Early pregnancy bleeding after assisted reproductive technology: a systematic review and secondary data analysis from 320 patients undergoing hormone replacement therapy frozen embryo transfer

STUDY QUESTION

How common is bleeding in early pregnancy after Hormone Replacement Therapy (HRT) Frozen Embryo Transfer (FET) and does bleeding affect the reproductive outcome?

SUMMARY ANSWER

A total of 47% of HRT-FET patients experience bleeding before the eighth week of gestation, however, bleeding does not affect the reproductive outcome.

WHAT IS KNOWN ALREADY

Bleeding occurs in 20% of spontaneously conceived pregnancies, although most will proceed to term. However, our knowledge regarding bleeding in early pregnancy after HRT-FET and the reproductive outcome is sparse.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review of the existing literature on early pregnancy bleeding after assisted reproductive technology (ART) to evaluate the bleeding prevalence and resulting reproductive outcome in this population. A random-effects proportional meta-analysis was conducted. Subsequently, we performed a prospective cohort study including 320 pregnant patients undergoing HRT-FET and a secondary analysis of the cohort study was performed to evaluate bleeding prevalence and reproductive outcome. The trial was conducted from January 2020 to November 2022 in a public fertility clinic.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A systematic literature search was performed, using MESH terms and included studies with data from ART patients and with early pregnancy bleeding as a separate outcome. The cohort study included patients with autologous vitrified blastocyst transfer treated in an HRT-FET protocol. In the event of a positive HCG-test, an early pregnancy scan was performed around 8 weeks of gestation. During this visit, patients answered a questionnaire regarding bleeding or spotting and its duration after the positive pregnancy test. The information was verified through medical files, and these were used to obtain information on reproductive outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

The review revealed a total of 12 studies of interest. The studies reported a prevalence of early pregnancy bleeding ranging from 2.1% to 36.2%. The random effects proportional meta-analysis resulted in a pooled effect estimate of the prevalence of early pregnancy bleeding in the ART population of 18.1% (95% CI (10.5; 27.1)). Four of the included studies included data on miscarriage rate following an episode of bleeding. All four studies showed a significantly increased risk of miscarriage in patients with early pregnancy bleeding as compared to patients with no history of bleeding. No studies investigated bleeding after HRT-FET specifically. In our HRT-FET cohort study, we found that a total of 47% (149/320) of patients with a positive pregnancy test experienced bleeding before 8 weeks of gestation. Generally, the bleeding was described as spotting with a median of 2 days (range 0.5-16 days). Out of 149 patients with one or several bleeding episodes, a total of 106 patients (71%) had an ongoing pregnancy at 12 weeks of gestation. In comparison, 171 patients reported no bleeding episodes and a total of 115 (67%) of these patients had an ongoing pregnancy at 12 weeks of gestation. This difference was not significant (P = 0.45). Furthermore there was no difference in the live birth rate between the two groups (P = 0.29).

LIMITATIONS, REASONS FOR CAUTION

Most studies included in the review were older and not all studies specified the type of ART. Moreover, the studies were of moderate methodological quality. The patients in the cohort study were treated in a personalized HRT-FET protocol using a rectal supplementary rescue regimen if serum progesterone levels were <35 nmol/l at embryo transfer. The results may not be applicable to other FET protocols, and the present data were based on self-reported symptoms. The systematic review revealed an increased risk of miscarriage following an episode of early pregnancy bleeding. However our cohort study found no such association. This discrepancy can partly be due to the fact, that the four studies in the review only included episodes of heavy bleeding. Also, none of the four studies included data on HRT-FET cycles making them unfit for direct comparison.

WIDER IMPLICATIONS OF THE FINDINGS

Episodes of early bleeding during pregnancy are associated with distress for the pregnant woman, especially in a cohort of infertile patients. Our cohort study showed that at least minor bleeding seems to be a common adverse event of early pregnancy after HRT-FET. From the systematic review, it seems that this prevalence is higher than what has previously been described in relation to other types of ART. However, minor bleeding during early pregnancy after HRT-FET does not seem to affect the reproductive outcome. Knowledge regarding the frequent occurrence of bleeding during early pregnancy after HRT-FET and the fact that this should not be used as a prognostic parameter will help the clinician in counselling patients.

STUDY FUNDING/COMPETING INTEREST(S)

Gedeon Richter Nordic supported this investigator-initiated study with an unrestricted grant as well as study medication (Cyclogest). B.A. has received an unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA, and Marckyrl Pharma. P.H. received honoraria for lectures from Merck, Gedeon Richter, Institut Biochimique SA (IBSA), and Besins as well as unrestricted research grants from Merck, Gedeon Richter, and Institut Biochimique SA (IBSA). The other authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

EudraCT no.: 2019-001539-29.

Rectal progesterone administration secures a high ongoing pregnancy rate in a personalized Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) protocol: a prospective interventional study

STUDY QUESTION

Can supplementation with rectal administration of progesterone secure high ongoing pregnancy rates (OPRs) in patients with low serum progesterone (P4) on the day of blastocyst transfer (ET)?

SUMMARY ANSWER

Rectally administered progesterone commencing on the ET day secures high OPRs in patients with serum P4 levels below 35 nmol/l (11 ng/ml).

WHAT IS KNOWN ALREADY

Low serum P4 levels at peri-implantation in Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) cycles impact reproductive outcomes negatively. However, studies have shown that patients with low P4 after a standard vaginal progesterone treatment can obtain live birth rates (LBRs) comparable to patients with optimal P4 levels if they receive additionalsubcutaneous progesterone, starting around the day of blastocyst transfer. In contrast, increasing vaginal progesterone supplementation in low serum P4 patients does not increase LBR. Another route of administration rarely used in ART is the rectal route, despite the fact that progesterone is well absorbed and serum P4 levels reach a maximum level after ∼2 h.

STUDY DESIGN, SIZE, DURATION

This prospective interventional study included a cohort of 488 HRT-FET cycles, in which a total of 374 patients had serum P4 levels ≥35 nmol/l (11 ng/ml) at ET, and 114 patients had serum P4 levels <35 nmol/l (11 ng/ml). The study was conducted from January 2020 to November 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients underwent HRT-FET in a public Fertility Clinic, and endometrial preparation included oral oestradiol (6 mg/24 h), followed by vaginal micronized progesterone, 400 mg/12 h. Blastocyst transfer and P4 measurements were performed on the sixth day of progesterone administration. In patients with serum P4 <35 nmol/l (11 ng/ml), 'rescue' was performed by rectal administration of progesterone (400 mg/12 h) starting that same day. In pregnant patients, rectal administration continued until Week 8 of gestation, and oestradiol and vaginal progesterone treatment continued until Week 10 of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 488 HRT-FET single blastocyst transfers, the mean age of the patients at oocyte retrieval (OR) was 30.9 ± 4.6 years and the mean BMI at ET 25.1 ± 3.5 kg/m2. The mean serum P4 level after vaginal progesterone administration on the day of ET was 48.9 ± 21.0 nmol/l (15.4 ± 6.6 ng/ml), and a total of 23% (114/488) of the patients had a serum P4 level lower than 35 nmol/l (11 ng/ml). The overall, positive hCG rate, clinical pregnancy rate, OPR week 12, and total pregnancy loss rate were 66% (320/488), 54% (265/488), 45% (221/488), and 31% (99/320), respectively. There was no significant difference in either OPR week 12 or total pregnancy loss rate between patients with P4 ≥35 nmol/l (11 ng/ml) and patients with P4 <35 nmol/l, who received rescue in terms of rectally administered progesterone, 45% versus 46%, P = 0.77 and 30% versus 34%, P = 0.53, respectively. OPR did not differ whether patients had initially low P4 and rectal rescue or were above the P4 cut-off. Logistic regression analysis showed that only age at OR and blastocyst scoring correlated with OPR week 12, independently of other factors like BMI and vitrification day of blastocysts (Day 5 or 6).

LIMITATIONS, REASONS FOR CAUTION

In this study, vaginal micronized progesterone pessaries, a solid pessary with progesterone suspended in vegetable hard fat, were used vaginally as well as rectally. It is unknown whether other vaginal progesterone products, such as capsules, gel, or tablet, could be used rectally with the same rescue effect.

WIDER IMPLICATIONS OF THE FINDINGS

A substantial part of HRT-FET patients receiving vaginal progesterone treatment has lowserum P4. Adding rectally administered progesterone in these patients increases the reproductive outcome. Importantly, rectal progesterone administration is considered convenient, and progesterone pessaries are easy to administer rectally and of low cost.

STUDY FUNDING/COMPETING INTEREST(S)

Gedeon Richter Nordic supported the study with an unrestricted grant as well as study medication. B.A. has received unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA and Marckyrl Pharma. P.H. has received honoraria for lectures from Gedeon Richter, Merck, IBSA and U.S.K. has received grant from Gedeon Richter Nordic, IBSA and Merck for studies outside this work and honoraria for teaching from Merck and Thillotts Pharma AB and conference expenses covered by Merck. The other co-authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER (25)

EudraCT no.: 2019-001539-29.

Invited review: The effect of milk feeding practices on dairy calf behavior, health, and performance-A systematic review

The aim of this systematic review was to summarize the literature assessing the effects of milk feeding practices on behavior, health, and performance on dairy calves. Peer-reviewed, published articles, written in English, directly comparing the effects of milk allowance, milk feeding methods, or milk feeding frequency on dairy calves were eligible for inclusion. Outcome measures could include sucking behavior, sucking on a teat (nutritive sucking, non-nutritive sucking on a teat), abnormal sucking behavior (non-nutritive sucking on pen fixtures, other oral behaviors, or cross-sucking), signs of hunger (vocalizations or unrewarded visits at the milk feeder), activity (lying time or locomotor play), feeding behavior (milk intake, starter intake, milk meal duration, or starter meal duration), growth (body weight or average daily gain), and health (occurrence of diarrhea, respiratory disease, or mortality). We conducted 2 targeted searches using Web of Science and PubMed to identify key literature. The resulting articles underwent a 2-step screening process. This process resulted in a final sample of 94 studies. The majority of studies investigated milk allowance (n = 69). Feeding higher milk allowances had a positive or desirable effect on growth, reduced signs of hunger, and increased locomotor play behavior during the preweaning period, whereas starter intake was reduced. Studies addressing health pointed to no effect of milk allowance, with no consistent evidence indicating that higher milk allowances result in diarrhea. Studies addressing milk feeding methods (n = 14) found that feeding milk by teat reduced cross-sucking and other abnormal oral behaviors. However, results on the effect of access to a dry teat were few and mixed. Milk feeding frequency (n = 14 studies) appeared to have little effect on feed intakes and growth; however, there is some evidence that calves with lower feeding frequency experience hunger. Overall, findings strongly suggest feeding higher volumes of milk using a teat; however, further work is needed to determine the optimal feeding frequency for dairy calves.

Comparison of off-the-shelf β-tricalcium phosphate implants with novel resorbable 3D printed implants in mandible ramus of pigs

Facial reconstructive surgery has already implemented the use of 3D printed Patient Specific Implants derived from CAD/CAM-based technologies as an alternative to preformed bone graft substitutes. 3D-printed patient-specific implants derived from CAD/CAM-based technologies are used in facial reconstructive surgery as an alternative to preformed bone graft substitutes. However, to minimize the invasiveness and long-term adverse effects of surgical interventions, the implant needs to exhibit exact fitting, porosity, density, and volume and be made from resorbable materials that allow ingrowth and formation of new bone tissue. Therefore, we present this pilot study using 3D-printed implants consisting of pure β-TCP, produced using a novel technique that assures these properties. Eight pigs received 3D-printed truncated porous cone bone implants paired with either an off-the-shelve a chronOS (DePuy Synthes chronOS Vivify Preforms) preformed block (n = 4) or a no-implant void (n = 4) in a surgically created defect on each side of the angle of the mandible. After 6 months, CT data showed that all 3D-printed implants performed as well as did the off-the-shelve implants, with predicted osteointegration medially and laterally and with minimal gapping between the implants and native bone. The CT findings were confirmed by histological analysis that revealed that the 3D-printed implants together with the off-the-shelve implants were almost complete resorbed. Much of the resorbed volume had been replaced by vascularized compact bone, and fusion between newly formed bone and native bone was observed in all implants, further indicating that the 3D-printed implants and off-the-shelve implants performed equally well. Only soft tissue developed in the void control sites. Further studies are needed to confirm these initial findings.

Impact of methodological choices in comparative effectiveness studies: application in natalizumab versus fingolimod comparison among patients with multiple sclerosis

Background

Natalizumab and fingolimod are used as high-efficacy treatments in relapsing–remitting multiple sclerosis. Several observational studies comparing these two drugs have shown variable results, using different methods to control treatment indication bias and manage censoring. The objective of this empirical study was to elucidate the impact of methods of causal inference on the results of comparative effectiveness studies.

Methods

Data from three observational multiple sclerosis registries (MSBase, the Danish MS Registry and French OFSEP registry) were combined. Four clinical outcomes were studied. Propensity scores were used to match or weigh the compared groups, allowing for estimating average treatment effect for treated or average treatment effect for the entire population. Analyses were conducted both in intention-to-treat and per-protocol frameworks. The impact of the positivity assumption was also assessed.

Results

Overall, 5,148 relapsing–remitting multiple sclerosis patients were included. In this well-powered sample, the 95% confidence intervals of the estimates overlapped widely. Propensity scores weighting and propensity scores matching procedures led to consistent results. Some differences were observed between average treatment effect for the entire population and average treatment effect for treated estimates. Intention-to-treat analyses were more conservative than per-protocol analyses. The most pronounced irregularities in outcomes and propensity scores were introduced by violation of the positivity assumption.

Conclusions

This applied study elucidates the influence of methodological decisions on the results of comparative effectiveness studies of treatments for multiple sclerosis. According to our results, there are no material differences between conclusions obtained with propensity scores matching or propensity scores weighting given that a study is sufficiently powered, models are correctly specified and positivity assumption is fulfilled.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01623-8.

Effects of dietary and milking frequency changes and administration of cabergoline on clinical udder characteristics in dairy cows during dry-off

We investigated the effects of 2 diet energy densities [normal lactation diet (NORM) vs. energy-reduced diet (REDU), both fed for ad libitum intake] and 2 daily milking frequencies [twice (2×) vs. once (1×)] during 1 week before the dry-off day, as well as effects of an injection of either a dopamine agonist [cabergoline (CAB); Velactis, Ceva Santé Animale, Libourne, France; labelled for use only with abrupt dry-off, e.g. no reduction in diet energy density or milking frequency before the last milking] or saline (SAL) following the last milking, on clinical udder characteristics of Holstein cows. During a week before and after the last milking, the following measures were recorded: palpation-based udder firmness and soreness; image-based hock-hock distance; responsiveness to mechanical udder stimulation and degree of udder fill measured with a dynamometer. Before the last milking, REDU cows displayed lower odds of having a firm udder and lower degree of udder fill, as well as lower responsiveness to mechanical udder stimulation, than NORM cows. After the last milking, REDU cows displayed shorter hock-hock distance compared with NORM cows. The effects of milking frequency on the clinical udder characteristics were unclear. Within 24 h following injection, CAB cows showed lower odds of having a firm udder, shorter hock-hock distance, and lower degree of udder fill than SAL cows, irrespective of treatment group before dry-off. In this study, reducing diet energy density prior to dry-off, and to some extent administering the dopamine agonist cabergoline after the last milking, resulted in fewest clinical udder changes.

Assessing effects of dietary and milking frequency changes and injection of cabergoline during dry-off on hunger in dairy cows using 2 feed-thwarting tests

We investigated the single and combined effects of 2 feeding levels (normal lactation diet vs. energy-reduced diet, both fed for ad libitum intake) and 2 daily milking frequencies (twice vs. once) during 1 wk before the dry-off day (d 0), as well as an intramuscular injection of either a dopamine agonist (cabergoline; Velactis, Ceva Santé Animale; labeled for use only with abrupt dry-off, e.g., no reduction in feeding level or milking frequency before the last milking) or saline after the last milking on d 0 on the feeding motivation of clinically healthy, loose-housed, pregnant, lactating Holstein cows. From d 0, all cows were fed the same dry-cow diet for ad libitum intake. Cows were subjected to 2 feed-thwarting tests, a test in the home pen using their diets (test A: d -6, -1, and 1; during 35 min when the feed bins were filled, but locked) and another test carried out in an adjacent pen in which access to concentrate provided in a familiar plastic box was blocked by a wire-mesh lid (test B: d -5 and 2). In test A, we recorded how often cows attempted to feed per 35 min, whether cows vocalized during the 35-min period, and latency to feed within 300 s after feed bins were unlocked. In test B, we recorded latency to approach either of 2 familiar boxes (the wire-mesh box and an identical open box with a small portion of concentrate) within 600 s and how often cows directed behaviors toward the wire-mesh box (number of occurences/5 min). On d -6 (test A), no clear differences in feeding motivation among treatments were found. On d -5 and -1, cows fed the energy-reduced diet displayed a higher probability of vocalizing (test A), were more than 50% quicker to feed (test A), were approximately 5× quicker to approach a box (test B), and directed 60% more behavior toward the wire-mesh box (test B) than cows fed the normal diet. Moreover, cows fed the energy-reduced diet attempted to feed approximately 75% more on d -1 compared with d -6 (test A). On d 2 (test B), cows previously fed the normal diet directed 40% more behavior toward the wire-mesh box than cows previously fed the energy-reduced diet. Reducing feeding level, either before or on the dry-off day, resulted in consistently increased feeding motivation, interpreted as a sign of hunger. No clear effects of change in milking frequency, singly or combined with reduced diet energy density, on feeding motivation were found before d 0. Whereas, on d 2, cows previously milked twice daily were quicker to approach a box than cows previously milked once daily. Cows injected with cabergoline attempted to feed more, but showed lower probability of vocalizing compared with saline-injected cows (d 1; test A), irrespective of treatment before d 0. The effects of cabergoline on feeding motivation are not easily interpreted and warrant further investigation. From a hunger perspective, reducing milking frequency rather than diet energy density seems to be a less negative management to reduce milk production before dry-off.

Cognitive processing of infant stimuli in pregnant women with and without affective disorders and the association to postpartum depression

Pregnancy and childbirth are among the strongest risk factors for depression but the neurocognitive mechanisms underlying this enhanced risk are unknown. This study investigated emotional and non-emotional cognition in 57 pregnant women with or without an affective disorder during their third trimester, and the association between cognitive biases and subsequent postpartum depression (PPD). Of the pregnant women, 22 had a diagnosis of unipolar disorder (UD) and seven of bipolar disorder (BD) in full or partial remission, while 28 had no history of affective disorder. We included a control group of 29 healthy non-pregnant women. First, participants were interviewed, completed non-emotional and emotional cognitive tests and lastly filled out questionnaires. The participants were assessed two times after birth: at a home visit shortly after birth, and with a telephone interview to assess PPD in the first six months after birth. Healthy pregnant women rated infant cries less negatively than non-pregnant women, possibly reflecting preparation for motherhood. Pregnant women with UD exhibited a negative bias in ratings of infant cries, whereas pregnant women with BD showed a positive bias in ratings of infant happy faces and recognition of adult facial expressions. Across all pregnant women, more negative ratings of infant cries were associated with enhanced risk of PPD. Negatively biased perception of infant cries during pregnancy may thus signal vulnerability toward PPD.

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Background

There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting.

Methods

In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias.

Results

A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching.

Conclusion

A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.

Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands

PURPOSE

Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries.

METHODS

A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries.

RESULTS

BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years.

CONCLUSIONS

In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

Effect of straw amount on feed intake and weight gain in growing pigs housed in pens with partly slatted floor

The provision of straw to pigs kept in conventional pens with concrete floor improves animal welfare, but the effects of straw on pigs' performance are unclear. In two steps, we investigated the relationship between amount of straw provided to pigs and measures of performance in a set-up maintaining constant space allowance and controlled room temperature. From approximately 30- to 85-kg BW, pigs were housed in groups of 18 in pens (5.48 m × 2.48 m) with concrete floor (1/3 solid, 1/3 drained and 1/3 slatted). The pens were cleaned manually twice a week, and the designated amount of fresh uncut wheat straw was provided daily onto the solid part of the floor. In the first step, 48 pens were assigned to 10-, 500- or 1000-g straw per pig per day, while in the second step, 90 pens were assigned to 10-, 80-, 150-, 220-, 290-, 360-, 430- or 500-g straw per pig per day. Pigs were weighed at the start of the experimental period at approximately 30 kg and again at approximately 85-kg BW. The average daily gain increased 8.1 g (SEM 17) for every extra 100-g straw added daily (P < 0.001) resulting in 40 g higher average daily gain with 500 compared to 10-g straw per pig per day. The feed conversion ratio was not affected by the amount of straw provided, as the feed intake tended to be higher with increasing amounts of straw. Thus, between 10 and 500 g, the more straw provided, the higher the daily weight gain. As the nutritional value of straw is considered minimal, this result is likely due to improved gut health from the increasing amounts of straw ingested and increased feed intake due to increased stimulation of exploratory behaviour with increasing amounts of straw available, or a combination of these. The observed tendency for a higher feed intake supports this suggestion, but studies are needed to establish the impact of these two contributing factors.

408Albuminuria as a predictor of incident ischemic stroke and myocardial infarction in patients with type 2 diabetes but without cardiovascular disease: A Danish cohort study

Background

Risk stratification in patients with type 2 diabetes continues to be an important priority in the management of diabetes-related morbidity and mortality. International guidelines generally recognize patients with diabetes and cardiovascular disease as high-risk patients. Risk stratification is, however, more uncertain in diabetes patients without cardiovascular disease. Micro- and macroalbuminuria have previously been identified as predictors of cardiovascular events and mortality in general cohorts of diabetes patients. However, less is known about the predictive value of albuminuria in patients with diabetes but without established cardiovascular disease.

Purpose

We aimed to examine the association between albuminuria level and the risk of ischemic stroke, myocardial infarction, and all-cause mortality in patients with type 2 diabetes and without a diagnosis of cardiovascular disease.

Methods

We linked Danish nationwide registries to identify patients with type 2 diabetes and without cardiovascular disease from May 2005 through June 2015. Based on two consecutive measurements of the urinary albumin excretion rate or albumin-to-creatinine ratio patients were stratified in categories of normoalbuminuria, microalbuminuria, and macroalbuminuria. Patients were followed for the outcomes ischemic stroke, myocardial infarction, and all-cause mortality until December 31, 2015. Five-year risk of outcomes were presented as cumulative incidence functions (with death as a competing event). Associations between albuminuria level and incidence of ischemic stroke, myocardial infarction, and all-cause mortality were evaluated with Cox proportional hazard regression adjusted for cardiovascular risk factors.

Results

The study population included 78,841 patients with type 2 diabetes (44.7% females, mean age 63.2). When comparing patients with microalbuminuria to patients with normoalbuminuria in an age- and sex-adjusted analysis, we found hazard ratios (HRs) of 1.45 (95% CI: 1.24–1.69), 1.45 (95% CI: 1.24–1.70), and 1.50 (95% CI: 1.39–1.61) for ischemic stroke, myocardial infarction, and all-cause mortality, respectively. Furthermore, macroalbuminuria was associated with HRs of 2.05 (95% CI: 1.70–2.48), 2.25 (95% CI: 1.86–2.71), and 2.03 (95% CI: 1.85–2.23) for ischemic stroke, myocardial infarction, and all-cause mortality, respectively. Similar results were found after adjusting for cardiovascular risk factors.

Conclusions

In this nationwide cohort study of patients with type 2 diabetes but without cardiovascular disease, patients with micro- and macroalbuminuria had a higher risk of incident ischemic stroke, myocardial infarction, and all-cause mortality. This finding supports that patients with micro- or macroalbuminuria should be screened regularly and followed closely in clinical practice. Moreover, these findings suggest that patients with type 2 diabetes and micro- or macroalbuminuria may benefit from intensive vascular risk reduction.

Grey water treatment in stacked multi-layer reactors with passive aeration and particle trapping

When adequately treated, grey water represents a potent alternative water resource, as it constitutes a large proportion of household wastewater. The objective of this paper was to test a full scale version of a novel compact grey water treatment technology, based on passive aeration and particle trapping in multiple layers. Using a modified dual porosity filtration technology, grey water from a public bath was passed through a stack of eight reactors, each 0.75 m × 0.55 × 0.22 m, serially connected for gravity driven flow from top to bottom in a zig-zag pattern. The topmost reactor served as pre-filter for removal of hair and other larger debris. The lower seven reactors facilitated degradation of bulk organic contaminants in biofilm established on a stack of five fibrous polyamide nets, and trapping of particles by sedimentation on five interlaid corrugated plastic plates. By operating the reactors in a time-controlled batch-mode, the corrugated plates further served to trap air and thus ensure passive aeration of the subsequent batch. The production rate was 1.2 m³/d and the hydraulic retention time 2 h, at an aerial footprint of 0.4 m², excluding storage tanks. After two weeks of initialization, a biofilm had established and the system was monitored for additionally three weeks. Significantly improved effluent quality was obtained as measured from reductions in turbidity (95%), total suspended solids (94%), chemical oxygen demand (87%), and microbiological parameters (55-98%), and from stable level of dissolved oxygen in effluent of 3.5 mg/L. Future optimization includes custom-made reactors for maximizing production capacity, improved removal of total N and total P, and addition of final disinfection.

Adherence to subcutaneous interferon beta-1a treatment using an electronic injection device: a prospective open-label Scandinavian noninterventional study (the ScanSmart study)

BACKGROUND

Disease modifying drugs help control the course of relapsing remitting multiple sclerosis (RRMS); however, good adherence is needed for long-term outcomes.

OBJECTIVE

To evaluate patient adherence to treatment with subcutaneous interferon beta-1a using RebiSmart^® and assess injection-site reactions and treatment satisfaction.

METHODS

This prospective, single-arm, open-label, noninterventional multicenter Phase IV trial included disease modifying drug-experienced mobile patients with RRMS. Adherence was measured over 12 weeks. Items 13-23, 35, 37, and 38 of the Multiple Sclerosis Treatment Concerns Questionnaire (injection-site reactions and treatment satisfaction) were recorded at 12 weeks.

RESULTS

Sixty patients were recruited (mean age 43.7 [±SD 7.9] years; 83% female; mean years since multiple sclerosis diagnosis 6.7 [SD 4.5]). Adherence data were obtained in 54 patients only due to technical problems with six devices. Over 12 weeks, 89% (n=48) of patients had ≥90% adherence to treatment. Most patients experienced mild influenza-like symptoms and injection-site reactions, and global side effects were minimal. Most patients (78%) rated the convenience as the most important aspect of the device, and most experienced no or mild pain.

CONCLUSION

RRMS patients treated with subcutaneous interferon beta-1a, administered with RebiSmart, demonstrated generally good adherence, and the treatment was generally well tolerated.

Effect of GnRHa ovulation trigger dose on follicular fluid characteristics and granulosa cell gene expression profiles

PURPOSE

A recent dose-finding study showed no significant differences in number of mature oocytes, embryos and top-quality embryos when triptorelin doses of 0.2, 0.3 or 0.4 mg were used to trigger final oocyte maturation in oocyte donors co-treated with a gonadotropin-releasing hormone (GnRH) antagonist. This analysis investigated whether triptorelin dosing for triggering final oocyte maturation in oocyte donors induced differences in follicular fluid (FF) hormone levels and granulosa cell gene expression.

METHODS

This single-centre, randomised, parallel, investigator-blinded trial was conducted in oocyte donors undergoing a single stimulation cycle at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam, from August 2014 to March 2015. A total of 165 women aged 18-35 years with body mass index <28 kg/m², anti-Müllerian hormone >1.25 ng/mL, and antral follicle count ≥6 were randomised to three different triptorelin doses for trigger. The main outcome was concentration of steroid hormones in FF collected from the first punctured follicle on each side. Moreover, luteinising hormone receptor (LHR), 3β-hydroxy-steroid-dehydrogenase (3ßHSD) and inhibin-Ba (INHB-A) gene expression in cumulus and mural granulosa cells were investigated in a subset of women from each group.

RESULTS

Progesterone and oestradiol levels in FF did not differ significantly by trigger doses; findings were similar for 3βHSD, LHR and INHB-A gene expression in both cumulus and mural granulosa cells.

CONCLUSIONS

In women co-treated with a GnRH antagonist, no significant differences in FF steroid levels and granulosa cell gene expression were seen when different triptorelin doses were used to trigger final oocyte maturation.

Short communication: Calving site selection of multiparous, group-housed dairy cows is influenced by site of a previous calving

A calving cow and her newborn calf appear to have an attracting effect on periparturient cows, which may potentially influence the functionality of future motivation-based calving pen designs. In this pilot study we examined whether calving site selection of group-housed Holstein dairy cows was affected by the site of a previous calving. Ten multiparous cows moved to 1 of 2 group pens 11 (range = 4-27) d before calving were included. Each pen consisted of an open area (9 × 9 m) connected to 6 secluded areas (4.5 × 3 m each), where cows could move freely between all areas. Time of calving, location of the breaking of the amniotic sac, as well as the place of birth were recorded. In all but 1 case cows calved within a distance of 1 cow length from where the previous calving took place, suggesting that the cows did not select calving site at random. These preliminary observations indicate that choice of calving site may be affected by the site of a previous calving, potentially explained by the presence of amniotic fluids.

Cross-validation of three predictive tools for non-sentinel node metastases in breast cancer patients with micrometastases or isolated tumor cells in the sentinel node

BACKGROUND

We cross-validated three existing models for the prediction of non-sentinel node metastases in patients with micrometastases or isolated tumor cells (ITC) in the sentinel node, developed in Danish and Finnish cohorts of breast cancer patients, to find the best model to identify patients who might benefit from further axillary treatment.

MATERIAL AND METHOD

Based on 484 Finnish breast cancer patients with micrometastases or ITC in sentinel node a model has been developed for the prediction of non-sentinel node metastases. Likewise, two separate models have been developed in 1577 Danish patients with micrometastases and 304 Danish patients with ITC, respectively. The models were cross-validated in the opposite cohort.

RESULTS

The Danish model for micrometatases was accurate when tested in the Finnish cohort, with a slight change in AUC from 0.64 to 0.63. The AUC of the Finnish model decreased from 0.68 to 0.58 when tested in the Danish cohort, and the AUC of the Danish model for ITC decreased from 0.73 to 0.52, when tested in the Finnish cohort. The Danish micrometastatic model identified 14-22% of the patients as high-risk patients with over 30% risk of non-sentinel node metastases while less than 1% was identified by the Finish model. In contrast, the Finish model predicted a much larger proportion of patients being in the low-risk group with less than 10% risk of non-sentinel node metastases.

CONCLUSION

The Danish model for micrometastases worked well in predicting high risk of non-sentinel node metastases and was accurate under external validation.

Characterization of chromium species in urban runoff

Little is known about the presence of the element Cr in its toxic hexavalent form Cr(VI) in stormwater runoff from urban areas. Most studies report only total Cr concentration, i.e., including also the nontoxic Cr(III) molecular form. The objective of this study was to evaluate a field method based on cation-exchange for characterization of Cr species in urban stormwater runoff and soil leachate. We used a 0.05 mol L Na and Ca solution and a soil leachate as matrices and spiked these with Cr(III), Cr(VI), or both in the concentration range of 1 to 100 μg L. We then filtered the test samples through cation-exchange cartridges. In the Na-Ca salt matrix, the Cr(III) was retained 100% and recovery values of Cr(VI) were 86 to 100%. Furthermore, in such a matrix, each cartridge could be reused at least nine times without a drop in retention of Cr(III) or recovery of Cr(VI). In a soil leachate matrix, the method appeared less applicable. Apparently Cr(III) forms complexes with dissolved organic matter, allowing it to bypass the cartridge, resulting in incomplete Cr(III) retention and thus incomplete speciation. The complexes are formed rapidly after spiking, thus changes in the Cr-species distribution are likely to occur within a few hours when fresh samples are stored. Furthermore, we concluded that Cr(III) at neutral pH in pure solution or complexed with dissolved organic C can sorb irreversibly to polyethylene and polypropylene containers. Our findings show that there is still a need for a method that can be applied to urban runoff in the field. Furthermore, cartridge speciation methods should ideally be tested before being applied on solutions containing organic matter.

Water Sensitive Urban Design retrofits in Copenhagen - 40% to the sewer, 60% to the city

Water Sensitive Urban Design (WSUD) is emerging in Denmark. This interdisciplinary desk study investigated the options for WSUD retrofitting in a 15 km(2) combined sewer catchment area in Copenhagen. The study was developed in collaboration with the City of Copenhagen and its water utility, and involved researchers representing hydrogeology, sewer hydraulics, environmental chemistry/economics/engineering, landscape architecture and urban planning. The resulting catchment strategy suggests the implementation of five sub-strategies. First, disconnection is focused within sites that are relatively easy to disconnect, due to stormwater quality, soil conditions, stakeholder issues, and the provision of unbuilt sites. Second, stormwater runoff is infiltrated in areas with relatively deep groundwater levels at a ratio that doesn't create a critical rise in the groundwater table to the surface. Third, neighbourhoods located near low-lying streams and public parks are disconnected from the sewer system and the sloping terrain is utilised to convey runoff. Fourth, the promotion of coherent blue and green wedges in the city is linked with WSUD retrofits and urban climate-proofing. Fifth, WSUD is implemented with delayed and regulated overflows to the sewer system. The results are partially adopted by the City of Copenhagen and currently under pilot testing.

PIK3CA mutations, PTEN, and pHER2 expression and impact on outcome in HER2-positive early-stage breast cancer patients treated with adjuvant chemotherapy and trastuzumab

BACKGROUND

This study was conducted to determine the frequency of PIK3CA mutations and human epidermal growth factor receptor-2 (HER2) phosphorylation status (pHER2-Tyr1221/1222) and if PIK3CA, phosphatase and tensin homolog (PTEN), or pHER2 has an impact on outcome in HER2-positive early-stage breast cancer patients treated with adjuvant chemotherapy and trastuzumab.

PATIENTS AND METHODS

Two hundred and forty HER2-positive early-stage breast cancer patients receiving adjuvant treatment (cyclophosphamide 600 mg/m2, epirubicin 60 mg/m2, and fluorouracil 600 mg/m2) before administration of 1 year trastuzumab were assessable. PTEN and pHER2 expression were assessed by immunohistochemistry. PIK3CA mutations (exons 9 and 20) were determined by pyrosequencing.

RESULTS

Five-year overall survival (OS) and invasive disease-free survival were 87.8% and 81.0%, respectively. Twenty-six percent of patients had a PIK3CA mutation, 24% were PTEN low, 45% pHER2 high, and 47% patients had increased PI3K pathway activation (PTEN low and/or PIK3CA mutation). No significant correlations were observed between the clinicopathological variables and PIK3CA, PTEN, and pHER2 status. In both univariate and multivariate analyses, patients with PIK3CA mutations or high PI3K pathway activity had a significant worse OS [multivariate: hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.01-4.51, P=0.046; and HR 2.35, 95% CI 1.10-5.04, P=0.03].

CONCLUSION

Patients with PIK3CA mutations or increased PI3K pathway activity had a significantly poorer survival despite adequate treatment with adjuvant chemotherapy and trastuzumab.

A conceptual framework for addressing complexity and unfolding transition dynamics when developing sustainable adaptation strategies in urban water management

To achieve a successful and sustainable adaptation to climate change we need to transform the way we think about change. Much water management research has focused on technical innovation with a range of new solutions developed to achieve a 'more sustainable and integrated urban water management cycle'. But Danish municipalities and utility companies are struggling to bring such solutions into practice. 'Green infrastructure', for example, requires the consideration of a larger range of aspects related to the urban context than the traditional urban water system optimization. There is the need for standardized methods and guidelines to organize transdisciplinary processes where different types of knowledge and perspectives are taken into account. On the basis of the macro-meso-micro pattern inspired by complexity science and transition theory, we developed a conceptual framework to organize processes addressing the complexity characterizing urban water management in the context of climate change. In this paper the framework is used to organize a research process aiming at understanding and unfolding urban dynamics for sustainable transition. The final goal is to enable local authorities and utilities to create the basis for managing and catalysing the technical and organizational innovation necessary for a sustainable transition towards climate change adaptation in urban areas.

Feeding motivation and plasma metabolites in pregnant sows fed diets rich in dietary fiber either once or twice daily

The present study investigated the effects of source and level of dietary fiber (DF) and feeding frequency (once vs. twice daily) on feeding motivation and plasma metabolites at 4 different time points post feeding. Sixty pregnant sows (Sus scrofa, 4 blocks of 15 sows) were allocated to 1 of 5 diets within blocks. Four diets were restricted (approximately 35 MJ ME/d): a barley and wheat control diet (171 g DF/kg DM; 12 g DF/MJ ME), and 3 fiber diets formulated to contain 35% DF by including pectin residue (323 g DF/kg DM; 25 g DF/MJ ME), potato pulp (404 g DF/kg DM; 29 g DF/MJ ME), or sugar beet pulp (367 g DF/kg DM; 25 g DF/MJ ME). The fifth diet was a mixture including an equal amount of the 3 fiber diets offered semi ad libitum (ad libitum access to feed during 6 periods of 1 h starting at 0300, 0600, 1100, 1500, 1800, and 2300; 354 g DF/kg DM; 25 g DF/MJ ME). The experimental period included 2 periods of 4 wk each. Restricted-fed sows were fed once daily (0800 h) during the first period and twice daily (0800 and 1500 h) during the second period, or vice versa. Semi ad libitum fed sows had access to feed 6 times a day in both periods. In each period, the feeding motivation was assessed in an operant conditioning test, and samples of peripheral blood were taken in a balanced design, at 0900, 1200, 1900, and 0700 h, corresponding to 1, 4, 11, and 23 h after feeding for restricted sows fed once daily. No differences in the feeding motivation were found between the 4 restricted diets at any of the time points post feeding, but semi ad libitum fed sows had a decreased feeding motivation (P < 0.001). Among the restricted-fed sows, feeding twice daily resulted in decreased feeding motivation at 1900 h (P < 0.001) and at 0700h (P < 0.05) compared with feeding once daily, but not at 0900 and 1200 h, indicating that feeding twice daily reduced feeding motivation during the night compared with feeding once daily. Among restricted-fed sows, plasma concentrations of short-chain fatty acids (SCFA) were greater in sows fed high-fiber diets compared with the control (P = 0.02). Nonesterified fatty acid was least in sows on the control diet and greatest in sows on the potato diet, whereas sows on the pectin and sugar beet diets were intermediate (P < 0.001). Less diurnal variation in glucose (P < 0.001) was seen in sows on high-fiber diets. In spite of the found effects on plasma metabolites, the applied level of fiber in the diet of restrictedly fed sows did not reduce their feeding motivation irrespective of fiber source.

Postoperative changes in fatigue, physical function and body composition: an analysis of the amalgamated data from five randomized trials on patients undergoing colorectal surgery

AIM

Changes in postoperative fatigue, physical function and body composition were described in patients after open colorectal surgery, and factors that predicted postoperative fatigue 1 month after surgery were identified.

METHOD

Data from five clinical intervention studies from 1991 to 2005 were amalgamated. Patients (n = 385) were examined preoperatively, at discharge and 1 month postoperatively. The level of fatigue was scored subjectively from 1 'fit' to 10 'fatigued' on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, lean body mass and fat mass. A logistic regression analysis was used to identify the predictors of a high fatigue score 1 month postoperatively.

RESULTS

Preoperatively, only 17% had a high fatigue score (≥ 5.5), whereas 65 and 30% had a high fatigue score at discharge and 1 month postoperatively, respectively. Postoperatively, there was a significant fall in physical performance, weight, lean body mass and fat mass that did not normalize by 1 month. High preoperative and discharge fatigue scores, major complications and the loss of lean body mass significantly increased the risk of fatigue 1 month postoperatively.

CONCLUSION

Open colorectal surgery was associated with a significant increase in postoperative fatigue and a decline in physical performance, weight and lean body mass. Major complications, a high perioperative fatigue score and the loss of lean body mass increased the risk of long-term fatigue.

Randomized double-blind placebo-controlled crossover study of caffeine in patients with intermittent claudication

Background

Intermittent claudication is a disabling symptom of peripheral arterial disease for which few medical treatments are available. This study investigated the effect of caffeine on physical capacity in patients with intermittent claudication.

Methods

This randomized double-blind placebo-controlled crossover study included 88 patients recruited by surgeons from outpatient clinics. The participants abstained from caffeine for 48 h before each test and then received either a placebo or oral caffeine (6 mg/kg). After 75 min, pain-free and maximal walking distance on a treadmill, perceived pain, reaction times, postural stability, maximal isometric knee extension strength, submaximal knee extension endurance and cognitive function were measured. The analysis was by intention to treat.

Results

Caffeine increased the pain-free walking distance by 20·0 (95 per cent confidence interval 3·7 to 38·8) per cent (P = 0·014), maximal walking distance by 26·6 (12·1 to 43·0) per cent (P &lt; 0·001), muscle strength by 9·8 (3·0 to 17·0) per cent (P = 0·005) and endurance by 21·4 (1·2 to 45·7) per cent (P = 0·004). However, postural stability was reduced significantly, by 22·1 (11·7 to 33·4) per cent with eyes open (P &lt; 0·001) and by 21·8 (7·6 to 37·8) per cent with eyes closed (P = 0·002). Neither reaction time nor cognition was affected.

Conclusion

In patients with moderate intermittent claudication, caffeine increased walking distance, maximal strength and endurance, but affected balance adversely. Registration number: NCT00388128 (http://www.clinicaltrials.gov).

Drug therapy for improving walking distance in intermittent claudication: a systematic review and meta-analysis of robust randomised controlled studies

OBJECTIVES

To evaluate the efficacy of pharmacological interventions in improving walking capacity and health-related quality of life for people with intermittent claudication. DATASOURCES: We searched Medline, EMBASE, Cochrane library and relevant websites for studies published from the start of the databases to February 2009. In addition, reference lists were manually searched.

REVIEW METHODS

Based upon a power calculation, only robust (n>56), peer-reviewed, double-blinded, randomised and placebo-controlled trials were included. The main outcomes evaluated were maximal walking distance (MWD) and pain-free walking distance on a treadmill. Random models were used in the statistical analysis, and chi-square test were used to test for heterogeneity.

RESULTS

Among 220 trials, only 43 trials fulfilled the quality criteria. Treatment periods, follow-up and treadmill protocols varied substantially. Vasodilator agents and phosphodiesterase inhibitors show robust significant results compared to placebo, but the improvements in MWD are modest. The highest benefit was caused by lipid-lowering agents, which in mean gained above 160 m in MWD, while the other agents only improved MWD about 50 m.

CONCLUSION

Several drugs have shown to improve MWD, but with limited benefits. Statins seem to be the most efficient drug at the moment.

The effects of milk feeding method and group size on feeding behavior and cross-sucking in group-housed dairy calves

This study investigated the effect of teat feeding and group size on cross-sucking and competition for milk in dairy calves. Ninety-six Holstein-Friesian male and female calves were allocated to either pairs or groups of 6 and fed milk either from a bucket or via a teat. Calves fed via a teat spent more time ingesting the milk. They spent time sucking the empty teat after milk intake and they spent less time cross-sucking compared with calves fed from buckets. The results show that teat feeding reduces cross-sucking in groups of 6 calves. Calves in groups of 6 ingested the milk faster than calves housed in pairs, which suggests that the competition for milk was greater than in pairs. Teat-fed calves changed to another teat more often than bucket-fed calves changed to another bucket during milk intake. Thus, the use of teat feeding did not reduce the competition for milk as compared with bucket feeding and future studies should focus on improving teat-feeding methods so that they reduce competition for milk in group-housed calves.

Effect of darbepoetin alfa on physical function in patients undergoing surgery for colorectal cancer. A randomized, double-blind, placebo-controlled study

OBJECTIVE

To study whether perioperative treatment with darbepoetin alfa (DA) improves physical performance following colorectal cancer surgery.

METHODS

Patients admitted for planned colorectal cancer surgery were randomized to receive either weekly placebo or DA 300 or 150 microg depending on the hemoglobin (Hb) concentration. Patients were assessed 10 days before, as well as 7 and 30 days after surgery for work capacity, postural sway, muscle strength, fatigue and quality of life (QoL). The primary outcome measure were the changes in patients' physical performance from preoperative to postoperative day 7.

RESULTS

Of 221 included patients, 151 were evaluable. Baseline characteristics were similar in the 2 groups. Patients receiving DA had a significantly better working capacity on day 7 (p = 0.03) and day 30 (p = 0.03) compared with the placebo group. There were no statistically significant differences between the 2 groups on days 7 or 30 for fatigue, postural sway and QoL. DA treatment significantly (p < 0.01) reduced the decrease in Hb concentrations on day 7 and resulted in an earlier return (p < 0.01) to the preoperative Hb concentration compared to placebo treatment.

CONCLUSION

Perioperative DA treatment improved postoperative work capacity and Hb concentrations, but had no effect on postoperative fatigue, postural sway, QoL and muscle strength.

Axillary lymph node micrometastases in invasive breast cancer: national figures on incidence and overall survival

The purpose of this study was to estimate the incidence and prognostic value of axillary lymph node micrometastases (Nmic) of 2 mm or less in breast carcinomas. Results are based on data from the Danish Breast Cancer Cooperative Group (DBCG). The study was carried out as a nationwide, population-based trial with a study series consisting of 6,959 women under 75 years of age registered in the national DBCG data base from 1 January 1990 to 31 October 1994. All patients had contracted operable primary breast carcinoma, stage I-III, classified according to the TNM system as T1-T3, N0-N1, M0. Women with four or more metastatic axillary lymph nodes were excluded. All patients were treated systematically according to approved national guidelines and treatment protocols. Metastases were recognized microscopically on haematoxylin and eosin-stained sections. In case of doubt immunohistochemical staining for cytokeratin was performed. There was no serial sectioning. Micrometastases were tumour deposits of 2 mm or smaller, and accordingly included deposits of 0.2 mm and smaller. With a median observation time of 10 years and 2 months, women with Nmic (N=427) experienced a significantly worse overall survival (OS) compared with node-negative (Nneg) women (N=4,767) (relative risk (RR)=1.20, 95% CI: 1.01-1.43), irrespective of menopausal status. Women with macrometastases (Nmac) (N=1,765) had significantly worse final outcome than women with Nmic (RR=1.54, 95% CI: 1.29-1.85), irrespective of menopausal status. Multivariate analysis adjusted for patient-, histopathologic-, and loco-regional therapeutic variables showed that cases with Nmic had a significantly higher risk of death relative to Nneg cases (adjusted RR=1.49, 95% CI: 1.18-1.90). Interaction analysis showed that the number of nodes examined had a significant impact on adjusted relative risk of death according to axillary status. Furthermore, the number of nodes involved significantly influenced adjusted risk of death in the Nmic compared to the Nmac series. In conclusion, the results of the present study revealed worse final outcome in women with Nmic compared with Nneg, where all Nmic cases received adjuvant systemic treatment. Interaction analysis showed that the number of retrieved axillary nodes and the number of affected nodes had a different influence on survival related to axillary status. The different risk pattern in Nmic vs Nmac patients indicates that Nmic cases do not show the traditional risk pattern as revealed by the Nmac cases, in which increasing number of positive nodes is associated with an orderly increasing adjusted RR.

Reaction of foster cows to prevention of suckling from and separation from four calves simultaneously or in two steps

The aim of this study was to investigate if a 2-step method of preventing suckling and cow-calf separation reduces the stress reaction in foster cows compared with a simultaneous separation method. Seven Swedish Holstein and 5 Swedish Red dairy cows were used as foster cows, each having a group of 4 calves. The foster cow-calf group was formed when calves were 1 wk old, and the calves were prevented from suckling at 10 wk of age. In 6 of the cow-calf groups, calves were prevented from suckling by simultaneous separation from the cow (control). In the other 6 groups, calves were fitted with a nose-flap, which prevented them from suckling while they were kept together with the cow for another 2 wk before they were separated (2-step). The behavior of the foster cows was observed at 4 observation periods, 0 to 2, 8.5 to 9.5, 24 to 26, and 72 to 74 h after the calves were prevented from suckling (2-step), after separation (2-step), and after calves were prevented from suckling by simultaneous separation (control). For both treatments, saliva cortisol was sampled once daily for 5 d at wk 10. This was repeated at wk 12 for the 2-step treatment. Heart rate was measured with the behavioral observations. Control foster cows vocalized more (P < 0.001) and walked more (P = 0.005) than the 2-step foster cows after prevention of suckling and after separation from the calves. When control cows were separated from their calves, they more frequently (P < 0.001) held their head out of the pen than was the case with 2-step cows when separated 2 wk after prevention of suckling. The variation in heart rate was larger in the control group compared with 2-step cows at 0 to 2 h after separation/prevention of suckling (P = 0.002). No effect of treatment was found on cortisol concentration. Our conclusion is that separating the 2 events "prevention of suckling" and "separation" reduces the stress experienced by the foster cow at weaning.

Short Communication: Identification of Diseased Calves by Use of Data from Automatic Milk Feeders

Housing calves in large groups is associated with a higher risk of respiratory disease and with increased difficulties in identifying diseased animals compared with single housing. The aim of the present study was to investigate the effect of clinical disease on some behaviors recorded by automatic milk feeders in pre-weaned dairy calves. The experiment included 27 calves from a Danish research farm and 41 calves from a Swedish research farm. The calves were fed restrictively from a computer-controlled milk feeder, and all calves were subjected to daily clinical examinations for 3 to 26 d, with information gathered on general condition, nasal discharge, lung auscultation findings, coughing, signs of dehydration, naval status, rectal temperature, fecal consistency, and presence of chin abscess, arthritis, umbilical hernia, poor body condition, and poor hair coat. Calves suffering from diarrhea, respiratory disease, fever, or unspecific decreased general condition for more than 2 d were considered to be diseased and were declared to have recovered when they had been free of clinical signs of the disease for at least 2 d. The effects of clinical status (healthy, diseased) on the number of rewarded and unrewarded visits to the calf feeder and drinking rate, respectively, were analyzed by variance component analysis using a mixed model. Milk consumption on diseased and nondiseased days within calves was compared using a Wilcoxon signed rank test. In total, 53 of the calves were diagnosed as diseased during the study period. All cases of diseases were mild and were associated with an unaffected or only mildly affected general condition. Diarrhea was diagnosed in 51 calves, 6 of which also had respiratory disease. In 2 calves, respiratory disease was the only diagnosis. Eleven calves had an unspecific decreased general condition. The number of unrewarded visits was significantly reduced when calves were diseased. In Swedish calves, there was also a tendency for rewarded visits to be reduced during diseased days. Drinking rate and number of rewarded visits increased with increasing age. No effect of clinical status on milk consumption was detected. The number of unrewarded visits was the most sensitive of the 4 feeding behaviors monitored to indicate clinical disease in calves fed restricted milk volumes.

Postoperative physical training following colorectal surgery: a randomised, placebo-controlled study

BACKGROUND AND AIMS

Major surgery is often followed by fatigue and reduced physical function. We wished to study if postoperative physical training reduced fatigue and improved physical function.

MATERIAL AND METHODS

Randomised, placebo-controlled, single-blinded study. Participants were unselected patients > or = 60 years undergoing elective colorectal surgery without disseminated cancer or inflammatory bowel disease. Group A trained muscular strength and work capacity. Group B performed relaxation exercises and received hot wrappings and massage. Main outcome measures were: fatigue (visual analogue scale), muscular strength, walking speed, physical performance test, and physical function questions (SF-36).

RESULTS

Preoperatively the two groups were similar except that A was more fatigued than B. By postoperative day seven fatigue had increased compared to preoperatively, more in B than A, but by day 30 and 90 there were no significant differences between groups. All indices of physical function decreased postoperative day seven and were at the preoperative level day 90 with no significant differences between groups in change in function. Day seven the change in knee extension strength tended to be lower in B than A but by day 30 changes were similar in both groups.

CONCLUSION

Postoperative training did not improve physical function, but reduced fatigue in hospital.

Metabolic effects of caffeine ingestion and physical work in 75-year old citizens. A randomized, double-blind, placebo-controlled, cross-over study

OBJECTIVE

Whereas caffeine has been demonstrated to impact substantially on the metabolic response to exercise in healthy young subjects, this issue remains to be addressed in healthy elderly subjects.

DESIGN AND PATIENTS

The metabolic response to caffeine ingestion (6 mg/kg) and exercise in healthy elderly citizens at 70 years was examined in a randomized, double-blind, placebo-controlled, cross-over study. We included 30 subjects attending for driver license renewal at their general practitioner. Participants abstained from caffeinated drinks and food for 48 h and were randomized to receive placebo-caffeine or caffeine-placebo with 1 week between sessions.

MEASUREMENTS

A cycling endurance test at 65% of the expected maximal heart rate was performed 1 h after intervention. Blood samples were taken before intervention, before cycling, after 5 min of cycling, and at exhaustion. Analysis was by intention-to-treat and P < 0.05 was regarded as significant.

RESULTS

Caffeine significantly increased the concentration of plasma epinephrine (by 42%, 39%, and 49%), serum-free fatty acids (by 53%, 44%, and 50%), and plasma lactate (by 46%, 36%, and 48%), and insulin resistance (homeostasis model assessment-IR) (by 21%, 26%, and 23%) during rest, after 5 min of cycling, and at exhaustion. At exhaustion, the concentration plasma norepinephrine was elevated by 29%. A decrease was seen with caffeine treatment in blood potassium after 5 min of cycling and at exhaustion (by 3% and 2%, respectively).

CONCLUSIONS

Caffeine treatment increased epinephrine, fatty acids, lactate and norepinephrine at different times during test session and led to insulin-resistance. Hence, caffeine ingestion elicits a similar metabolic response in elderly participants at 70 years old to that seen in younger subjects.

Computer-controlled milk feeding of group-housed calves: the effect of milk allowance and weaning type

Calves fed by computer-controlled milk feeders are often weaned gradually by reducing the size of the milk portions. However, reducing the number of milk portions instead may lower calves' occupation of the milk feeder and stimulate their concentrate intake, especially when they are offered a high milk allowance. Before weaning, but not during weaning, the calves on low milk allowance occupied the milk feeder more, consumed more concentrates, and had a lower daily gain. There was no interaction between milk allowance and weaning type. Weaning by reducing the number of milk portions resulted in more unrewarded visits to the milk feeder, but less time ingesting a similar amount of milk. The effect of milk allowance on milk feeder occupancy before weaning was not found when this allowance was halved during weaning.

Caffeine improves endurance in 75-yr-old citizens: a randomized, double-blind, placebo-controlled, crossover study

This study investigated the effect of caffeine on physical performance in healthy citizens aged > or =70 yr. The randomized, double-blind, placebo-controlled, crossover study was conducted in 15 men and 15 women recruited by their general practitioner. Participants abstained from caffeine for 48 h and were randomized to receive one capsule of placebo and then caffeine (6 mg/kg) or caffeine and then placebo with 1 wk in between. One hour after intervention, we measured reaction and movement times, postural stability, walking speed, cycling at 65% of expected maximal heart rate, perceived effort during cycling, maximal isometric arm flexion strength, and endurance. Analysis was by intention to treat, and P < 0.05 was regarded as significant. Caffeine increased cycling endurance by 25% [95% confidence interval (CI): 13-38; P = 0.0001] and isometric arm flexion endurance by 54% (95% CI: 29-83; P = 0.0001). Caffeine also reduced the rating of perceived exertion after 5 min of cycling by 11% (95% CI: 5-17; P = 0.002) and postural stability with eyes open by 25% (95% CI: 2-53; P = 0.03). Caffeine ingestion did not affect muscle strength, walking speed, reaction, and movement times. At the end of the study, 46% of participants correctly identified when they received caffeine and placebo. Caffeine increased exercise endurance in healthy citizens aged > or =70 yr, but the participants' reasons for stopping the test may have varied between subjects, as the cycling test was done at approximately 55% of maximal oxygen consumption. Further studies are required to investigate whether caffeine can be utilized to improve the physical performance of elderly citizens.

Little effect of physical training on body composition and nutritional intake following colorectal surgery--a randomised placebo-controlled trial

OBJECTIVE

Postoperatively patients have a reduction in nutritional intake and body weight. We studied the effect of postoperative physical training on nutritional intake and body composition.

METHODS

Patients > or =60 y admitted for elective colorectal surgery were randomised to train muscular strength (group A) or to nonstrengthening exercises (group B) for 3 months. Fat mass (FM) and lean body mass (LBM) were assessed with bioimpedance preoperatively, 7, 30, and 90 days postoperatively. Nutritional intake was registered in a subpopulation.

RESULTS

Of 119 included patients, 60 were randomised to group A and 59 to B. The changes in LBM at postoperative day 7 were a mean (s.d.) of 0.4 (2.1) kg in group A compared to -0.7 (2.0) kg in B. The difference between groups of 1.2 (0.5) kg at day 7 was statistically significant (P=0.03). At no other time was observed difference between groups in weight, LBM, or FM. The energy and protein intake rose during postoperative day 1-7 and rose further after discharge. At no time were differences between groups.

CONCLUSION

Physical training had little effect on body composition following abdominal surgery. The nutritional intake in well-nourished patients did not increase by training.

Transthoracic echocardiography for cardiopulmonary monitoring in intensive care

BACKGROUND AND OBJECTIVE

To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring.

METHODS

The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed.

RESULTS

Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive.

CONCLUSIONS

By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients.

RNA polymerase IV directs silencing of endogenous DNA

Plants encode subunits for a fourth RNA polymerase (Pol IV) in addition to the well-known DNA-dependent RNA polymerases I, II, and III. By mutation of the two largest subunits (NRPD1a and NRPD2), we show that Pol IV silences certain transposons and repetitive DNA in a short interfering RNA pathway involving RNA-dependent RNA polymerase 2 and Dicer-like 3. The existence of this distinct silencing polymerase may explain the paradoxical involvement of an RNA silencing pathway in maintenance of transcriptional silencing.

Computer-Controlled Milk Feeding of Dairy Calves: The Effects of Number of Calves per Feeder and Number of Milk Portions on Use of Feeder and Social Behavior

One hundred ninety-two calves (Holstein-Friesian, Danish Red, and Jersey) were allocated to either groups of 24 calves or groups of 12 calves with one computer-controlled milk feeder per group. Within group, one-half of the calves were offered the daily milk allowance in either 4 or 8 milk portions. In groups with 24 calves, there was a higher level of competition for access to the feeder than in groups with 12 calves. Calves waited longer for access, and while occupying the feeder, they were more often disturbed by other calves attempting to access the feeder. The increased level of competition resulted in a higher rate of milk ingestion among calves in groups of 24 and, as a result, a lower duration of time spent ingesting the milk and a lower occupation of the feeder per calf. The number of calves per feeder did not affect the amount of milk ingested, but the high level of disturbance and the increased feeding rate with 24 calves per feeder suggest that these calves were subject to social constraint. Offering the same milk allowance in 4 rather than 8 milk portions lowered the occupancy of the feeder. The number of portions did not affect the duration of ingesting milk, but the duration of occupying the feeder just after milk ingestion was lower with 4 than with 8 milk portions. Thus, fewer and larger portions may lower competition for access during the activity periods if all other factors remain equal.

Determinants of weak femoral artery pulse in dogs with mitral valve prolapse

In three substudies encompassing 247 dogs from two breeds predisposed to myxomatous mitral valve disease (MMVD), femoral artery pulse strength was palpated and related to potential explanatory factors, including quantitative echocardiographic measures of MMVD, aortic and femoral artery diameter and wall thickness and blood pressure. In addition, in 109 Cavalier King Charles Spaniels (of which 61 were included in the three substudies mentioned above), the relation between femoral artery pulse strength and presence of thrombocytopenia was investigated. In 26% of the dogs, a pulse </=50% of normal strength was detected; six dogs (2.0%) had an absent pulse unilaterally or bilaterally. Mitral valve prolapse severity, degree of obesity, heart rate and age all influenced femoral artery pulse strength negatively. Weak femoral artery pulses were not related to clinical signs or to decreased pulse pressure or stroke volume. A weak femoral artery pulse reflected reduced artery diameter and/or distension rather than occlusion. In conclusion, weak femoral artery pulses in dogs with MMVD seem to be associated with regional/local reductions in blood flow and not arteriosclerosis or platelet count.

Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery

OBJECTIVE

A postoperative regimen using a multimodal approach with enforced mobilization and early oral nutrition has been reported to improve convalescence but has not been compared with other postoperative regimens.

METHODS

Forty patients undergoing elective colorectal surgery were randomly allocated to an intervention group receiving comprehensive information on the importance of mobilization, balanced anesthesia, and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics, postoperative analgesia with epidural morphine, and mobilization without fixed goals. All patients were offered early oral nutrition. The regimens were compared by means of ambulation time and physical activity, voluntary muscle strength, pulmonary function, and body composition.

RESULTS

The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 (P = 0.0004) and within 8 h versus 2 h on day 4 (P = 0.0003). The voluntary strength of the quadriceps muscle decreased by 3% in the intervention group versus 15% in the control group on day 7 (P = 0.04). Two months postoperatively, the difference between groups was the same (P = 0.02).

CONCLUSION

This active per- and postoperative regimen based on a multimodal approach improved ambulation time and muscle function during admission and late convalescence.

Impact of axillary dissection on staging and regional control in breast tumors < or = 10 mm--the DBCG experience. The Danish Breast Cancer Cooperative Group (DBCG), Rigshisoutalet, Copenhagen, Denmark

Data from 4771 patients with tumor diameters < or = 10 mm were analyzed. Results of surgery and pathoanatomical examinations indicated that nodal status was related to diameter, but not to number of nodes removed. More axillary metastases were found in group T1b tumors than in T1a. In 8% of tumors, at least 4 positive nodes were identified. Mean number of positive nodes was related to number of nodes removed, and when 10 or more nodes were removed a significantly lower axillary recurrence rate and better recurrence-free survival were demonstrated, confirming that axillary surgery has two goals: staging and regional disease control. Age, receptor status, grade and histological type, but not tumor location, were related to prognosis. In accordance with the classical prognostic factors, it was not possible to define a patient group where axillary surgery was superfluous. We conclude that proper staging and regional control renders a full axillary level I-II dissection necessary.

[Should all younger patients with breast cancer be offered adjuvant cytotoxic chemotherapy?]

The aim of the study was to investigate whether young age at diagnosis is a negative prognostic factor in primary breast cancer and how stage of disease at diagnosis and treatment may influence such an association. It was conducted as a retrospective cohort study based on a population-based data-base of breast cancer diagnosis with detailed information on tumour characteristics, treatment regimens, and vital status and included 10,356 patients with primary breast cancer less than 50 years of age at diagnosis. The main outcome measures were relative risk of dying within the first ten years after diagnosis according to age at diagnosis, adjusted for effect of known prognostic factors and expected mortality. Overall, young patients with low risk disease who did not receive adjuvant treatment had a significantly increasing risk of dying with decreasing age at diagnosis (adjusted relative risk: 45-49 years: 1 (reference); 40-44 years: 1.12 (0.89-1.40); 35-39 years: 1.40 (1.10-1.78); < 35 years: 2.18 (1.64-2.89). However, a similar trend was not seen in young patients who received adjuvant cytotoxic therapy. We found the same difference as above when comparing women receiving no treatment with those receiving adjuvant cytotoxic therapy within strata of node negative patients and patients with the same tumour size. In conclusion, the negative prognostic effect of young age is almost exclusively seen in women diagnosed with low risk disease not receiving adjuvant cytotoxic therapy, whereas young women who receive adjuvant cytotoxic therapy have the same prognosis as middle-aged women. These results suggest that young women with breast cancer, on the basis of age alone, should be regarded as high risk patients and be given adjuvant cytotoxic therapy.

IFNgamma enhances microglial reactions to hippocampal axonal degeneration

Glial reactivity is implicated in CNS repair and regenerative responses. Microglia, the cells responding earliest to axonal injury, produce tumor necrosis factor-alpha (TNFalpha), a cytokine with both cytopathic and neuroprotective effects. We have studied activation of hippocampal microglia to produce TNFalpha in response to transection of perforant path axons in SJL/J mice. TNFalpha mRNA was produced in a transient manner, peaking at 2 d and falling again by 5 d after lesioning. This was unlike other markers of glial reactivity, such as Mac-1 upregulation, which were sustained over longer time periods. Message for the immune cytokine interferon-gamma (IFNgamma) was undetectable, and glial reactivity to axonal lesions occurred as normal in IFNgamma-deficient mice. Microglial responses to lesion-induced neuronal injury were markedly enhanced in myelin basic protein promoter-driven transgenic mice, in which IFNgamma was endogenously produced in hippocampus. The kinetics of TNFalpha downregulation 5 d after lesion was not affected by transgenic IFNgamma, indicating that IFNgamma acts as an amplifier and not an inducer of response. These results are discussed in the context of a regenerative role for TNFalpha in the CNS, which is innately regulated and potentiated by IFNgamma.

Axonal sprouting regulates myelin basic protein gene expression in denervated mouse hippocampus

The regulation of oligodendrocyte gene expression and myelination in vivo in the normal and injured adult CNS is still poorly understood. We have analyzed the effects of axotomy-induced axonal sprouting and microglial activation, on oligodendrocyte myelin basic protein (MBP) gene expression from 2 to 35 days after transection of the entorhino-hippocampal perforant path axonal projection. In situ hybridization analysis showed that anterograde axonal and terminal degeneration lead to upregulated oligodendrocyte MBP mRNA expression starting between day 2 and day 4, in (1) the deep part of stratum radiatum of CA3 and the dentate hilus, which display axonal sprouting but no degenerative changes or microglial activation, and (2) the outer part of the molecular layer of the fascia dentata, and in stratum moleculare of CA3 and stratum lacunosum-moleculare of CA1, areas that display dense anterograde axonal and terminal degeneration, myelin degenerative changes, microglial activation and axotomi-induced axonal sprouting. Oligodendrocyte MBP mRNA expression reached maximum in both these areas at day 7. MBP gene transcription remained constant in stratum radiatum, stratum pyramidale and stratum oriens of CA1, areas that were unaffected by perforant path transection. These results provide strong evidence that oligodendrocyte MBP gene expression can be regulated by axonal sprouting independently of microglial activation in the injured adult CNS.