COVID-19 infection may cause ketosis and ketoacidosis

The present study included 658 hospitalized patients with confirmed COVID-19. Forty-two (6.4%) out of 658 patients presented with ketosis on admission with no obvious fever or diarrhoea. They had a median (interquartile range [IQR]) age of 47.0 (38.0-70.3) years, and 16 (38.1%) were men. Patients with ketosis were younger (median age 47.0 vs. 58.0 years; P = 0.003) and had a greater prevalence of fatigue (31.0% vs. 10.6%; P < 0.001), diabetes (35.7% vs. 18.5%; P = 0.007) and digestive disorders (31.0% vs. 12.0%; P < 0.001). They had a longer median (IQR) length of hospital stay (19.0 [12.8-33.3] vs. 16.0 [10.0-24.0] days; P < 0.001) and a higher mortality rate (21.4% vs. 8.9%; P = 0.017). Three (20.0%) out of the 15 patients with diabetic ketosis developed acidosis, five patients (26.7%) with diabetic ketosis died, and one of these (25.0%) presented with acidosis. Two (7.4%) and four (14.3%) of the 27 non-diabetic ketotic patients developed severe acidosis and died, respectively, and one (25.0%) of these presented with acidosis. This suggests that COVID-19 infection caused ketosis or ketoacidosis, and induced diabetic ketoacidosis for those with diabetes. Ketosis increased the length of hospital stay and mortality. Meanwhile, diabetes increased the length of hospital stay for patients with ketosis but had no effect on their mortality.

Monitoring and testing dairy herds for metabolic disease

Clinical impressions of metabolic disease problems in dairy herds can be corroborated with herd-based metabolic testing. Ruminal pH should be evaluated in herds showing clinical signs associated with SARA (lame cows, thin cows, high herd removals or death loss across all stages of lactation, or milk fat depression). Testing a herd for the prevalence of SCK via blood BHB sampling in early lactation is useful in almost any dairy herd, and particularly if the herd is experiencing a high incidence of displaced abomasum or high removal rates of early lactation cows. If cows are experiencing SCK within the first 3 weeks of lactation, then consider NEFA testing of the prefresh cows to corroborate prefresh negative energy balance. Finally, monitoring cows on the day of calving for parturient hypocalcemia can provide early detection of diet-induced problems in calcium homeostasis. If hypocalcemia problems are present despite supplementing anionic salts before calving, then it may be helpful to evaluate mean urinary pH of a group of the prefresh cows. Quantitative testing strategies based on statistical analyses can be used to establish minimum sample sizes and interpretation guidelines for all of these tests.

Subclinical ketosis in lactating dairy cattle

Subclinical ketosis is an important and common condition of early-lactation dairy cattle. It is associated with losses in milk production and increased risk of periparturient disease. Prevention depends on several factors, including proper transition-cow nutrition, management of body condition, and the use of certain feed additives such as niacin, propylene glycol, and ionophores. All currently available cowside tests for subclinical ketosis have certain limitations in their use. Effective monitoring schemes for subclinical ketosis can be developed, however, and these may be useful in many herd health programs.

Postpartum body condition score and results from the first test day milk as predictors of disease, fertility, yield, and culling in commercial dairy herds

The study used field data from a regular herd health service to investigate the relationships between body condition scores or first test day milk data and disease incidence, milk yield, fertility, and culling. Path model analysis with adjustment for time at risk was applied to delineate the time sequence of events. Milk fever occurred more often in fat cows, and endometritis occurred between calving and 20 d of lactation more often in thin cows. Fat cows were less likely to conceive at first service than were cows in normal condition. Fat body condition postpartum, higher first test day milk yield, and a fat to protein ratio of > 1.5 increased body condition loss. Fat or thin condition or condition loss was not related to other lactation diseases, fertility parameters, milk yield, or culling. First test day milk yield was 1.3 kg higher after milk fever and was 7.1 kg lower after displaced abomasum. Higher first test day milk yield directly increased the risk of ovarian cyst and lameness, increased 100-d milk yield, and reduced the risk of culling and indirectly decreased reproductive performance. Cows with a fat to protein ratio of > 1.5 had higher risks for ketosis, displaced abomasum, ovarian cyst, lameness, and mastitis. Those cows produced more milk but showed poor reproductive performance. Given this type of herd health data, we concluded that the first test day milk yield and the fat to protein ratio were more reliable indicators of disease, fertility, and milk yield than was body condition score or loss of body condition score.

Path analysis of dry period nutrition, postpartum metabolic and reproductive disorders, and mastitis in Holstein cows

Path analysis and logistic regression were used to model direct and indirect relationships among clinical periparturient (within 30 d after calving) retained placenta, metritis, veterinary-assisted dystocia, uncomplicated and complicated ketosis, left displaced abomasum, parturient paresis, mastitis, and estimated nutrient intakes (protein, calcium, phosphorus, energy; coded into terciles) in the last 3 wk of the dry period. Data were from 1,374 multiparous Holstein lactations for calvings from March 1981 through February 1982 in 31 commercial herds in central New York. Periparturient disorders occurred as a complex. Odds ratios for the multiplicative effects of parturient paresis on incidence of veterinary-assisted dystocia, retained placenta, complicated ketosis, and clinical mastitis were 7.2, 4.0, 23.6, and 5.4, respectively. Reproductive disorders were interrelated. Retained placenta, left displaced abomasum, and parturient paresis directly increased risk of complicated ketosis (odds ratios were 16.4, 53.5, and 23.6, respectively). Higher terciles of estimated energy intake in the last 3 wk of the dry period decreased risk of veterinary-assisted dystocia and left displaced abomasum, while higher terciles of estimated protein intake decreased risk of retained placenta and uncomplicated ketosis. Estimated nutrient intakes were directly related to subsequent metabolic disorders and directly and indirectly related (mediated by metabolic disorders) to reproductive disorders. The study suggests that feeding higher intakes (relative to National Research Council recommendations) of protein and energy in the last 3 week of the dry period may reduce the incidence of metabolic and reproductive disorders. Exact recommendations as to the amounts and types of feed cannot be made from our results.

Elevated non-esterified fatty acids and β-hydroxybutyrate and their association with transition dairy cow performance

Dairy cows pass through a period of negative energy balance as they transition from late gestation to early lactation. Poor adaptation through this period, expressed as excessively elevated concentrations of non-esterified fatty acids (NEFAs) pre- or post-partum and elevated concentrations of β-hydroxybutyrate post-partum, increases an individual animal's risk of post-partum disease, removal from the herd, reproductive difficulty, and reduced milk production. Field studies have shown that subclinical ketosis often affects 40% of cows in a herd although the incidence can be as high as 80%. Peak incidence occurs at 5 days in milk, and cows that develop subclinical ketosis in the first week of lactation have a higher risk of negative effects and reduced milk production than cows that develop subclinical ketosis in the second week of lactation. Herds with more than a 15-20% prevalence of excessively elevated concentrations of NEFAs and β-hydroxybutyrate in early lactation have higher rates of negative subsequent events, poorer reproduction, and lower milk yield than herds with a lower prevalence of negative energy balance. This paper reviews (1) strategies for testing of energy-related metabolites, (2) consequences of poor adaptation to negative energy balance (for individual animals and for herds), (3) treatment approaches for affected cows, and (4) economic considerations for testing and treating cows with poor adaptation to negative energy balance.

Recommendations for recording and calculating the incidence of selected clinical diseases of dairy cattle

The report upon which the current discussion is based was prepared in response to the increasing interest of the dairy industry in the recording of clinical disease data. The major objective was to introduce guidelines and standards for the recording and presentation of the diseases of dairy cattle. Eight clinically identifiable diseases of economic importance to the dairy industry were considered: milk fever, retained placenta, metritis, ketosis, left displaced abomasum, cystic ovarian disease, lameness, and clinical mastitis. Standardized definitions for these diseases were established through consultation with industry partners. Two approaches to summarization and reporting were proposed. For retrospective analysis, which is used when historical data are summarized for genetic evaluation for example, lactational incidence risk (cumulative incidence) has been recommended. For current analysis, which is used for herd health monitoring, a true incidence rate has been recommended. Milk fever and retained placenta were exceptions to the latter because of their short periods of risk. For these two diseases, lactational incidence risks are reported.

Body condition related to ketosis and reproductive performance in Norwegian dairy cows

The relationships between body condition score (BCS) and ketosis, and between BCS and reproductive performance in 732 moderate yielding, dual-purpose cows were studied. The cows were of the breed Norwegian Cattle. Farms with tie-stall barns and a history of high ketosis incidence were chosen for the study. Sixteen assessors visited the farms monthly and the same assessor assigned a BCS to each cow once a month. A BCS of 3.5 or higher at calving was associated with increased risk for ketosis. Cows that subsequently developed ketosis had higher BCS than healthy cows before the disease was diagnosed, and they lost more body condition than did the latter after ketosis had occurred. Summer calving cows and primiparous cows showed the lowest risk of ketosis. A history of ketosis before first service decreased the likelihood of conception to that service. Loss in body condition during the postpartum period was associated with decreased likelihood of conception to first service, prolonged calving to conception intervals and increased number of artificial inseminations per conception. Reproductive performance was not associated with BCS at calving. We concluded that BCS is a useful method of monitoring relations among nutritional management, reproduction, and ketosis in moderate yielding dual-purpose cows.

Epidemiology of metabolic disorders in dairy cattle: association among host characteristics, disease, and production

Logistic regression was used to investigate the effects of host characteristics, production, and 23 veterinary diagnoses on the odds of contracting seven metabolic disorders among 61,124 Finnish Ayrshire cows that calved during 1983. Cows in higher producing herds were at increased risk of parturient paresis, udder edema, and ketosis. Cows that had higher previous yields were at increased risk of parturient and nonparturient paresis and ketosis. All of the metabolic disorders except udder edema were directly interrelated. Dystocia, prolapsed uterus, other infertility, and abortion were not risk factors for any of the seven metabolic disorders; however, retained placenta, early metritis, traumatic reticuloperitonitis, acute and chronic mastitis, and foot or leg injury each were direct risk factors for at least two metabolic disorders.

The relationship between milk yield and the incidence of some diseases in dairy cows

Logistic regression models were used to examine the relationship between milk yield and incidence of certain disorders. Lactations (n = 2197) of 1074 Holstein-Friesian cows from 10 dairies (25 to 146 cows per dairy) in Lower Saxony were studied. The 305-d yield from the previous and current lactations served as the standards for milk yield. Eight disorder complexes were considered: retained placenta, metritis, ovarian cysts, mastitis, claw diseases, milk fever, ketosis, and displaced abomasum. Each disorder complex was modeled separately. In addition to milk yield, the influences of the lactation number, the calving season and the other disorder complexes were examined with the "herd" factor taken into account. A correlation between retained placenta, mastitis, and milk fever to milk yield during the previous lactation was found to be probable and for ketosis and displaced abomasum such a correlation was found to be possible. A connection to the yield in the current lactation was shown for ovarian cysts, claw diseases, and milk fever. No relationship to milk yield existed for metritis. An influence of the lactation number was also demonstrated in various models. Single models allowed a demonstration of the influences of both milk yield and lactation number. Limitations of the model types are discussed.

Results and Evaluation of Thirty Years of Health Recordings in the Norwegian Dairy Cattle Population

The results are based on the Norwegian Cattle Health Recording System, which has been in place for the entire country since 1975. The dairy breeds in Norway consist of 94% Norwegian Red and 4% crossbreeds with Norwegian Red. No other breed consists of more than 0.5% of the total population. During the past 30 yr, there have been 11,563,692 dairy cows within the recording system, corresponding to 8,633,532 cow-years and 8,632,516 calvings. This population consisted of 3,038,675 first-calving cows. Altogether, 8,435,704 different diagnoses were recorded from 4,444,485 different cows each year. The general trend for all recordings was an increase in the incidence rate of all cases from 0.74 per 365 d at risk (cow-year) in 1976 to 1.36 in 1990, and then a decrease to 0.62 in 2002. The corresponding figures for cows treated per cow-year were 0.44 up to a maximum of 0.82, and then a decrease to 0.46 per cow-year in 2002. The most common diseases were acute (severe to moderate) clinical mastitis, chronic (mild) clinical mastitis, ketosis, milk fever, teat injuries, retained placenta, silent heat or anestrous, indigestion, cystic ovaries, and metritis. Clinical mastitis increased from 0.15 cows treated per cow-year in 1975 to 0.44 in 1994, and then decreased to 0.23 in 2002. Ketosis began at 0.10 in 1975, increased to 0.24 in 1985, and then decreased to 0.05 in 2005. For several of the most common diseases, there was a reduction of more than 50% from the 1990s to the years after 2000. Validation processes confirmed that this fluctuation reflected the general trend in the population. The disease recording system also reflected the known outbreaks of bovine respiratory syncytial virus during 1976, 1989 to 1990, and 1995. A marked increase in malformation diagnoses could be seen in 1986 and in 1989 and 1990. These could be related to the Chernobyl nuclear power plant accident in April 1986. The diagnosis that showed the most stability throughout these 30 yr was retained placenta. The 3 main reasons for the large fluctuation for many of the diseases could be the following: a breeding effect, an effect of preventive work, and an effect of changing the therapeutic attitude. Many of the actions taken to bring about improvements would not have been possible without a functioning and practical recording system. Our experience is that an organ-related diagnosis system with up to 60 or 70 different diagnoses will meet the needs of the dairy industry.

Direct-Fed Microbial Supplementation on Ruminal Digestion, Health, and Performance of Pre- and Postpartum Dairy Cattle

Effects of supplementing direct-fed microbial agents (DFM) to dairy cows during the transition period were evaluated. Forty-four Holstein cows were fed close-up and lactating diets that did or did not contain 2 g of DFM/cow per d. The direct-fed microbial (DFM) supplement was fed at a rate of 2 × 109 viable yeast cells and 5 × 109 cfu of bacteria per cow per day [corrected].Supplemented cows were fed the DFM 21 d prior to expected calving date through 10 wk postpartum. Cows supplemented with DFM had higher estimated ruminally available dry matter (DM) for both corn silage and haylage than did control cows. Supplemented cows consumed more DM during both the pre- and postpartum periods. In addition, those supplemented with DFM produced 2.3 kg more milk/cow per d than did nonsupplemented cows. There was no difference in 3.5% fat-corrected milk. Milk fat percentage was lower, but not depressed (4.76 vs. 4.44%) for cows receiving DFM. There were no differences in milk fat yield or milk protein percentage and yield. Cows consuming DFM had higher blood glucose postpartum, as well as lower beta-hydroxybutyrate levels both prepartum and on d 1 postpartum. Plasma nonesterified fatty acid concentration was not statistically affected by DFM, but was numerically lower prepartum and higher postpartum for supplemented cows. This study demonstrated that targeted DFM supplementation enhanced ruminal digestion of forage DM. Early lactation cows receiving supplemental DFM produced more milk and consumed more DM during the pre- and postpartum periods. Cows consuming DFM, however, experienced a lower, but not depressed, fat percentage compared with nonsupplemented cows.

Relationship Between Time in Range, Glycemic Variability, HbA1c, and Complications in Adults With Type 1 Diabetes Mellitus

PURPOSE

Real-time continuous glucose monitoring (RT-CGM) provides information on glycemic variability (GV), time in range (TIR), and guidance to avoid hypoglycemia, thereby complimenting HbA1c for diabetes management. We investigated whether GV and TIR were independently associated with chronic and acute diabetes complications.

METHODS

Between September 2014 and January 2017, 515 subjects with type 1 diabetes using sensor-augmented pump therapy were followed for 24 months. The link between baseline HbA1c and CGM-derived glucometrics (TIR [70-180 mg/dL], coefficient of variation [CV], and SD) obtained from the first 2 weeks of RT-CGM use and the presence of complications was investigated. Complications were defined as: composite microvascular complications (presence of neuropathy, retinopathy, or nephropathy), macrovascular complications, and hospitalization for hypoglycemia and/or ketoacidosis.

RESULTS

Individuals with microvascular complications were older (P < 0.001), had a longer diabetes duration (P < 0.001), a higher HbA1c (7.8 ± 0.9 vs 7.5 ± 0.9%, P < 0.001), and spent less time in range (60.4 ± 12.2 vs 63.9 ± 13.8%, P = 0.022) compared with those without microvascular complication. Diabetes duration (odds ratio [OR] = 1.12 [1.09-1.15], P < 0.001) and TIR (OR = 0.97 [0.95-0.99], P = 0.005) were independent risk factors for composite microvascular complications, whereas SD and CV were not. Age (OR = 1.08 [1.03-1.14], P = 0.003) and HbA1c (OR = 1.80 [1.02-3.14], P = 0.044) were risk factors for macrovascular complications. TIR (OR = 0.97 [0.95-0.99], P = 0.021) was the only independent risk factor for hospitalizations for hypoglycemia or ketoacidosis.

CONCLUSIONS

Lower TIR was associated with the presence of composite microvascular complications and with hospitalization for hypoglycemia or ketoacidosis. TIR, SD, and CV were not associated with macrovascular complications.

Induction of ketosis in rats fed low-carbohydrate, high-fat diets depends on the relative abundance of dietary fat and protein

Low-carbohydrate/high-fat diets (LC-HFDs) in rodent models have been implicated with both weight loss and as a therapeutic approach to treat neurological diseases. LC-HFDs are known to induce ketosis; however, systematic studies analyzing the impact of the macronutrient composition on ketosis induction and weight loss success are lacking. Male Wistar rats were pair-fed for 4 wk either a standard chow diet or one of three different LC-HFDs, which only differed in the relative abundance of fat and protein (percentages of fat/protein in dry matter: LC-75/10; LC-65/20; LC-55/30). We subsequently measured body composition by nuclear magnetic resonance (NMR), analyzed blood chemistry and urine acetone content, evaluated gene expression changes of key ketogenic and gluconeogenic genes, and measured energy expenditure (EE) and locomotor activity (LA) during the first 4 days and after 3 wk on the respective diets. Compared with chow, rats fed with LC-75/10, LC-65/20, and LC-55/30 gained significantly less body weight. Reductions in body weight were mainly due to lower lean body mass and paralleled by significantly increased fat mass. Levels of β-hydroxybutyate were significantly elevated feeding LC-75/10 and LC-65/20 but decreased in parallel to reductions in dietary fat. Acetone was about 16-fold higher with LC-75/10 only (P < 0.001). In contrast, rats fed with LC-55/30 were not ketotic. Serum fibroblast growth factor-21, hepatic mRNA expression of hydroxymethylglutaryl-CoA-lyase, peroxisome proliferator-activated receptor-γ coactivator-1α, and peroxisome proliferator-activated receptor-γ coactivator-1β were increased with LC-75/10 only. Expression of phosphoenolpyruvate carboxykinase and glucose-6-phosphatase was downregulated by 50-70% in LC-HF groups. Furthermore, EE and LA were significantly decreased in all groups fed with LC-HFDs after 3 wk on the diets. In rats, the absence of dietary carbohydrates per se does not induce ketosis. LC-HFDs must be high in fat, but also low in protein contents to be clearly ketogenic. Independent of the macronutrient composition, LC-HFD-induced weight loss is not due to increased EE and LA.

Mastitis, ketosis, and milk fever in 31 organic and 93 conventional Norwegian dairy herds

The aim of this study was to investigate differences in disease incidence between organic and conventional herds. The study was based on data from the Norwegian Dairy Herd Recording, which includes the Norwegian Cattle Health Recording System. All herds certified for organic farming in 1994 with a herd size of more than five cow-years were included. Conventional herds were matched on size and region, and from these, three herds were randomly selected for each organic herd. This resulted in a study group of 31 organic and 93 conventional herds with data from 1994 through 1997. The study unit was the cow within a lactation. Factors influencing disease incidence were studied by means of a generalized linear model approach. Management system had a highly significant effect on disease incidence. Odds ratios for organic compared with conventional herds were as follows: mastitis, 0.38; ketosis, 0.33; and milk fever, 0.60. Other significant factors that emerged in modeling the three diseases were year and lactation category for mastitis; lactation category, maximum milk yield, and season for ketosis; and lactation category and milk yield for milk fever. There was no marked difference in milk somatic cell count (SCC) between organic and conventional herds. However, cows in organic herds had lower SCC in lactation two and greater counts in lactations six and higher.

Nonlinear mixed model analyses of five production disorders of dairy cattle

A standardized threshold model was used to estimate herd variability and the impact of some risk factors on the incidence of retained placenta, metritis, ketosis, ovulatory dysfunction, and mastitis. Data consisted of records for 18,110 Swedish Red and White cows in 924 herds and 14,940 Swedish Friesian cows in 772 herds. Only first, second, and third party cows were included, and the breeds were analyzed separately. Herds were considered to be random effects, and variance components were estimated by the counterpart of REML for a threshold model. Estimated intraherd correlations varied from .04 to .18 and were lowest for the incidence of retained placenta (for both breeds) and highest for ketosis and ovulatory dysfunction for Swedish Red and White and Swedish Friesian breeds, respectively. Parity increased predicted lactational incidence risks for all disorders except metritis, but season of calving had no profound effect. Dystocia and stillbirth increased the risk of retained placenta; dystocia and retained placenta increased the risk of metritis. The risk of ketosis was not influence by any of the considered risk factor diseases, and the risk of mastitis was influenced only by retained placenta for Swedish Red and White cows. For both breeds, the risk of ovulatory dysfunction was increased by metritis and ketosis.

Presenting features of idiopathic ketotic hypoglycemia

Idiopathic ketotic hypoglycemia (IKH) is an important cause of emergent hypoglycemia among children. We present a case series of 24 patients with IKH in an effort to provide a current clinical description of this disorder. Secondly, we provide a crude lower-bound estimate of the incidence of IKH in an Emergency Department (ED) setting. The charts of 94 non-diabetic patients presenting to an ED during a period of 64 months with a diagnosis of hypoglycemia as identified via ICD-9 codes were reviewed. Eleven patients, accounting for 24.4% of all significant hypoglycemic episodes unrelated to diabetes in children over 6 months of age, were diagnosed with IKH. These patients accounted for 31.4% of hypoglycemic episodes among previously heathy children older than 6 months. A further review of 13 individuals with IKH identified from an endocrinology specialty clinic was also performed. Among all 24 individuals identified with IKH, the mean age of presentation was 30.8 months. We have found IKH to be the most common cause of hypoglycemia among previously healthy ED patients during childhood. In our series, patients with IKH presented initially before 5 years of age with symptomatic hypoglycemia during the morning hours after a moderate fast. These patients were found to have ketonuria with symptoms resolving after glucose administration. Patients with IKH were more likely to be Caucasian, male gender, and have a low body weight.

An ecological analysis of risk factors for postpartum disorders of Holstein-Friesian cows from thirty-two New York farms

Path analysis and multiple logistic-normal regression were used to model the interrelationships between stated herd management practices and herd 30-d postpartum incidence rates of dystocia, retained placenta, and clinical postpartum metritis, cystic ovary, milk fever, ketosis, left displaced abomasum, and mastitis. Management risk factors were obtained from a personal interview questionnaire. Data were from 2141 multiparous Holstein calvings from May 1981 through April 1982 in 32 commercial herds in the vicinity of Cornell University. Farms where the stated policy was to administer low calcium diets to the dry cows experienced more dystocia and retained placenta. More dystocia was experienced on farms where the stated policy was to administer extra vitamin D to dry cows, where dry cows were housed with the milking cows, or where calving occurred in maternity pens rather than stanchions. There was an increased likelihood of milk fever and left displaced abomasum on farms on which the stated policy was to lead feed. Farms where dairy farmers treated cases of retained placenta had more retained placenta than farms on which the treatment was done by the veterinarian. Farms reporting the practice of feeding the cows to increase their weight during the dry period had increased odds of ketosis.

Transition diseases in grazing dairy cows are related to serum cholesterol and other analytes

The objectives of this study were to describe the incidence of postpartum disease and to evaluate the association with serum cholesterol concentrations during the first 3 weeks after calving in grazing dairy cows. The association between non-esterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), calcium and postpartum diseases was also evaluated. A total of 307 Holstein dairy cows from 6 commercial grazing herds in Osorno, Chile, were monitored from calving until 21 days in milk. Cases of retained placenta, clinical hypocalcemia and clinical mastitis were recorded by the farmer using established definitions. Twice weekly, cows were evaluated for metritis by the same veterinarian based on vaginal discharge and body temperature. Postpartum blood samples were collected weekly and analyzed for serum concentrations of cholesterol, NEFA, BHBA and calcium. Cows were considered as having subclinical ketosis if BHBA >1.2 mmol/L, and subclinical hypocalcemia if calcium <2.0 mmol/L in any of the 3 weekly samples. Overall, 56% of the cows studied developed at least one clinical or subclinical disease after calving. Incidence of individual diseases was 8.8% for retained placenta, 4.2% for clinical hypocalcemia, 11.7% for clinical mastitis, 41.1% for metritis, 19.9% for subclinical hypocalcemia and 16.6% for subclinical ketosis. Lower postpartum cholesterol in cows was associated with developing severe metritis or having more than one clinical disease after calving. For every 0.4 mmol/L decrease in serum cholesterol cows were nearly twice as likely to be diagnosed with multiple clinical diseases after calving. Higher BHBA concentrations and lower calcium concentrations during week 1 were associated with severe cases of metritis. Low serum calcium concentration during week 1 was also associated with developing more than one clinical disorder after calving. In conclusion, the incidence of postpartum diseases can be high even in grazing herds and lower serum cholesterol concentrations were associated with occurrence of clinical postpatum disorders.

Ketogenic diet: outpatient initiation, without fluid, or caloric restrictions

Although the ketogenic diet has been used for more than 80 years, the optimal methods of initiating the diet and its maintenance have not been clearly defined. This retrospective study was performed to review our experience with initiation of the ketogenic diet in the outpatient and inpatient settings and maintenance of the diet without fluid or caloric restriction. We analyzed 54 patients who had medically intractable epilepsy of whom 44% manifested some degree of mental retardation, 80% had multiple seizure types, and failed on average 4.8 antiepileptic drugs. Forty-four patients underwent induction of the ketogenic diet on an outpatient basis and 21 as inpatients. Three patients in each group were fasted at the initiation of the diet. No significant differences were observed with regard to seizure control in that 62% and 71% had greater than 50% improvement in the outpatient and inpatient groups, respectively. Both groups manifested improvement in alertness and social interaction. The efficacy of a ketogenic diet in the symptomatic epilepsies was confirmed, and benefit for medically refractory childhood absence epilepsy was documented. We conclude that a prospective, randomized trial is necessary to compare outpatient vs inpatient initiation of the ketogenic diet and the utility of fluid and caloric restriction.

Women's perspectives on the management and consequences of hyperemesis gravidarum - a descriptive interview study

OBJECTIVE

Hyperemesis gravidarum (HG) affects 0.3-3% of pregnant women and is a leading cause of hospitalization in early pregnancy. The aim of the study was to investigate women's treatment and management of HG, as well as the consequences of HG on women's daily life.

DESIGN AND SETTING

A cross-sectional study based on a structured telephone interview and an online questionnaire. Participants were recruited by social media and by the Norwegian patient's organization for HG.

SUBJECTS

Norwegian women that experienced HG.

MAIN OUTCOME MEASURE

Women's perspectives on management and consequences of HG.

RESULTS

The study included 107 women. Maternal morbidity was profound; about 3/4 of participants were hospitalized due to HG, and the majority showed clinical signs of dehydration (79%), ketonuria (75%), and >5% weight loss (84%). Antiemetics were used by >90% and frequently prescribed "as needed". Metoclopramide (71%) and meclozine (51%) were most commonly used. Participants described HG as having severe psychosocial consequences and profound impact on daily activities. Almost two out of five reported thoughts of elective abortion, and 8 women had at least one elective pregnancy termination due to HG. Overall, 20 women (19%) changed GPs due to dissatisfaction with HG management.

CONCLUSION

Despite the high psychosocial burden and major impact on daily activities, many women with HG reported a lack of support from healthcare professionals and suboptimal management. Greater awareness and knowledge among healthcare professionals is needed to improve care for women with HG. Key Points There is a paucity of studies on management and the consequences of HG on women's daily lives and psychosocial burden. We found that: • Many women described HG as one of their worst life experiences with profound morbidity. • Many women reported suboptimal management of HG and lack of support from healthcare professionals. • Greater understanding of patient perspectives among healthcare professionals is important to improve care and management for HG patients.

Prepartum monensin for the reduction of energy associated disease in postpartum dairy cows

A total of 1317 Holstein cows from 45 farms in the Canadian provinces of Quebec, Prince Edward Island (PEI) and Ontario were enrolled in a randomized trial during 1998 and 1999 to further confirm the efficacy of a monensin controlled release capsule in preventing periparturient disease in lactating dairy cows. Cows were randomized on the farms to receive either a monensin controlled release capsule (CRC) 2 to 4 wk before expected calving or to serve as negative controls. Health data were collected for 90 d postcalving and were analyzed with logistic regression accounting for the intraherd correlation with generalized estimating equations. Monensin CRC significantly reduced the incidence of both clinical ketosis and abomasal displacement post-calving. There was a numerical but nonsignificant decrease in the incidence of retained placenta in cows receiving a monensin CRC. A pooled analysis of two separate but similar studies (conducted in 1995 and 1998) demonstrated a strengthened association between monensin CRC administration precalving and reduced periparturient disease. A 40% reduction in both abomasal displacement and clinical ketosis was observed with precalving administration of a monensin CRC. In addition, the larger dataset highlighted a trend for a 25% reduction in the incidence of retained placenta in monensin-treated cows. Improved energy metabolism as a result of monensin treatment is likely the mechanism for the reduction in incidence of all three of these diseases. Thus the term "energy associated disease" was created to assess the combined impact of the precalving monensin treatment on the incidence of retained placenta, displaced abomasum, and clinical ketosis. The monensin controlled release capsule reduced the incidence of energy associated disease by 30%.

Relationship between overfeeding, metritis and ketosis in high yielding dairy cows

The association between overfeeding before calving, metritis and ketosis in seven dairy herds was investigated. The overall rate of ketonuria in 695 adult cows tested routinely between seven and 14 days post partum was 18 per cent and that of post parturient uterine diseases was 56.5 per cent. Eighty per cent of all cows with ketonuria concurrently suffered from post parturient uterine diseases. Ketonuria was found by a retrospective analysis to be independently associated with both overfeeding before calving and post parturient uterine diseases. In view of the additional risks of both metritis and ketonuria associated with overfeeding before calving and the fact that the risk of ketonuria in cows which had metritis was also found to be associated with overfeeding, it is argued that the term 'complicated' rather than 'secondary' ketosis should be applied to such cases, and that appropriate therapeutic measures should be taken accordingly.

Managing People with Diabetes Fasting for Ramadan During the COVID-19 Pandemic: A South Asian Health Foundation Update

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast.

Clinical ketosis: phenotypic and genetic correlations between occurrences and with milk yield

The repeatability and heritability of ketosis were estimated using data from 28,277 Finnish Ayrshire cows. A four-trait linear model including community-year, calving age and month, genetic group, and random sire effects was used to describe first and second lactation milk yields and veterinary diagnoses of ketosis. Variance components were estimated using REML. The disease traits were also analyzed with a categorical model including the same effects except that community and year were separate factors. Variance components were estimated with marginal maximum likelihood. Genetic relationships between 339 sires analyzed were included in models. The phenotypic correlation between the first and second lactation was defined as a repeatability of trait. The lactational incidence risk of ketosis was .05 in both the first and the second lactation. Average milk production was 4956 and 5547 kg in the first and second lactations, respectively. Estimates of heritabilities were .09 and .07 for ketosis and .23 and .19 for milk in the first and second lactations, respectively. Genetic correlations between first and second lactation recordings were .64 for ketosis and .93 for milk. Repeatabilities between subsequent lactations were .36 (.13 in linear analysis) for ketosis and .68 for milk. In the first lactation, genetic relationship between milk yield and ketosis was unfavorable, but in the second lactation ketosis and milk yield were genetically and phenotypically unrelated.