The natural history of low-risk non-muscle-invasive bladder cancer: a collaborative multi-centre study

BACKGROUND

International guidelines vary in terms of their definition and recommendation for management of low-risk non-muscle-invasive bladder cancer (LRNMIBC). The ideal management for this large subset of bladder cancer patient remains unclear.

OBJECTIVE

To evaluate long-term outcomes of patients with LRNMIBC. As a secondary objective, to assess for intergroup heterogeneity in disease-specific outcomes between G1 and G2LG diseases.

METHODS

A multi-centre, retrospective study of patients who met the 2015 NICE definition of LRNMIBC. Timeline of diagnosis ranged from 01/01/2012 to 30/06/2016.

RESULTS

A total 390 patients had available follow-up data (G1: 142, G2LG: 249). Over a median follow-up time of 36 months (IQR 25-50), 29.2% of the patients developed a recurrence. G2LG patients were statistically more likely to develop a recurrence (G1: 26.8%, G2LG: 33.7%, p < 0.05). 51.8% of recurrences occurred after 1 year of surveillance. Progression to high-grade disease occurred in 1.8% (n = 7, G1: 3, G2LG: 4) and a further 1.0% (n = 4, G1:3, G2LG: 1) of patients developed muscle-invasive bladder cancer (MIBC).

CONCLUSION

The majority of recurrences occurred after 1 year of surveillance. The risk of disease progression was low; however, this was observed in a cohort of patients with regular cystoscopic follow-up. The risk may be higher if patients were pre-maturely discharged. If a 5-year surveillance programme were to be followed, 96.5% of recurrences would be captured. Lastly, there appears to be intergroup heterogeneity within LRNMIBC with G2LG patients having a statistically higher risk of recurrence compared to G1.

Evolutionary Transition in the Late Neogene Planktonic Foraminiferal Genus Truncorotalia

The fossil record provides empirical patterns of morphological change through time and is central to the study of the tempo and mode of evolution. Here we apply likelihood-based time-series analyses to the near-continuous fossil record of Neogene planktonic foraminifera and reveal a morphological shift along the Truncorotalia lineage. Based on a geometric morphometric dataset of 1,459 specimens, spanning 5.9–4.5 Ma, we recover a shift in the mode of evolution from a disparate latest Miocene morphospace to a highly constrained early Pliocene morphospace. Our recovered dynamics are consistent with those stipulated by Simpson's quantum evolution and Eldredge-Gould's punctuated equilibria and supports previous suppositions that even within a single lineage, evolutionary dynamics require a multi-parameter model framework to describe. We show that foraminiferal lineages are not necessarily gradual and can experience significant and rapid transitions along their evolutionary trajectories and reaffirm the utility of multivariate datasets for their future research.

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Evolution of planktonic foraminiferal anatomy across Miocene/Pliocene boundary

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Novel application of multivariate analyses to 1,459 specimens

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Evidence for a punctuated anatomical shift associated with the boundary

Predicting milk responses to cereal-based supplements in grazing dairy cows

The feeding of cereal-based supplements is common in the Australian dairy industry, as it allows cows to increase intakes of total dry matter (DM) and metabolisable energy (ME), while achieving greater stocking rates, greater pasture utilisation and greater milk production per hectare than occurs when cows are fed pasture-only diets. However, for this practice to be profitable, it is important to know how much extra milk, milk protein and milk fat are produced for each kilogram DM consumed. This is difficult to determine in such a complex biological system. We combined information from 24 concentrate-feeding experiments using meta-analysis techniques, so as to develop improved prediction models of the milk, milk protein and milk fat produced when cereal-based concentrates are fed to grazing, lactating dairy cows. Model terms, consistent with biological processes, linear, quadratic and factorial, were selected according to statistical significance. The models were then tested in two ways, namely, their goodness of fit to the data, and their ability to predict novel production data from a further six, unrelated, experiments. A sensitivity analysis was also undertaken to determine how sensitive these predictions are to changes in key inputs. The predictive model for milk yield was shown to very closely reflect milk yield (kg/cow.day) measured under the experimental conditions in unrelated experiments (r = 0.96), with very little bias (Lin’s bias correction factor = 0.98) and high concordance (Lin’s concordance coefficient = 0.95). Predictions generated by multiplying predicted milk protein concentration by predicted milk yield closely matched observed milk protein yield (kg/cow.day) (r = 0.96, Lin’s bias correction factor = 0.98, Lin’s concordance coefficient = 0.95), and predictions found by multiplying predicted milk fat concentration by predicted milk yield closely matched observed milk fat yield (kg/cow.day) (r = 0.94, Lin’s bias correction factor = 0.99, Lin’s concordance coefficient = 0.93). Factors included in the new models for milk, milk protein and milk fat yield reported here have been identified previously as elements that can influence milk production. The value to the dairy industry from being able to predict profitable amounts of concentrates to feed at various stages throughout lactation is considerable. For farmers and their advisers, being able to apply these models to estimate the immediate marginal milk protein and milk fat responses to supplementary feeds should lead to more robust, efficient and profitable milk production systems.

Variation in feeding behavior and milk production among dairy cows when supplemented with 2 amounts of mixed ration in combination with 2 amounts of pasture

Variation in feeding behavior and milk production of grazing dairy cows fed a mixed ration was measured. Experiments were conducted in spring (early lactation) and autumn (late lactation) with 48 Holstein-Friesian dairy cows. Pasture allowance (low vs. high) and amounts of supplement (low vs. high) were applied to determine the effect on variation among cows in feeding behavior and milk production. The experiments investigated 4 dietary treatments in a 2×2 factorial arrangement of treatments. Daily pasture allowances were 15kg of DM/cow per day (low) and 37kg of DM/cow per day (high; to ground level); and 12kg of DM/cow per day (low) and 31kg of DM/cow per day (high; to ground level), for the spring and autumn experiments, respectively. Supplements were offered at 6kg of DM/cow per day (low) and 14kg of DM/cow per day (high); and 6kg of DM/cow per day (low) and 12kg of DM/cow per day (high), for the spring and autumn experiments, respectively. There were 2groups of 6 cows per treatment. All treatments received a partial mixed ration, defined as a total mixed ration fed between periods of grazing that contained wheat grain, corn grain, alfalfa hay, and canola meal. The grain-to-forage ratio of the supplements was 78:22 (DM basis) in both spring and autumn. In both experiments, the pre-experimental period was 14d followed by a 10-d experimental period. The variation among cows within a group in feeding behavior was influenced by the amount of supplement but not the amount of pasture offered. The variation among cows in pasture eating time approximately doubled when the amount of supplement offered increased, indicating that to reduce the variability among cows, supplement feeding management strategies need to be considered. Increasing pasture allowance had no effect on pasture eating time although pasture intake increased as a result of increased grazing intensity compared with the low pasture allowance. However, increasing the amount of supplement in the partial mixed ration feeding system reduced pasture eating time by 51min/cow per day.

Incorporating mixed rations and formulated grain mixes into the diet of grazing cows: Effects on milk composition and coagulation properties, and the yield and quality of Cheddar cheese

Effects of different strategies for feeding supplements to grazing dairy cows on the composition and coagulation properties of milk and the subsequent yield and quality of Cheddar cheese were measured. The experiment used milk from 72 Holstein-Friesian cows, averaging 45d in milk, fed according to 1 of 3 feeding strategies: (1) cows grazed a restricted allowance of perennial ryegrass pasture [approximately 14kg of dry matter (DM)/cow per day, to ground level] supplemented with milled wheat grain fed in the milking parlor and alfalfa hay offered in the paddock (control); (2) same pasture and allowance as control, supplemented with a formulated grain mix containing wheat grain, corn grain, and canola meal fed in the parlor and alfalfa hay fed in the paddock (FGM); or (3) same pasture and allowance as control, supplemented with a partial mixed ration comprising the same formulated grain mix but mixed with alfalfa hay and presented on a feed pad after each milking (PMR). For all strategies, supplements provided the same metabolizable energy and grain:forage ratio (78:22, DM basis). Within each feeding strategy, milk was sampled from cows receiving either 8 or 16kg (DM) of supplement/cow per day. There were 2 replicated groups of 6 cows per supplement amount per dietary strategy; approximately 250L of milk was sampled from each for analyses of composition and coagulation properties and the manufacture of Cheddar cheese. The experiment had a 14-d adaptation period and a 14-d measurement period. For cows fed according to the control strategy, those fed 16kg/cow per day produced milk with lower concentrations of milk fat than cows fed 8kg/cow per day. This effect was not observed for cows fed according to the FGM and PMR strategies. Milk from cows fed 16kg of DM/cow per day according to the control strategy yielded less Cheddar cheese than milk from cows fed according to the PMR strategy, with cheese yields from FGM cows being intermediate. Amount of supplement offered had minor effects on percentages of some fatty acids. We observed few other effects of feeding strategy on milk composition, types of milk protein, milk coagulation properties, or the composition and quality of the resultant Cheddar cheese. These data show that, compared with the traditional control strategy, feeding PMR or FGM may increase milk fat concentration and the subsequent yield of Cheddar cheese without compromising cheese composition or quality.

Milk production responses to different strategies for feeding supplements to grazing dairy cows

Milk production responses of grazing cows offered supplements in different ways were measured. Holstein-Friesian cows, averaging 45 d in milk, were allocated into 8 groups of 24, with 2 groups randomly assigned to each of 4 feeding strategies. These were control: cows grazed a restricted allowance of perennial ryegrass pasture supplemented with milled wheat grain fed in the milking parlor and alfalfa hay offered in the paddock; FGM: same pasture and allowance as the control supplemented with a formulated grain mix containing wheat grain, corn grain, and canola meal fed in the parlor and alfalfa hay fed in the paddock; PMRL: same pasture and allowance as the control, supplemented with a PMR consisting of the same FGM but mixed with alfalfa hay and presented on a feed pad after each milking; and PMRH: same PMR fed in the same way as PMRL but with a higher pasture allowance. For all strategies, supplements provided the same metabolizable energy and grain:forage ratio [75:25, dry matter (DM) basis]. Each group of 24 cows was further allocated into 4 groups of 6, which were randomly assigned to receive 8, 12, 14, or 16 kg of DM supplement/cow per d. Thus, 2 replicated groups per supplement amount per dietary strategy were used. The experiment had a 14-d adaptation period and a 14-d measurement period. Pasture allowance, measured to ground level, was approximately 14 kg of DM/d for control, FGM, and PMRL cows, and 28 kg of DM/d for the PMRH cows, and was offered in addition to the supplement. Positive linear responses to increasing amounts of supplement were observed for yield of milk, energy-corrected milk, fat, and protein for cows on all 4 supplement feeding strategies. Production of energy-corrected milk was greatest for PMRH cows, intermediate for FGM and PMRL cows, and lowest for control cows. Some of these differences in milk production related to differences in intake of pasture and supplement. Milk fat concentration decreased with increasing amount of supplement for all feeding strategies, but the decline was most marked for the control cows. Milk protein concentration increased for all groups as the amount of supplement increased, but was greater for FGM, PMRL, and PMRH cows than control cows. It is concluded that when supplements are fed to grazing dairy cows, inclusion of corn grain and canola meal can increase milk production even at similar metabolizable energy intakes, and that it does not matter whether these supplements are fed as a PMR or in the parlor and paddock.

A case of human to human transmission of orf between mother and child

Orf is caused by a parapoxvirus. In adults, it is commonly associated with specific occupations, whereas cases in children tend to be associated with household or recreational exposure. Spontaneous recovery usually occurs within 6 weeks. Infection in humans is believed to be through exposure to an infected animal or fomite. We present a case of a 13-month-old boy who was exposed to orf through his mother, a farmer, who had contracted the disease through administering medication to an infected animal. We believe that this may represent only the fifth case of human to human transmission of orf reported in the literature.

The effects on ruminal pH and serum haptoglobin after feeding a grain-based supplement to grazing dairy cows as a partial mixed ration or during milking

Ruminal pH and serum concentrations of haptoglobin (Hp) were measured in order to assess the risk of subacute ruminal acidosis (SARA) in grazing cows offered rolled wheat grain twice daily in the dairy at milking (Control group; n= 64), or as a partial mixed ration (PMR group; n= 64) on a feedpad. Cows were allocated various levels of the supplement (8, 10, 12 or 14 kg dry matter/day). Ruminal pH was measured in 16 rumen-fistulated cows (eight PMR and eight Control group cows), using indwelling pH meters, recording every 10 min for 14 days. Serum Hp was analysed in samples collected from 125 cows. No differences in ruminal pH or serum Hp concentration were found between treatment groups, or levels of feeding. It was concluded that, using ruminal pH patterns and Hp as markers of SARA at the feeding levels used in this study, there were no differences between grazing cows fed the supplement either as grain in the dairy or as a PMR fed on a feedpad.

New Zealand juvenile oyster mortality associated with ostreid herpesvirus 1-an opportunistic longitudinal study

During the 2010-11 summer outbreak of ostreid herpesvirus 1 (OsHV-1) in New Zealand, an opportunistic longitudinal field study was conducted. OsHV-1 PCR-negative oyster spat (Crassostrea gigas) were relocated to an OsHV-1 PCR-positive area of the North Island of New Zealand that was experiencing juvenile oyster mortalities. Over a period of 13 d, spat were monitored for mortality, sampled for histopathology, and tested for the presence of OsHV-1 using real time PCR and Vibrio culture. Histopathology showed some evidence of tissue pathology; however, no consistent progressive pathology was apparent. Field mortalities were evident from Day 6 on. After 5 and 7 d of exposure, 83 and 100% of spat, respectively, tested positive for the virus by real time PCR. Vibrio species recovered during the longitudinal study included V. splendidus and V. aestuarianus. This study offers insight into the rapidity of onset and virulence of the virus in naïve oyster spat in New Zealand waters.

Feeding a partial mixed ration once a day did not increase milk production compared with feeding grain in the dairy and forage in the paddock

This experiment measured milk production responses of grazing cows offered supplements in different ways. Holstein-Friesian cows averaging 89 days in milk, were allocated into six groups of 36 (each group including three rumen-fistulated cows). Two groups were randomly assigned to each of three dietary treatments: (1) cows were offered milled barley grain twice daily at milking and pasture silage in the paddock (Control); (2) the same amounts of milled barley grain and pasture silage were fed as a partial mixed ration (PMR) once a day following morning milking (PMR1); and (3) cows were supplemented with a PMR containing milled barley grain, lucerne hay, maize silage and crushed maize grain fed once a day following morning milking (PMR2). All dietary treatments were formulated to provide the same metabolisable energy and cows were offered a restricted allowance of ~14 kg DM/cow.day (to ground level) of perennial ryegrass pasture in addition to their supplement. Each group of 36 cows was further divided into four groups of nine, each of which were offered supplements at either 6, 8, 10 and 12 kg DM/cow.day. The experiment consisted of a 14-day adaptation period and an 11-day measurement period. Cows fed PMR1 and PMR2 once a day did not show an increase in milk production compared with the traditional feeding system (Control). Presumably this was a result of asynchronous supply of nutrients to the rumen (in isoenergetic diets) compromising conditions for digestion and milk production.

Replacing wheat with canola meal in a partial mixed ration increases the milk production of cows grazing at a restricted pasture allowance in spring

Milk production responses were measured in grazing cows offered supplements in different ways. Holstein–Friesian cows averaging 70 days in milk were allocated into 20 groups of eight, each including one rumen-fistulated cow. One of three dietary treatments was then randomly assigned to each of the 20 groups. Treatments were (1) Control (8 groups), where cows were supplemented with rolled wheat grain fed twice daily in the dairy and pasture silage provided in the paddock; (2) partial mixed ration (PMR; 8 groups), where cows were offered a PMR comprising rolled wheat grain, maize grain, maize silage and lucerne hay, which was presented on a feedpad immediately after each milking; the PMR was formulated to provide the same estimated metabolisable energy intake as the Control supplements; and (3) PMR+Canola (4 groups), where cows were fed in the same way as the PMR cows, except that a proportion of the wheat in the PMR was replaced with solvent-extracted canola meal. This ration was formulated to provide the same metabolisable energy as the Control and PMR treatments, but had greater amounts of crude protein. For Control and PMR treatments, supplements were offered at 8, 10, 12 or 14 kg DM/cow.day (2 groups per amount) while for the PMR+Canola treatment supplement was offered at 12 or 14 kg DM/cow.day (2 groups per amount). In addition to their supplements, all groups grazed an allowance of ~14 kg DM/cow.day (measured to ground level) of perennial ryegrass pasture. Yields of energy-corrected milk increased linearly with increasing supplement intake, but there was no difference between Control and PMR cows. When canola meal was added to the PMR, there was an increase in energy-corrected milk at a predicted supplement intake of 13.0 kg DM/cow.day. This was associated with a greater concentration and yield of milk fat in the PMR+Canola cows. Ruminal fluid pH and DM intake from pasture were also greater in PMR+Canola cows. It is concluded that farmers feeding high amounts of supplements to grazing cows could increase milk production by carefully considering the composition and form of the supplement mix, including the inclusion of canola meal.

Effects of different strategies for feeding supplements on milk production responses in cows grazing a restricted pasture allowance

Milk production responses of grazing cows offered supplements in different ways were measured. Holstein-Friesian cows, averaging 227 d in milk, were allocated into 6 groups of 36, with 2 groups randomly assigned to each of 3 feeding strategies: (1) cows grazed perennial ryegrass pasture supplemented with milled barley grain fed in the milking parlor and pasture silage offered in the paddock (control); (2) same pasture and allotment supplemented with the same amounts of milled barley grain and pasture silage, but presented as a mixed ration after each milking (PMR 1); and (3) same pasture and allotment, supplemented with a mixed ration of milled barley grain, alfalfa hay, corn silage, and crushed corn grain (PMR 2). For all strategies, supplements provided the same metabolizable energy and grain:forage ratio. [75:25, dry matter (DM) basis]. Each group of 36 cows was further allocated into 4 groups of 9, which were assigned to receive 6, 8, 10, or 12 kg of supplement DM/cow per day. Thus, there were 2 replicated groups per supplement amount per dietary strategy. The experiment had a 14-d adaptation period and an 11-d measurement period. Pasture allotment was approximately 14 kg of DM/d for all cows and was offered in addition to the supplement. Positive quadratic responses to increasing amounts of supplement were observed for yield of milk, energy-corrected milk (ECM), and fat and protein, and positive linear responses for concentrations of fat and protein for cows on all 3 supplement feeding strategies. No difference existed between feeding strategy groups in yield of milk, ECM, or protein at any amount of supplement offered, but yield and concentration of fat was higher in PMR 2 cows compared with control and PMR 1 cows at the highest amounts of supplementation. Responses in marginal ECM production per additional kilogram of supplement were also greater for PMR 2 than control and PMR 1 cows when large amounts of supplement were consumed. For all diets, marked daily variation occurred in ruminal fluid volatile fatty acids and pH, especially in cows fed the largest amounts of supplement. It was concluded that when supplements are fed to grazing dairy cows, a simple mix of grain and pasture silage has no benefit over traditional strategies of feeding grain in the parlor and forage in the paddock. However, yield of milk fat and marginal milk production responses can be greater if the strategy uses an isoenergetic ration that also contains alfalfa hay, corn silage, and corn grain.

Making the case for a 'fifth wave' in public health

This paper will argue that the UK has seen several phases of public health improvement since the Industrial Revolution, and that each of these can be linked to major shifts in thinking about the nature of society and health itself. The authors are not, however, attempting to delineate firm sequences of events (or imply causality) as this would require a level of analysis of the relationship between economy, society and culture which is beyond the scope of this paper. Rather, it is suggested that each phase of health improvement can be thought of in metaphorical terms as a 'wave'. The first wave is associated with great public works and other developments arising from social responses to the profound disruptions which followed the Industrial Revolution. The second wave saw the emergence of medicine as science. The third wave involved the redesign of our social institutions during the 20th Century and gave birth to the welfare state. The fourth wave has been dominated by efforts to combat disease risk factors and the emergence of systems thinking. Although a trough of public health activity continues from each wave, none exerts the same impact as when it first emerged. This paper will discuss the complex challenges of obesity, inequality and loss of wellbeing, together with the broader problems of exponential growth in population, money creation and energy usage. As exponential growth is unsustainable on a finite planet, inevitable change looms. Taken together, these analyses suggest that a fifth wave of public health development is now needed; one which will need to differ radically from its forerunners. The authors invite others to join them in envisioning its nature and in furthering the debate about future public health.

Feed conversion efficiency and marginal milk production responses of pasture-fed dairy cows offered supplementary grain during an extended lactation

A study was conducted to quantify the feed conversion efficiency (FCE) and marginal milk responses of pasture-fed cows offered supplementary grain during an extended lactation of 670 days. The experiment used three groups of 10 Holstein cows in four experimental periods of 4 weeks, beginning when cows were ~60, 240, 420 and 530 days in milk (DIM). In each experimental period, cows were individually fed diets of either freshly cut perennial ryegrass pasture supplemented with triticale (60 and 420 DIM), or pasture silage and lucerne hay supplemented with wheat (240 and 530 DIM). On each occasion, one of the three groups was offered additional grain at 0.0, 2.5 or 5.0 kg DM/cow.day. Milk production was measured daily and concentrations of milk fat and protein weekly. These data were used to calculate FCE and marginal responses of milk, energy-corrected milk and milk solids (fat + protein). Results showed FCE was highest at 60 DIM and lowest at 530 DIM. Increased DM intake because of increased grain intake led to increased FCE at 240 and 530 DIM when the energy concentration of forage was lowest. Marginal milk responses were not different at any stage of lactation. For milk solids and energy-corrected milk, responses at 240 DIM were the same as at 530 DIM, but greater than at 60 DIM and 420 DIM. This study provides the first Australian data about FCE and marginal milk production responses to grain supplementation of pasture-fed cows undergoing an extended lactation. The results should provide farmers with confidence that good responses to grain can be achieved even in the latter part of a 22-month lactation.

Effect of compliance with recommended calf-rearing practices on control of bovine Johne's disease

OBJECTIVE

To assess the degree of compliance with recommended management procedures for the control of bovine Johne's disease and study the relationship between aspects of calf management and testing/disease outcomes in the herds.

PROCEDURE

Fifty-four south Gippsland dairy herds participating in the Victorian bovine Johne's disease test and control program were visited between July and November 2002 and an audit of calf rearing practices was conducted. The results of testing completed under the program were analysed for each of the herds. Twenty seven management factors were examined for a relationship with the presence of clinical cases of Johne's disease or cattle with positive ELISA test results that were born after the completion of the second whole herd test. Logistic regression was used to examine the strength of relationships between the management practices and the frequency with which new cases of Johne's disease arose. RESULTS AND CONCULSIONS: Calves were removed from their dams within 12 hours of birth in only 17 (31.5%) of the herds. However, in all but one herd the calves were removed within 24 hours of birth. In 42 herds (77.8%) calf rearing facilities were adequately separated from adult cattle and the faeces from adult cattle. In 41 herds (75.9%) calves up to the age of 12 months were grazed on paddocks that were free of manure or effluent from adult cattle. However, in only 10 (18.5%) of the herds were all three of these calf management practices applied. Feeding whole milk containing antibiotic residues, or providing water for calves from birth, were found to have statistically significant associations with an increased occurrence of cases of bovine Johne's disease in the study herds. The practice of allowing cows to calve in a paddock was found to be associated with reduced occurrence of bovine Johne's disease. These associations were still found after analysis that included herd size, the number of clinical cases that had occurred in the herds before the start of testing, the number of animals with positive ELISA tests that were detected at the first test and the number of years of participation in the test and cull program. Early separation of newborn calves from cows and grazing calves under 12 months of age in areas free of adult cattle were not found to be protective against Johne's disease.

Multiple courses of antenatal corticosteroids: a systematic review and meta-analysis

OBJECTIVE

To assess the effects of multiple courses of antenatal corticosteroids on perinatal and neonatal death and neonatal, infant, and maternal disease.

METHODS

MEDLINE and Embase were searched for human studies published in English. Studies that compared multiple courses of antenatal corticosteroids versus a single course were included if they were published in full and were controlled for gestational age at birth. Meta-analyses (odds ratio and 95% confidence interval) were undertaken when possible.

RESULTS

Eight observational studies were included. Selection bias was present in all studies. Multiple courses of antenatal corticosteroids were associated with a decreased risk of respiratory distress syndrome (odds ratio, 0.79; 95% confidence interval, 0.64 to 0.98) and patent ductus arteriosus (odds ratio, 0.56; 95% confidence interval, 0.35 to 0.90) and were associated with an increased risk of endometritis (odds ratio, 3.42; 95% confidence interval, 1.92 to 6.11). There was no significant effect on other neonatal and maternal outcomes.

CONCLUSION

It is not possible to establish the true effects of multiple courses of antenatal corticosteroids by a review of the results of observational studies because of the effect of confounding variables. Randomized controlled trials are needed to address this important issue.

Antenatal corticosteroids for preterm birth

A single course of antenatal corticosteroids is a rare example of a treatment that yields both a health benefit and a cost savings. This article reviews the history and background of antenatal corticosteroids, its use in clinical practice and the controversy today regarding the use of multiple courses of antenatal corticosteroids.

The yield, quality and irrigation response of summer forage crops suitable for a dairy pasture renovation program in north-western Tasmania

The yield and quality of perennial ryegrass, short-rotation ryegrass–perennial ryegrass mix, oats, millet, maize, rape, kale, pasja and turnips were determined over a 13-week summer period in 1995–96 and 1996–97. The experiment was conducted on the Elliott Research Station in north-western Tasmania (145˚E, 41˚S) and consisted of 2 irrigated and 2 dryland main plots. Within each main plot was a randomised complete block design with 9 forage crop subplots. Where forage is required through the summer, there is little advantage in establishing millet or oats over a spring-sown ryegrass pasture, mainly as the former still require replacement with permanent pasture in the autumn. However, if additional forage is required from late January then turnips are clearly superior to the other forages evaluated in all respects, apart from a low bulb crude protein (CP) content. Turnips responded significantly to irrigation, producing between 15 and 22 kg DM/ha.mm irrigation applied, with yields ranging between 7.9 and 10.6 t DM/ha dryland and between 13.5 and 14.4 t DM/ha under irrigation. The metabolisable energy (ME) and CP contents of turnips were 12.5 MJ/kg DM and 12.4% in the shoots and 13.4 MJ/kg DM and 7.0% in the bulbs, respectively. In comparison, the other fodder crops tested yielded between 4 and 6 t DM/ha under dryland conditions and between 5 and 7 t DM/ha under irrigated conditions. Turnips were most economic, costing on average A$120/t DM irrigated and $160/t DM dryland, while spring renovation to perennial ryegrass cost $385/t DM irrigated and $344/t DM dryland; clearly more expensive than purchased feeds for this period. These findings confirm the choice of many farmers that, of the species examined, turnips are the most suitable as a summer fodder crop, both irrigated or dryland, and integrate well with a pasture renovation rotation.

Hospital selection for unit cost estimates in multicentre economic evaluations. Does the choice of hospitals make a difference?

OBJECTIVE

The objectives of this study were (i) to develop a conceptual framework for selecting hospitals for unit cost estimates in national and international multicentre trials and (ii) to test the impact of alternative hospital selection on the cost results.

DESIGN AND SETTING

Within the conceptual framework, the following considerations which can be used when selecting a sample of hospitals for unit cost estimates in multicentre trials were identified: the number of hospitals; the sampling method; and the desired level of geographical subanalysis. Results from a recently completed international multicentre trial were used to explore changes in cost results obtained by using alternative methods of selecting and stratifying hospitals for unit cost estimates.

PATIENTS AND PARTICIPANTS

The study included 5041 women from 72 hospitals in 6 countries with prelabour rupture of the membranes at term.

INTERVENTIONS

The women were randomly assigned to induction of labour with intravenous oxytocin, induction of labour with prostaglandin E2 gel, or expectant management for up to 4 days with labour induced if complications developed.

MAIN OUTCOME MEASURES AND RESULTS

Across each of the 4 management strategies of the study, the method of selecting and stratifying hospitals resulted in a 30 to 55% difference between the lowest and highest median unit cost estimates. In some cases, the relative ranking of the least to most expensive strategy varied across methods of hospital selection. The statistical comparisons across strategies found that the method used had a substantial impact on the conclusions of the economic evaluation.

CONCLUSIONS

Unit cost information should be collected from as many hospitals as possible. Multivariate hospital cost studies are needed to identify important cost drivers that will assist with hospital selection in the future.

Turnips and protein supplements for lactating dairy cows

Many farmers in southern Victoria grow fodder turnips as a summer feed for lactating dairy cows. This paper reports on 2 experiments that measured the milk yields and liveweight changes of cows offered a basal forage diet and combinations of turnips, barley and protein supplements (cottonseed meal or lupins). A stall feeding experiment was conducted over 26 days with 40 Friesian cows in mid lactation offered 1 of 5 dietary treatments. All cows were offered 10 kg DM/day of a basal diet comprising pasture, pasture hay and pasture silage which is similar to that available on many southern Victorian dairy farms during summer. Cows in a control group did not receive additional feed supplements. Cows in the other 4 groups were offered a supplement of 5 kg DM/cow.day of either turnips, barley or a mixture containing 3 kg DM/cow.day of turnips and 2.0 kg DM/cow.day of either crushed lupins or cottonseed meal. The marginal milk responses from barley, turnips, turnips + lupins and turnips + cottonseed meal were 0.80, 0.92, 1.15 and 1.00 L/kg DM of supplement eaten. There were no significant differences (P>0.05) in the liveweight changes of the supplemented groups. Samples of the feeds used in this experiment were placed in nylon bags and incubated in the rumen of non-lactating dairy cows. The ‘&Oslash;rskov’ protein degradation parameters for these feeds are compared with the published values for a range of Australian feeds. The rate and extent of degradation of protein from the turnip leaves, turnip bulbs and crushed barley were all similar. A grazing experiment was conducted over 65 days with 56 Friesian cows in mid lactation, offered 1 of 4 dietary treatments. All groups were allowed to graze pasture (5 kg DM/cow.day), were offered 3 kg DM/cow.day of pasture silage and were fed different combinations of barley, cottonseed meal and lupins. In addition, 3 of the groups separately strip-grazed turnips (about 5 kg DM/cow.day). The group fed a supplement of 8.0 kg/cow.day of barley yielded similar quantities (18.3 L/cow.day) of milk and milk constituents as another group fed 4.0 kg DM/cow.day of barley and 4.5 kg DM/cow.day of turnips. Furthermore, when either 1.5 kg DM of cottonseed meal or 2.0 kg of lupins were fed in place of barley, milk yield increased by 1.4 L/cow.day. Dietary treatment had no significant (P>0.05) effects on liveweight changes. From this grazing experiment it is concluded that turnips can be used as a cheaper alternative to barley in order to maintain high levels of milk production in summer–autumn. We estimate that if the above quantities of protein supplement were fed with turnips, at 1997–98 prices, lupins would increase profits by 12 cents/cow.day, but there would be no financial benefit from the cottonseed meal. The findings from both experiments show that supplements of rumen-degradable protein (lupins) can produce an economic milk response when fed to cows on typical summer diets (pasture/silage/barley and turnips) in southern Victoria.

Evaluating the benefits of a patient information video during the informed consent process

The study objective was to evaluate the effect of a patient information video during the informed consent process of a perinatal trial. Ninety women, between 19 and 33 weeks gestation, were randomised to receive written information about this perinatal trial and watch an information video or to receive written information only. Participants completed a questionnaire immediately after entry and 2-4 weeks later assessing knowledge of; feelings about the worth of; and willingness for future participation in the perinatal trial. When initially asked, more women who watched the video thought they would consent to the study (chi 2 = 6.3; df = 1; P = 0.01). No differences in knowledge about the perinatal trial were found initially, but 2-4 weeks later more knowledge had been retained by women who had watched the video (chi 2 = 6.7; df = 1; P = 0.01). These results suggest that a patient information video combined with an information sheet may result in greater participation in a research trial and may increase women's knowledge of a specific health problem and related research trial.

Symbiotic effectiveness of Rhizobium leguminosarum bv. trifolii collected from pastures in south-western Victoria

Summary. The whole-soil inoculation method was used to assess the symbiotic effectiveness of rhizobia populations in soils collected from 18 randomly-selected pastures in south-western Victoria. This was part of a larger study which described the condition of pasture within this region. Based on the shoot weights of test subterranean clover plants, cv. Mount Barker, effectiveness varied from 36 to 94% depending on the site of rhizobia collection. This range was wider than that found in an earlier survey of rhizobia effectiveness conducted nearby. WU95, the commercial inoculant for subterranean clover, was significantly more effective than 9 of the rhizobia samples. Rhizobia from 2 sites were especially poor and their effectiveness (37%) was not significantly different from the nil inoculum control (28%). Symbiotic effectiveness was not related to soil pH, available sulfur, available phosphorus, total nitrogen or mean annual rainfall for each site where rhizobia were collected. After pooling data for all sites, the shoot weights were significantly related to the proportions of plants with nodules assigned high nodulation scores. In contrast, low scores, within 1 of 6 categories, did not significantly affect shoot weight. The technique of using mean nodulation score was less capable of discriminating differences in symbiotic effectiveness, compared with assessment based on test plant weight.

Doppler velocimetry of the fetal middle cerebral and renal arteries: interobserver reliability

Using color and pulsed Doppler ultrasonography, the interobserver reliability of measurements in the fetal circulation was evaluated in 41 pregnancies of 25 to 39 weeks' gestation. Two observers recorded flow velocity waveforms from the middle cerebral and renal arteries for measurement of peak systolic, minimum diastolic, and mean velocities, pulsatility index, and resistive index. Intraclass correlation coefficient of reliability was calculated by analysis of variance. Substantial interobserver agreement was found for pulsatility index and minimum diastolic velocity in both arteries. Therefore, these measurements have the greatest clinical applicability.

Menses cup evaluation study

OBJECTIVE

To determine whether the menses cup is well tolerated by menstruating women.

DESIGN

Prospective descriptive clinical study.

SETTING

Normal human volunteers in an academic research environment.

PARTICIPANTS

Fifty-one menstruating women recruited between June to December 1991.

INTERVENTIONS

Each participant was provided with two menses cups and an instruction sheet. Baseline information, including age, occupation, martial status, parity, description of menstrual flow, and current method used to cope with menstrual flow was collected. Subjects were asked to describe their experience with the cup at 1-, 2-, 6-, and 12-month intervals.

MAIN OUTCOME MEASURE

The proportion of women who found the cup acceptable.

RESULTS

The cup was used by 51 subjects for a total of 159 cycles. Overall, 23 women (45%) found the cup an acceptable method for coping with menses. Among 29 (57%) women who used the cup for two or more cycles, 62% found it acceptable.

CONCLUSION

The menses cup may be an acceptable method for some women for coping with menstrual flow.

Cost-effectiveness of induction of labour versus serial antenatal monitoring in the Canadian Multicentre Postterm Pregnancy Trial

OBJECTIVE

To determine the cost-effectiveness of induction of labour versus serial fetal monitoring while awaiting spontaneous labour in postterm pregnancies.

DESIGN

Cost-effectiveness and cost-minimization analyses conducted as part of a Canadian multicentre randomized clinical trial.

SETTING

Twenty-two Canadian hospitals, of which 19 were teaching hospitals and 3 were community hospitals.

PATIENTS

Women with uncomplicated pregnancies of 41 or more weeks' gestation were randomly assigned to induction of labour or serial antenatal monitoring. Of the 3418 women enrolled, no data were received on 11. Therefore, results were based on data from 1701 women in the induction arm of the study and 1706 women in the monitoring arm.

MAIN OUTCOME MEASURES

Perinatal mortality and neonatal morbidity, rates of cesarean section and health care costs. Hospital costing models were developed specifically for the study. Data on use of major resources (e.g., length of hospital stay, surgical procedures, major diagnostic tests and procedures, and medications) for all trial participants were collected and combined with data on minor tests and procedures (e.g., laboratory tests) abstracted from a detailed review of medical records of a sample of patients.

RESULTS

Because the results of the clinical trial showed a nonsignificant difference in perinatal mortality and neonatal morbidity between the induction and monitoring arms, the authors conducted a cost-minimization rather than a cost-effectiveness analysis. The mean cost per patient with a postterm pregnancy managed through monitoring was $3132 (95% confidence interval [CI] $3090 to $3174) and per patient who underwent induction of labour was $2939 (95% CI $2898 to $2981), for a difference of $193. The significantly higher (p < 0.0001) mean cost per patient in the monitoring arm was due mainly to the costs of additional monitoring and the significantly higher rates of cesarean section among these patients. Estimated conservatively, the savings resulting from a universal policy of managing postterm pregnancies by induction of labour in Canada may be as high as $8 million a year.

CONCLUSIONS

A policy of managing postterm pregnancy through induction of labour not only results in more favourable outcomes than a monitoring strategy but does so at a lower cost.

Breech delivery at term: a critical review of the literature

OBJECTIVE

To determine whether planned vaginal or elective cesarean delivery is better for singleton term breech infants.

DATA SOURCES

Articles that included singleton term pregnancies with breech presentation published in English between 1966 and September 1992 were searched through the Index Medicus, Oxford Database of Perinatal Trials, and MEDLINE.

METHODS OF STUDY SELECTION

We reviewed 24 studies that presented results according to the intended mode of delivery in terms of the following adverse outcomes: perinatal mortality, low 5-minute Apgar score, traumatic neonatal morbidity, overall short-term neonatal morbidity, long-term infant morbidity, and maternal morbidity and mortality.

DATA EXTRACTION AND SYNTHESIS

The effect of planned vaginal delivery, compared with planned cesarean delivery, for each adverse outcome was determined by calculating a typical odds ratio. Perinatal mortality was higher for the planned vaginal delivery groups than for the elective cesarean groups, with a typical odds ratio of 3.86 (95% confidence interval [CI] 2.22-6.69). Neonatal morbidity due to trauma was also higher for the planned vaginal delivery groups, with a typical odds ratio of 3.96 (95% CI 2.76-5.67).

CONCLUSION

The results suggest that planned vaginal delivery may be associated with higher perinatal mortality and morbidity rates than planned cesarean delivery. Because of selection bias in the majority of studies, differences in outcomes may be due to factors other than the planned method of delivery. An appropriately sized, randomized controlled trial is needed to answer this question definitively.

Met-enkephalin secretion from mixed cultures of hypothalamic neurons and astrocytes

Release of the endogenous opioid pentapeptide, met-enkephalin, from primary cultures of dissociated fetal rat hypothalamic cells was studied using an assay system which could both measure and differentiate between free met-enkephalin and the larger enkephalin-containing peptides (ECPs), which are the processing intermediates of the enkephalin precursor. The cultures were maintained in fully defined, serum-free medium and contained both neurons and astrocytes. Free met-enkephalin was secreted from the cultures in significant quantities in response to nonspecific depolarisation with 56 mM potassium, by a mechanism dependent upon extracellular calcium. Under basal conditions, barely detectable amounts of free peptide were released, whereas ECPs were secreted in significant quantities which were not reduced by the removal of extracellular calcium. As the period of culture increased, so did the quantitative importance of this constitutive ECP secretion, relative to the stimulated release of free peptide. Treatment of the cultures with the cytotoxic agent, cytosine arabinoside, attenuated this temporal increase of ECP secretion, whilst leaving the stimulated release of free met-enkephalin relatively unaffected. This suggested that the met-enkephalin secretion seen within the cultures reflected the presence of at least two distinct enkephalinergic cell types and that the change in the nature of the secreted enkephalin was at least in part, due to the proliferation of one of these cell populations. These results are consistent with secretion of met-enkephalin from both neurons and astrocytes within these cultures. We propose that the neurons secreted essentially fully processed peptide in a regulated manner, whilst the mitotic glial cells constitutively secreted non- or partially processed precursor peptides.(ABSTRACT TRUNCATED AT 250 WORDS)

Triticum tauschii: reaction to the take-all fungus (Gaeumannomyces graminis var. tritici)

Reactions of 398 accessions of Triticum tawchii to the take-all fungus [Gaeumannomyces graminis var. tritici (Ggt] were assessed. Nineteen accessions were selected for more detailed studies. T. tauschii accessions were identified that had less tissue blackening and more remaining green tissue when challenged by the fungus than the susceptible T. aestivum cv. Condor. However, tissue blackening in the T. tauschii accessions was much greater than that in Avena sativa cv. New Zealand Cape. Synthetic allohexaploid wheats produced from different Triticum turgidum var. durum (genome AABB) accessions and accessions of T. tauschii (genome DD) which had low tissue blackening or high remaining green tissue had more tissue blackening and less remaining green tissue than the T. tauschii parents. The potential of this material for breeding take-all resistant wheats together with experimental methods to minimize the possible confounding effects of seed weight, seed source and genetic effects are discussed.