on a 10-point scale], and two levels of energy intake during the 3 weeks preceding calving (75 and 125 % of estimated requirements). Liver samples were obtained at −7, 7, and 28 d relative to parturition and subsequent RNA was hybridized to the Agilent 44 K Bovine (V2) Microarray chip. The Dynamic Impact Approach was used for pathway analysis, and Ingenuity Pathway Analysis was used for gene network analysis.

Results

The greater number of differentially expressed genes in BCS4 cows in response to prepartum feed allowance (1071 vs 310, over the entire transition period) indicates that these animals were more responsive to prepartum nutrition management than optimally-conditioned cows. However, independent of prepartum BCS, pathway analysis revealed that prepartal feeding level had a marked effect on carbohydrate, amino acid, lipid, and glycan metabolism. Altered carbohydrate and amino acid metabolism suggest a greater and more prolonged negative energy balance postpartum in BCS5 cows overfed prepartum. This is supported by opposite effects of prepartum feeding in BCS4 compared with BCS5 cows in pathways encompassing amino acid, vitamin, and co-factor metabolism. The prepartum feed restriction ameliorates the metabolic adaptation to the onset of lactation in BCS5 cows, while detrimentally affecting BCS4 cows, which seem to better adapt when overfed. Alterations in the glycosaminoglycans synthesis pathway support this idea, indicating better hepatic health status in feed-restricted BCS5 and overfed BCS4 cows. Furthermore, IPA network analysis suggests liver damage in feed-restricted thin cows, likely due to metabolic overload.

Conclusion

Overall, the data support the hypothesis that overfeeding in late-pregnancy should be limited to underconditioned cows, while cows with optimal degree of body condition should be maintained on an energy-restricted diet.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-016-3191-3) contains supplementary material, which is available to authorized users.

Plasma exosome profiles from dairy cows with divergent fertility phenotypes

Cell-to-cell communication in physiological and pathological conditions may be influenced by neighboring cells, distant tissues, or local environmental factors. Exosomes are specific subsets of extracellular vesicles that internalize and deliver their content to near and distant sites. Exosomes may play a role in the maternal-embryo crosstalk vital for the recognition and maintenance of a pregnancy; however, their role in dairy cow reproduction has not been established. This study aimed to characterize the exosome profile in the plasma of 2 strains of dairy cow with divergent fertility phenotypes. Plasma was obtained and characterized on the basis of genetic ancestry as fertile (FERT; <23% North American genetics, New Zealand Holstein-Friesian strain, n=8) or subfertile (SUBFERT; >92% North American genetics, North American Holstein-Friesian strain, n=8). Exosomes were isolated by differential and buoyant density centrifugation and characterized by size distribution (nanoparticle tracking analysis, NanoSight NS500, NanoSight Ltd., Amesbury, UK), the presence of CD63 (Western blot), and their morphology (electron microscopy). The total number of exosomes was determined by quantifying the immunoreactive CD63 (ExoELISA kit, System Biosciences), and the protein content established by mass spectrometry. Enriched exosome fractions were identified as cup-shape vesicles with diameters around 100 nm and positive for the CD63 marker. The concentration of exosomes was 50% greater in FERT cows. Mass spectrometry identified 104 and 117 proteins in FERT and SUBFERT cows, of which 23 and 36 were unique, respectively. Gene ontology analysis revealed enrichment for proteins involved in immunomodulatory processes and cell-to-cell communication. Although the role of exosomes in dairy cow reproduction remains to be elucidated, their quantification and content in models with divergent fertility phenotypes could provide novel information to support both physiological and genetic approaches to improving dairy cow fertility.

Extracorporeal life support for victims of drowning

AIM

Unintentional drowning is a significant public health concern in the United States and represents a leading cause of death in the pediatric population. Extracorporeal life support (ECLS) may be used to support drowning victims, but outcomes have not been well defined. This study examined survival rates and risk factors for death in this population.

METHODS

Retrospective data from the Extracorporeal Life Support Organization registry was examined to determine outcomes of ECLS and risk factors for death in drowning victims.

RESULTS

Two hundred forty-seven patients who received ECLS following a drowning event between 1986 and 2015 were identified. Eighty-four (34%) did not experience cardiac arrest prior to ECLS, whereas 86 (35%) experienced a pre-ECLS cardiac arrest but had return of spontaneous circulation prior to ECLS, and 77 (31%) were placed on ECLS during cardiopulmonary resuscitation (ECPR). Overall survival was 51.4%; 71.4% in patients who did not experience a cardiac arrest, 57.0% in patients who required cardiopulmonary resuscitation prior to ECLS, and 23.4% in patients who received ECPR (p<0.001). Logistic regression analysis identified ECPR, venoarterial mode of ECLS, renal failure, and cardiopulmonary resuscitation during ECLS as risk factors associated with mortality.

CONCLUSIONS

Outcomes in drowning victims supported with ECLS are encouraging; particularly in patients who do not experience cardiac arrest. These data suggest that early initiation of ECLS in drowning patients with respiratory insufficiency may be beneficial to reduce the likelihood of complete cardiopulmonary failure and ECPR. Additionally, ECLS appears to improve survival in patients who experience post-drowning cardiac arrest.

Extracorporeal Life Support for Pediatric Heart Failure

Extracorporeal life support (ECLS) represents an essential component in the treatment of the pediatric patient with refractory heart failure. Defined as the use of an extracorporeal system to provide cardiopulmonary support, ECLS provides hemodynamic support to facilitate end-organ recovery and can be used as a salvage therapy during acute cardiorespiratory failure. Support strategies employed in pediatric cardiac patients include bridge to recovery, bridge to therapy, and bridge to transplant. Advances in extracorporeal technology and refinements in patient selection have allowed wider application of this therapy in pediatric heart failure patients.