Processing of corn-based dog foods through pelleting, baking and extrusion and their effect on apparent total tract digestibility and colonic health of adult dogs

Different food processing parameters may alter starch granule structure and its cooking degree. With lower thermomechanical energy, more resistant starch (RS) is retained in the food, which may benefit gastrointestinal (GI) health. The objective of this study was to determine the effect of food processing on dietary utilization and dog gut health. Experimental diets containing 56% corn as the sole starch source were produced through pelleting, baking, and extrusion and compared to a baked control diet in which the corn was replaced with dextrose. The extruded diet resulted in the highest level (P < 0.05) of in vitro starch cook and lowest RS, while baked was intermediate and pelleted had the lowest starch cook and highest RS. To evaluate the in vivo effects of these treatments, 12 dogs were adapted to foods for 9 d, and feces were collected for 5 d in a replicated 4 × 4 Latin square design. Feces were scored for consistency using an ordinal scale, and parametric data included apparent digestibility (ATTD), parameters indicative of gut health, and the microbial composition, which was centered log-ratio transformed before operational taxonomic unit (OTU) analyses. Fecal scores were analyzed by ordinal logistic regression, and parametric data were analyzed as mixed models. Overall ATTD was greater (P < 0.05) in extruded, followed by baked and pelleted. Dogs fed the control had osmotic diarrhea, whereas dogs fed the other treatments had mostly acceptable fecal scores, with extrusion leading to the best fecal quality. The control also led to high fecal pH and low SCFAs, indicating dysbiosis. All corn foods had similar (P > 0.05) fecal SCFAs and extruded tended (P = 0.055) to promote higher fecal butyrate than baked and pelleted. The microbiome of dogs fed the corn foods had similar α diversity indices, and OTUs at the species and phyla levels were mostly alike and different from the control. In conclusion, the higher levels of in vitro RS did not translate into a better in vivo fermentation profile, and extruded kibble performed best regarding fecal quality, ATTD, and fecal SCFAs.

Tolerability of long-term cannabidiol supplementation to healthy adult dogs

BACKGROUND

Cannabidiol (CBD) has therapeutic potential in companion animals. Shorter-term studies have determined that CBD is well tolerated in dogs with mild adverse effects and an increase in alkaline phosphatase (ALP) activity. There is need to assess CBD's long-term tolerability.

HYPOTHESIS

Determine the long-term tolerability of CBD administered PO to healthy dogs for 36 weeks at dosages of 5 and 10 mg/kg body weight (BW)/day. Our hypothesis was that CBD would be well tolerated by dogs.

METHODS

Eighteen healthy adult beagle dogs were randomly assigned to 3 groups of 6 each that received 0, 5, or 10 mg/kg BW/day CBD PO. Dogs were adapted to their housing for 3 weeks and received treatment for 36 weeks once daily with food. Adverse events (AEs) were recorded daily. Blood biochemistry profiles were monitored every 4 weeks. Data were analyzed as repeated measures over time using a mixed model, with significance at α = 0.05.

RESULTS

The 0 and 5 mg/kg treatment groups had similar fecal scores, and the 10 mg/kg treatment group had higher frequency of soft feces. No other significant AEs were noted. An increase (P < .0001) in ALP activity occurred in groups that received CBD. Remaining blood variables were within reference range.

CONCLUSIONS AND CLINICAL IMPORTANCE

Chronic administration of CBD in healthy dogs at 5 mg/kg was better tolerated than 10 mg/kg, and both dosages caused an increase in ALP activity. Although our data does not indicate hepatic damage, it is recommended to monitor liver function in dogs receiving CBD chronically.

Long-term effect of oral cannabidiol administration to healthy adult dogs on tear production, intraocular pressure, and tear concentrations

OBJECTIVE

To determine the chronic effects of oral cannabidiol (CBD) use on tear production, intraocular pressure (IOP), and concentration of CBD in tears of healthy dogs.

ANIMALS STUDIED

Eighteen healthy research Beagles.

PROCEDURES

This was a masked, placebo-controlled, randomized prospective study. Eighteen dogs were randomly assigned to three groups (six dogs per group) based on daily dosage of oral MCT oil (placebo), CBD 5 mg/kg, and CBD 10 mg/kg. Schirmer tear test (STT-1) and IOP were measured twice daily (7 am and 7 pm) every 4 weeks for 36 weeks. Week 36 tears were collected and analyzed for CBD concentrations (ng/mL) using liquid chromatography/mass spectrometry. A mixed linear model was used as the statistical method and p-value <.05 was considered significant.

RESULTS

No significant differences were found between placebo vs. 5 mg/kg vs. 10 mg/kg for STT-1 or IOP (AM and PM). CBD was detected in 10 out of 11 (91%) viable tear samples receiving 5 mg/kg or 10 mg/kg dosages. One sample in the 5 mg/kg group had inadequate tear volume for analysis. The CBD concentration in tears was at or below the lower limit of quantification in placebo group, 4.12-11.2 ng/mL for the 5 mg/kg group, and 6.22-152 ng/mL for the 10 mg/kg group.

CONCLUSIONS

Long-term administration of oral CBD in healthy research beagles demonstrates a favorable safety profile regarding ocular tolerability. Oral CBD administration does not appear to affect tear production or IOP over a 36-week period. This is the first canine study positively identifying concentrations of CBD in tears following oral administration.

The efficacy and safety of cannabidiol as adjunct treatment for drug-resistant idiopathic epilepsy in 51 dogs: A double-blinded crossover study

BACKGROUND

Approximately 30% of dogs with idiopathic epilepsy (IE) are drug-resistant. Recent studies have suggested cannabidiol (CBD) may be an effective anticonvulsant in dogs with IE.

OBJECTIVE

To evaluate the addition of CBD to antiseizure drugs (ASDs) on seizure frequency and to report adverse events in dogs with drug-resistant IE.

ANIMALS

Fifty-one dogs. Dogs having at least 2 seizures per month while receiving at least 1 ASD were included in the trial.

METHODS

Double-blinded placebo-controlled crossover study. The 5 mg/kg/day dosage met futility requirements after 12 dogs, and a dosage of 9 mg/kg/day was used in the next 39 dogs. Dogs were randomly assigned to receive CBD or placebo for 3 months, with a 1-month washout period between oils. Total numbers of seizures and seizure days were recorded. Diagnostic testing was performed periodically throughout the trial.

RESULTS

At the 9 mg/kg/day dose, the decrease in total seizure frequency was significant compared with placebo. A 24.1% decrease in seizure days occurred in dogs receiving CBD and a 5.8% increase occurred in dogs receiving placebo (P ≤ .05). No significant difference was found in the number of responders (≥50% decrease in total seizures or seizure days). Liver enzyme activities increased at both dosages. Decreased appetite and vomiting were more common in the CBD phase (P ≤ .05).

CONCLUSIONS AND CLINICAL IMPORTANCE

Cannabidiol decreased total seizures and seizure days compared to placebo when administered to dogs PO at 9 mg/kg/day. Liver enzymes should be monitored with administration of CBD in dogs.

Cannabidiol plasma determination and pharmacokinetics conducted at beginning, middle and end of long-term supplementation of a broad-spectrum hemp oil to healthy adult dogs

Introduction

Veterinary hemp products containing cannabidiol (CBD) and negligible psychoactive (THC) have increased popularity since hemp (with <0.3% THC) was removed from schedule 1 substances under the Controlled Substances Act in 2018. This was accompanied by increased CBD research, mostly on the short-term safety and efficacy for inflammatory and neurological conditions. It is imperative to understand how CBD is metabolized or accumulated in the body long-term, thus the goal of the present work was to determine monthly plasma CBD concentrations, as well as changes in pharmacokinetic (PK) parameters in chronically dosed dogs.

Methods

The study was a masked, placebo-controlled, randomized design. Six adult beagles were assigned to placebo, 5 and 10 mg/kg/day CBD treatment groups. Dogs received oral oil treatment once daily for 36 weeks. Blood was collected once every 4 weeks pre- and postprandially for CBD plasma determination (at 0 and 2 h). Pharmacokinetics were conducted at 0, 18 and 36 weeks. Pharmacokinetics and monthly CBD plasma data of dogs who received CBD were analyzed as repeated measures over time using a mixed model, with significance at α = 0.05.

Results

Average plasma CBD at 5 and 10 mg/kg were 97.3 ng/mL and 236.8 ng/mL pre-prandial, 341 ng/mL and 1,068 ng/mL postprandial, respectively. PK parameters suggested CBD accumulation over time, with significant increases in Cmax and AUC at both the 18 and 36-week timepoints. Cmax and AUC were dose proportional. Half-life demonstrated large inter-individual variations and increased (p < 0.05) at weeks 18 and 36 compared to baseline. Volume of distribution was not affected by time or treatment, while MRT increased, and clearance decreased over time (p < 0.05).

Conclusions and clinical importance

Chronic administration of CBD to healthy adult dogs led to a dose-proportional accumulation in the body for 36 weeks, which was confirmed by an increased half-life, total exposure, mean residence time and plasma peak. Our data also suggests that CBD plasma levels may have less daily variation if administered twice daily.

Scientific Validation of Cannabidiol for Management of Dog and Cat Diseases

Cannabidiol (CBD) is a non-psychotropic phytocannabinoid of the plant Cannabis sativa L. CBD is increasingly being explored as an alternative to conventional therapies to treat health disorders in dogs and cats. Mechanisms of action of CBD have been investigated mostly in rodents and in vitro and include modulation of CB1, CB2, 5-HT, GPR, and opioid receptors. In companion animals, CBD appears to have good bioavailability and safety profile with few side effects at physiological doses. Some dog studies have found CBD to improve clinical signs associated with osteoarthritis, pruritus, and epilepsy. However, further studies are needed to conclude a therapeutic action of CBD for each of these conditions, as well as for decreasing anxiety and aggression in dogs and cats. Herein, we summarize the available scientific evidence associated with the mechanisms of action of CBD, including pharmacokinetics, safety, regulation, and efficacy in ameliorating various health conditions in dogs and cats.

A Low to Medium-Shear Extruded Kibble with Greater Resistant Starch Increased Fecal Oligosaccharides, Butyric Acid, and Other Saccharolytic Fermentation By-Products in Dogs

The objective of this study was to assess whether diets with increased resistant starch (RS) had a positive effect on markers of colonic health in dogs. Three identical diets were extruded with high, medium and low shear (HS, MS and LS) to incrementally increase RS, and fed to 24 dogs in a replicated 3 × 3 William's Latin square design for 28-day periods. Fasting blood and fresh feces were collected on the last week of each period. Fecal quality was maintained among treatments. Gut integrity markers were measured by ELISA. Fecal short-chain fatty acids (SCFAs) were measured by LC MS/MS. In addition, the microbiota of dogs was determined from fresh feces by 16s rRNA high throughput sequencing. Untargeted metabolomics of both feces and serum were determined by UPLC. Data were analyzed using mixed models. There were no treatment effects on satiety hormones or gut integrity markers. Dogs fed LS or MS diets had marginal evidence (p < 0.10) for decreased fecal pH and for higher concentration (p < 0.05) of butyric acid and fecal oligosaccharides, succinate and lactate. Also, dogs fed the MS or LS diets had a shift towards more saccharolytic bacteria.

A review: nutrition and process attributes of corn in pet foods

Corn is one of the largest cereal crops worldwide and plays an important role in the U.S. economy. The pet food market is growing every year, and although corn is well utilized by dogs, some marketing claims have attributed a negative image to this cereal. Thus, the objective of this work was to review the literature regarding corn and its co-products, as well as describe the processing of these ingredients as they pertain to pet foods. Corn is well digested by both dogs and cats and provides nutrients. The processing of corn generates co-products such as corn gluten meal and distillers dried grains with solubles that retain quality protein, and fibrous components that dilute dietary energy. Further, corn has much functionality in extrusion processing. It may yield resistant starch under certain processing conditions, promoting colonic health. Carotenoids in corn may enhance immune support in companion animals if concentrated. Mycotoxin contamination in grains represent a health hazard but are well controlled by safety measures. Genetically modified (GM) corn is still controversial regarding its long-term potential for mutagenicity or carcinogenicity, thus more long-term studies are needed. In conclusion, the negative perception by some in the pet food market may not be warranted in pet foods using corn and its co-products.

PSVI-20 The Effect of Resistant Starch Type II on Satiety Hormones of Fasting Dogs

Resistant starches comprise the starch fraction that escapes small intestine (SI) digestion and reaches the colon, where it is fermented by saccharolytic bacteria that produce beneficial postbiotics. Moreover, slowly digestible starches lower glycemic index and may promote satiety. The objectives of this study were to assess whether diets having increased RS perturbed fasting levels of satiety hormones in dogs. Diets with three levels of resistant starch (RS type II) were produced via extrusion at three levels of mechanical energy. Nine male and 15 female adult Beagle dogs were fed the low, medium and high RS foods in a 3x3 Latin square design (n = 24). The study was approved by IACUC at Hill’s Pet Nutrition (# 883.0.0.0). Fasting blood was collected in the morning on days 27 and 28 of each period, and serum was separated and frozen at -70°C until analysis. Satiety hormones were measured by ELISA. Data was first converted to natural log to approximate normal distribution and then analyzed as a mixed model by the GLIMMIX procedure from SAS (v 9.4) with diet as fixed effect and dog and period as random effects. Ghrelin, gastric inhibitory polypeptide (GIP), glucagon-like peptide 1 (GLP-1), glucagon, leptin, pancreatic polypeptide (PP) and peptide YY (PYY) were not different across treatments likely due to the fasting state of dogs. Surprisingly, only insulin increased with higher RS consumption. It is possible that more propionate (not measured) was produced in the colon of dogs fed the high RS diet, which went through gluconeogenesis in the liver and resulted in a change in the time of glucose entering the blood stream. This could explain the insulin increase during fasting, but needs to be verified by measurement of fecal SCFA. Future research should explore the effect of type II RS on satiety hormones at multiple time points postprandial.

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Evaluation of faba beans as an ingredient in dog diets: apparent total tract digestibility of extruded diets with graded levels of dehulled faba beans (Vicia faba L.) by dogs

The growing pet food market is continuously in search for novel ingredients. Legumes such as faba beans (FB) are increasing in popularity and are known to benefit human health, but little is known about their use in pet foods. The objective of this study was to determine the effect of dehulled FB utilization by dogs. Experimental diets were extruded with 0%, 10%, 20%, and 30% FB inclusion (FB0, FB10, FB20, and FB30, respectively). Beagle dogs (n = 12) were fed the diets for 9-d adaptation with 5-d total fecal collection in a replicated 4 × 4 Latin square design. Apparent total tract digestibility (ATTD) was determined by external marker Cr₂O₃. At the culmination of each period, blood samples were collected from brachial venipuncture for complete blood count and blood chemistry. Palatability was determined with a 2-bowl test (n = 20). Means of blood parameters were separated by multivariate analysis of variance (MANOVA) with the aid of statistical software (SAS v9.4). Contrasts and least square means of fecal parameters and ATTD were computed. Significance level was considered to be α = 0.05. Dogs ate all food on offer and maintained body weight. There was no difference (P > 0.05) among treatments (FB10, FB20, and FB30) and the control (FB0) relative to food intake, fecal output (“as is” basis), and fecal score, but feces were softer when dogs were fed the treatments (P = 0.031) and there was a linear increase (P = 0.011) in defecation frequency (stools/day) when FB increased in the diets. Dry matter, organic matter, and crude protein digestibilities were slightly higher when dogs were fed the control diet (P < 0.05) compared with the FB diets. All blood and serum chemistry parameters were similar among treatments and within the reference ranges. Dogs preferred the control diet relative to the 10% and 30% FB diets, but the 20% FB preference was similar to the control. Dogs remained healthy, maintained body weight and no adverse health events were observed during the study. Dehulled FB are a suitable ingredient for dog foods, but concentrations should not exceed 20% to avoid reduction in palatability and stool quality.

Galactoligosaccharide and a prebiotic blend improve colonic health and immunity of adult dogs

This study aimed to evaluate the effects of two prebiotics in different concentrations on nutrient digestibility, fermentative products and immunological variables in adult dogs. Twenty-four adult dogs were randomly divided into six blocks according to their metabolic body weights (BW0.75); within these groups, dogs were randomized to four treatments: control without prebiotics (CO); inclusion of 0.5% prebiotic blend Yes-Golf (B1); inclusion of 1.0% galactooligosaccharide (GOS); and inclusion of 1.0% prebiotic blend Yes-Golf (B2). The experiment lasted 30 days, with 20 days adaptation and 10 days stool and blood collection. Results were analyzed for normality and means were separated by ANOVA and adjusted by the Tukey test at the significance level of 5.0%. Prebiotic supplementation had no effect on apparent digestibility coefficients (ADC), total stool production and fecal scores (p > 0.05). Prebiotics evaluated also did not alter fecal pH, nor the concentrations of ammonia, lactic acid, short chain fatty acids (SCFA) and most fecal branched chain fatty acids (BCFA) (p > 0.05). The addition of GOS decreased the concentration of iso-valeric acid (p = 0.0423). Regarding immunological variables, concentrations of fecal IgA were not influenced by the treatments. Treatments GOS and B2 increased the total number of polymorphonuclear cells, as well as the oxidative burst in relation to treatments B1 and CO (p < 0.0001). Treatment B2 improved the rate of S. aureus phagocytosis in relation to CO (p = 0.0111), and both the GOS and B2 treatments had a better index for E. coli phagocytosis than the CO treatment (p = 0.0067). In conclusion, there was indication that both prebiotics GOS and B2 at 1.0% inclusion improved the immunity of healthy dogs.

Starch characterization of commercial extruded dry pet foods

Starches provide an effective energy source for dogs and cats and can affect health according to its inclusion and extent of digestion. The starch fraction that escapes small intestine (SI) digestion is called resistant starch (RS) and is desirable due to its prebiotic function. Starch is not an essential nutrient for dogs and cats and thus is not reported on commercial pet food labels. Hence, the objective of this work was to characterize starches in commercial pet foods. The top five pet food companies by sales were selected to represent U.S. pet foods, which were divided into four strata with a sampling frame of 654 foods: dog grain based (372 foods), dog grain free (71 foods), cat grain based (175 foods), and cat grain free (38 foods). Five random foods within each stratum were purchased (20 total). Starch analyses (total starch, resistant starch, and starch cook), as well as nutrient analyses were conducted on all foods. Total starch, RS, and starch cook means were compared using a two-group Z-test on dog vs. cat and grain-based (GB) vs. grain-free (GF) diets, and differences were considered significant at a P < 0.05. Total starch was higher (P < 0.05) in dog than cat food, and starch cook was greater (P < 0.05) in GF diets. A regression analysis showed that nitrogen-free extract was a good predictor of total starch. Resistant starch was low and not different among groups. A post hoc test showed that a total sample size of at least 28 diets per group would be required to detect differences in RS between GF and GB diets, if one exists.

Nutritional inadequacies in commercial vegan foods for dogs and cats

The objective of this study was to evaluate the macronutrients composition, fatty acid and amino acid profiles, and essential minerals content of all vegan foods for dogs and cats available in the Brazilian market, and to compare results with FEDIAF (2019) and AAFCO (2019) recommendations. Four vegan pet foods were assessed (three for dogs and one for cats). The comparisons were made in a descriptive manner. All foods met the minimum recommendations for macronutrients. Arachidonic acid was not reported in any food label. Regarding the FEDIAF recommendations, one food for dogs had low calcium, another had low potassium and a third had low sodium. The cat food presented potassium content lower than recommended. The Ca:P ratio did not meet the minimum recommendation of FEDIAF (2019) and AAFCO (2019) in any of the dog’s foods analyzed, and the cat food also did not present the minimum recommendation based on FEDIAF (2019). Copper concentrations exceeded the legal limit in all foods. Zinc concentrations exceeded this limit in two foods (one for dogs and one for cats) and iron levels exceeded the legal limit in one dog food. One of the dog foods did not meet the minimum recommendation for methionine and the cat food did not meet the minimum recommendation for arginine. In addition, when the amount of nutrients consumed by animals with low energy requirements was simulated, in addition to the same non-conformities described above, it was observed that the cat food does not meet the minimum recommended of protein and taurine in unit/Kg^0.67. It was concluded that all foods analyzed had one or more nutrients below the recommended levels and some presented zinc and copper excess, therefore, these foods should not be recommended for dogs and cats, because dietary deficiencies found may lead to health risks for dogs and cats. Furthermore, manufacturers should review their formulations to ensure the nutritional adequacy of these foods.

Comparison of four digestibility markers to estimate fecal output of dogs

Twelve adult beagle dogs (10.6 ± 1.4 kg) were fed extruded dog diets in which the starch sources were whole sorghum, sorghum flour, sorghum mill-feed, or an equal combination of rice, corn, and wheat. The experiment was conducted as a replicated Latin square design digestibility study. Estimates of fecal organic matter (OM), crude protein (CP), crude fat (CF), and gross energy (GE) outputs were determined by four methods: total fecal collection (TFC), chromic oxide (Cr₂O₃), titanium dioxide (TiO₂), and acid insoluble ash (AIA). The correlation among the fecal output estimates by the four methods by partial correlation coefficients from the Error SSCP Matrix (Pearson) were considered significant at P < 0.05. The external markers, Cr₂O₃ and TiO₂, had a higher (P < 0.05) OM fecal output Pearson correlation to TFC than the intrinsic marker AIA (R = 0.931 for Cr₂O₃ vs. TiO₂; R = 0.559 for TFC vs. Cr₂O₃; R = 0.592 for TFC vs. TiO₂; R = 0.291 for AIA vs. TFC). Interestingly, TiO₂ highly correlated (P < 0.05) to Cr₂O₃ (R = 0.93 for OM), and was also correlated highly to TFC and AIA. The study suggests that TiO₂ may be a preferred marker to estimate fecal output in dogs vs. Cr₂O₃. The use of AIA represents a potential option for determining digestibility for diets in which external markers are impractical.

The Effect of Increasing Levels of Dehulled Faba Beans (Vicia faba L.) on Extrusion and Product Parameters for Dry Expanded Dog Food

The growing pet food market is continuously in search for novel ingredients. Legumes such as faba beans are increasingly popular in human nutrition but have not yet been explored in pet foods. Extruded dog diets were produced with 0, 10, 20, and 30% dehulled faba bean (DFB) inclusion (FB0, FB10, FB20, and FB30, respectively) in exchange for rice and corn gluten meal. Fixed processing inputs were extruder screw configuration, die size (5.2 mm diameter), dry feed rate (237 kg/h), extruder water and steam (0%), and die knife speed (1100 rpm). Variable inputs were managed by an operator with the goal to obtain similar kibble bulk density at the extruder die (OE) across treatments. Output parameters were measured at the pre-conditioner, extruder, and kibble. Measurements were collected at uniform time increments during production of each experimental diet and considered treatment replicates. Single degree of freedom contrasts were analyzed on extrusion and product outputs. The target of producing diets with similar wet bulk density was achieved, with moderate modifications at the pre-conditioner (PC) and extruder. As DFB increased, diets had increased retention time and water at the PC to improve starch hydration and swelling. The FB20 and FB30 required a more restricted flow to improve kibble expansion. After drying, the FB20 and FB30 diets were denser, harder and tougher (p < 0.05) than FB0 and FB10. The increasing levels of DFB up to 30% can be effectively controlled in an extruded pet food application with modest changes to extrusion parameters.

Malaria parasitemia and childhood diarrhea in a peri-urban area of Guinea-Bissau

To examine the association between diarrhea in early childhood and malaria parasitemia, we conducted a nested case-control study in Guinea-Bissau of 297 children with diarrhea and a similar number of children without diarrhea matched for age, season, and residential area. There were no associations between diarrhea and parasite rate, parasite density, or clinical malaria. However, anti-malarials were easily available and frequently used, which was reflected by a 0.7% prevalence of children with a parasite density > 100/200 leukocytes. Thus, the findings do not preclude that diarrhea may be a sign of clinical malaria or high-parasite density in endemic areas with lower use of antimalarials.

High mortality despite good care-seeking behaviour: a community study of childhood deaths in Guinea-Bissau

The care-seeking behaviour of mothers of 125 children deceased aged 1-30 months was investigated by verbal autopsy in an urban area of Guinea-Bissau. A total of 93% of the children were seen at a health centre or hospital during the 2 weeks before death. In a previous survey covering the period 1987-90 we found that 78% of the children who died had presented for consultation (8); despite this increase in care seeking, infant mortality had not decreased. Comparison of elapsed time from disease onset to first consultation between children who died and matched surviving controls indicated that the interval was shorter for children who died than for those who survived (odds ratio (OR) = 0.7; 95% confidence interval (CI): 0.5-0.99). Of the 125 terminally ill children, 56 were hospitalized. A total of 20 children died on the way to hospital or while waiting in the outpatient clinic. Lack of hospital beds resulted in 15 mothers being refused hospitalization for their child. Of hospitalized children, 42% were discharged as improved or recovered during the 30 days preceding death. These results reveal a need for improved hospital admission criteria, improved recognition of the symptoms of serious illness, better discharge criteria, and the implementation of quality assurance systems for health services.