Associations between body condition, rumen fill, diarrhoea and lameness and ruminal acidosis in Australian dairy herds.

AIMS: To investigate associations between ruminal acidosis and body condition score (BCS), prevalence of poor rumen fill, diarrhoea and lameness in dairy cows in New South Wales and Victoria, Australia. METHODS: This was a cross-sectional study conducted in 100 dairy herds in five regions of Australia. Feeding practices, diets and management practices of herds were assessed. Lactating cows within herds were sampled for rumen biochemistry (n = 8 per herd) and scored for body condition, rumen fill and locomotion (n = 15 per herd). The consistency of faecal pats (n = 20 per herd) from the lactating herd was also scored. A perineal faecal staining score was given to each herd. Herds were classified as subclinically acidotic (ACID), suboptimal (SO) and non-acidotic (Normal) when ≥3/8 cows per herd were allocated to previously defined categories based on rumen biochemical measures. Multivariate logistic regression models were used to examine associations between the prevalence of conditions within a herd and explanatory variables. RESULTS: Median BCS and perineal staining score were not associated with herd category (p >0.05). In the multivariate models, herds with a high prevalence of low rumen fill scores (≤2/5) were more likely to be categorised Normal than SO with an associated increased risk of 69% (p = 0.05). Herds that had a greater prevalence of lame cows (locomotion scores ≥3/5), had 103% higher risk of being categorised as ACID than SO (p = 0.034). In a multivariate logistic regression model, with herd modelled as a random effect, an increase of 1% of pasture in the diet was associated with a 5.5% increase in risk of high faecal scores (≥4/5) indicating diarrhoea (p = 0.001). CONCLUSIONS AND CLINICAL RELEVANCE: This study confirmed that herd categories based on rumen function are associated with biological outcomes consistent with acidosis. Herds that had a higher risk of lameness also had a much higher risk of being categorised ACID than SO. Herds with a high prevalence of low rumen scores were more likely to be categorised Normal than SO. The findings indicate that differences in rumen metabolism identified for herd categories ACID, SO and Normal were associated with differences in disease risk and physiology. The study also identified an association between pasture feeding and higher faecal scores. This study suggests that there is a challenge for farmers seeking to increase milk production of cows on pasture to maintain the health of cattle.

Carryover effects of potassium supplementation on calcium homeostasis in dairy cows at parturition.

The purpose of this study was to test whether supplementation with K improves bone mineral density (BMD) in older cows so that by parturition their bone is better able to mobilize Ca. Twenty-four Holstein Friesian cows (6 mo pregnant, lactating, and in their third or later lactation) were allocated to 2 equal groups and individually fed twice daily a total diet comprising low K oaten hay plus a pelleted concentrate fortified with or without K(2)CO(3) to achieve 3.12% K/kg of DM in the total diet of the K-supplemented (KS) cows compared with 1.50% K/kg of DM for the control cows. The cows were fed their respective diets from the beginning of their sixth month of pregnancy until 2 wk before the expected date of parturition. The strategy was to use K to stimulate a mild increase in extracellular pH to potentially improve BMD well before parturition, when high K contents in the diet are considered safe, but cease supplementing in the few weeks prepartum, when high intakes of K are known to be problematic. The expectation was that the effect of the denser bone would carry through to benefit the cow's plasma Ca, P, and Mg status at parturition. Prior to the period of K supplementation, the cows were part of a commercial pasture-based herd, to which they were returned at the end of the supplementation period and treated as 1 group from at least 11 d prepartum until the end of the study at d 42 of the next lactation. Supplementation with K successfully induced a sustained increase of urinary pH throughout late lactation and into the dry period, as expected. The KS cows consistently averaged a urine pH 0.25+/-0.10 U higher than the controls. However, there was no significant effect of K supplementation on BMD, bone mineral concentrations, plasma osteocalcin, urinary deoxypyridinoline:creatinine plasma Ca, or plasma P concentrations during or immediately after the cessation of supplementation, nor where there any carryover effects during parturition or by d 42 of lactation. Instead, there was an unexpected decrease in the concentration of Mg in plasma of the KS cows compared with the control cows that extended from 0.5 to 2.5 d postpartum. The timing of the decline in plasma Mg was paralleled by declines in plasma concentrations of 1,25 dihydroxy-vitamin D(3) and urinary excretion of Ca and Mg, whereas urinary excretion of P increased; all changes were consistent with a hypomagnesemia that could increase the risk of hypocalcemia. These data suggest that, in addition to the well-documented negative effects of K when fed immediately at parturition, the effects of high dietary K diets can carry over for at least 11 d to trigger a mild hypomagnesemia at parturition. Because K supplementation did not improve BMD prepartum, it was not possible to conclude for or against an ability of denser bone to reduce the risk of hypocalcemia in older cows at parturition.

Energy balance and reproduction on dairy cows fed to achieve low or high milk production on a pasture-based system.

This study investigated the energy balance, metabolic changes, reproduction, and health in Australian Holstein-Friesian cows of average genetic merit fed to produce 6,000 L of milk/cow per lactation (restricted production; Rp) on a predominantly grazed pasture diet, or 9,000 L of milk/cow per lactation (high production: Hp) on a more intensive feeding regimen by using a partial mixed ration to supplement pasture. The mean 4% fat-corrected milk (FCM) and standard deviation achieved was 8,466 +/- 1,162 L/cow per lactation for the Hp herd and 6,748 +/- 787 L/cow per lactation for the Rp herd. During early lactation, the degree of estimated negative energy balance was less in the Hp cows than in the Rp cows (-16.1 vs. -29.1 MJ/cow per day, respectively). Consequently, the mobilization of body reserves was also lower in the Hp cows, and this was reflected in lower concentrations of nonesterified fatty acids (0.70 vs. 0.84 mmol/L) and beta-hydroxybutyrate (0.51 vs. 0.69 mmol/L) and greater concentrations of glucose (3.51 vs. 3.34 mmol/L) and insulin-like growth factor-I (78.9 vs. 58.7 ng/mL) for Hp and Rp cows, respectively. After calving, body condition score and body weight decreased to a similar extent in both herds and did not reflect the differences in mobilization of body reserves between the 2 herds. Reproductive performance was not significantly related to level of milk yield. The mean interval from calving to first active corpus luteum was 33 (SD = 20) d postpartum, and there were 1.4 (SD = 0.8) estrus cycles before the beginning of the breeding period (>50 d postpartum). The interval from calving to pregnancy was 114 d, and the pregnancy rate after 12 wk of mating was 74%. The number of cows with ovarian abnormalities was also similar between the 2 herds. Cows with a long postpartum anestrus had the lowest concentration of insulin-like growth factor-I. The number of health-related disorders was also similar between the herds, with the exception of mastitis, for which the incidence was significantly greater in the Hp cows. The results indicate that the production per cow could be increased from 6,748 L of FCM/cow per lactation for cows grazing pasture and supplemented with concentrates only at milking to 8,466 L of FCM/ cow per lactation, in one lactation, by supplementing pasture with a partial mixed ration. Despite the fact that production per cow increased substantially, the degree of estimated negative energy balance and the metabolic changes in early lactation were lower and reproductive performance was maintained.

Premilking teat preparation for Australian pasture-based cows milked by an automated milking system.

Economic viability of automatic milking systems (AMS) within an Australian pasture-based farming system will be largely determined by the throughput (cows milked/h), which is the result of processes occurring while the cow is in the AMS milking crate. Premilking udder preparation is automated and optional on all AMS. Yet, very few conventional farms in Australia conduct premilking teat preparation regimens, with the majority (78%) strategically washing only visibly dirty teats before milking cup attachment. The objective was to determine the impact of udder preparation in an AMS on the total time spent by cows in the AMS milking unit (crate time). An experiment was conducted with 80 lactating Holstein-Friesian cows in a crossover design over two 5-wk periods to determine the effect of premilking teat preparation (no wash vs. wash) on milk yield, milk harvest rates, and total crate time per milking session in an AMS. Within this study there was no significant effect of treatment on quarter milk conductivity (no wash = 4,858 vs. wash = 4,829 +/- SE = 17 microS/cm), milk blood concentration (no wash = 115.7 vs. wash = 112.3 +/- 7.3 ppm) or test-day somatic cell counts (no wash = 2.044 vs. wash = 2.039 +/- 0.025 log(10) SCC). There was similar total daily milk yield for the 2 treatments (no wash = 20.5 vs. wash = 20.1 +/- 0.2 kg of milk), but a greater mean quarter milk flow rate resulting from the wash treatment (no wash = 0.950 vs. wash = 0.981 +/- 0.013 kg of milk/min). The faster milking was not sufficient to counter the time associated with washing, resulting in longer crate time (no wash = 6.02 vs. wash = 7.12 +/- 0.08 min/milking session) and therefore, lower harvest rate (no wash = 2.08 vs. wash = 1.74 +/- 0.02 kg of milk/min crate time). Not washing teats would allow more efficient AMS utilization by potentially allowing more cows to be milked per machine, which would likely have a positive effect on the economic viability of this technology. The results indicate that a longer term study, investigating the effect of washing teats on udder health and milk quality, is warranted.

Holstein-Friesian dairy cows under a predominantly grazing system: interaction between genotype and environment.

A 5 yr whole-system study, beginning in June 1994, compared the productivity of high [HGM; Australian Breeding Value (ABV) of 49.1 kg of fat plus protein] and low [LGM; ABV of 2.3 kg of fat plus protein] genetic merit cows. Cows from both groups were fed at 3 levels of concentrate (C): 0.34 (low C), 0.84 (medium C), and 1.71 (high C) t of DM/cow per lactation. Thus, there were 6 treatments (farmlets) composed of 18 cows each. The 30 blocks of pasture on each farmlet were matched between farmlets for pasture growth before the study (and soil characteristics and aspect). Cows were culled, and pasture and feed use were managed so as not to bias any one treatment. Genetic merit, level of feeding, and their interaction were significant effects for protein content, protein/cow, and milk and protein/ha. For fat and milk yield/cow, genetic merit and level of feeding were significant, whereas there was no significant effect of genetic merit on fat content. The difference of 46.8 kg of fat plus protein yield between the ABV of HGM and LGM cows and the actual difference in production between the 2 groups was not significantly different except for low C (27 kg) cows. This was due to a 3-fold lower protein yield difference (6 kg/cow) compared with an ABV difference for protein yield of 17.9 kg/cow. The dramatic effect of treatment on protein is in line with differences in the mean protein content (2.89% for the HGM - low C cows compared with a mean of 3.02% for the remaining groups) and mean body condition score [4.3 for HGM - low C cows compared with 4.8 for the mean of the remaining groups (scale 1 to 8)], both indicators reflecting a higher negative energy balance in the HGM - low C cows. When individual cow production was plotted against ABV for production of milk or protein yield all relationships were quadratic, but the slope was relatively flat (low response to ABV) for the low C cows, steeper for the medium C cows and steepest (but not linear) for the high C cows. The relationship between ABV for fat yield and actual fat yield was linear for all levels of concentrate. The mean milk yield/ha from pasture for the 6 farmlets over the 5 yr was 11,868 L, 11,417 L, or 7,761 L for the HGM cows fed at low C, medium C, or high C, respectively, and 10,579 L, 9,800 L, or 5,812 L for LGM cows, fed at low C, medium C, or high C, respectively. The response to concentrates fed was very high for the HGM - medium C cows at 0.115 kg fat plus protein or 1.75 L milk/kg of concentrate fed, with comparable figures of 0.083 kg and 1.0 L, 0.86 kg and 1.47 L and 0.066 and 0.92 L/kg of concentrate fed for the HGM - high C, LGM - medium C, and LGM - high C, respectively. The results show a significant genetic merit by environment (level of feeding) interaction for reproduction and most production parameters when considered in terms of the individual cow and the whole farm system.

The definition of acidosis in dairy herds predominantly fed on pasture and concentrates.

This cross-sectional survey examined the prevalence of ruminal acidosis and the effects of acidosis on the production of dairy cattle. Eight fresh cows, 3 primiparous and 5 multiparous (< 100 d in milk), were selected randomly from each of 100 dairy herds in 5 regions of Australia. Rumen fluid was obtained from each cow by rumenocentesis and a stomach tube, and samples were tested for pH. Stomach tube rumen fluid samples were analyzed for volatile fatty acid, ammonia, and D-lactate concentrations. On the basis of the results of all assays, cows were categorized into 3 distinct categories (categories 1, 2, and 3) by cluster analysis. The percentages of cattle in categories 1, 2, and 3 were 10.2, 29.9, and 59.9%, respectively. Mean rumen pH for categories 1, 2, and 3 were 5.74 +/- 0.47, 6.18 +/- 0.44, and 6.33 +/- 0.43, respectively. Biochemically, categories 1, 2, and 3 were characterized, respectively, as follows: mean total VFA concentration (mM), 100.74 +/- 23.22, 94.79 +/- 18.13, and 62.81 +/- 15.65; mean ammonia concentration (mM), 2.46 +/- 2.02, 7.79 +/- 3.75, and 3.64 +/- 2.03; and mean D-lactate concentration (mM), 0.34 +/- 0.86, 0.28 +/- 0.97, and 0.12 +/- 0.51. Category 1 cows had higher propionate, valerate, isovalerate, and caproate concentrations and were of lower parity than cows in other categories. Cows in category 1 had higher milk production but lower milk fat content than category 2 cows. Herds were assigned to 1 of 3 groups according to the numbers of cows assigned to each category. Herds with > or = 3 of the 8 cows in category 1 were classified as acidotic. Herds with > or = 3 of the 8 cows in category 2 were classified as having suboptimal rumen function, and herds with > or = 3 of the 8 cows in category 3 were classified as normal. Herds that had 3 or more of the 8 cows in category 1 (acidotic herds) had diets with higher energy and nonfiber carbohydrate contents and a lower neutral detergent fiber content than herds with a high prevalence of category 2 or 3 cows. The lack of significance of a herd effect in the statistical models developed suggests that the categories were robust across production systems, in which diets varied from all pasture to total mixed rations. A point prevalence of 10% (95% credible interval, 8 to 12%) of cows with an acidotic profile indicates a high risk for acidosis in the cattle sampled. The higher nonfiber carbohydrate and lower neutral detergent fiber contents of diets for herds with a high prevalence of category 1 cows (acidotic herds) indicates that there may be opportunities to reduce the risk of acidosis by dietary manipulation.

Optimal choice of dairy forages in eastern Australia.

Although several forage species such as perennial ryegrass are predominant, there is a wide range of forage species that could be grown in subtropical and temperate regions in Australia as dairy pastures. These species have differing seasonal patterns of growth, nutrient quality, and water-use efficiency, as demonstrated in a large experiment evaluating over 30 species at the University of Sydney (Camden, New South Wales, Australia). Some species can be grazed, whereas others require mechanical harvesting, which incurs a further cost. Previous comparisons of species that relied on yield of dry matter per unit of some input (typically land or water) did not simultaneously take into account the season in which forage is produced, or other factors related to the costs of production and delivery to the cows. To effectively compare the profitability of individual species, or combinations of species, requires the use of a whole-farm, multiperiod model. Linear programming was used to find the most profitable mix of forage species for an irrigated dairy farm in a warm temperate irrigation region of New South Wales, Australia. It was concluded that for a typical farmer facing the prevailing milk and purchased feed prices with average milk production per cow, the most profitable mix of species would include a large proportion of perennial ryegrass (Lolium perenne) and prairie grass (Bromus willdenowii). The result was robust to changes in seasonal milk pricing and a move from year-round to a more seasonal calving pattern.

Clinical acidosis in a Gippsland dairy herd.

OBJECTIVE: To report on spontaneous clinical and subclinical acidosis in a large dairy herd, to evaluate the diets and feeding strategies involved, and to report on measures of rumen function in the cows affected. DESIGN: A Gippsland dairy herd was sampled as part of a wider randomised cross-sectional study that examined the prevalence, risk factors for, and effects of, acidosis on rumen function of dairy cattle. Three herds on the farm were involved in the study: the transition herd (cows 3 weeks prior to calving), the very fresh lactating herd (1 < days in milk < 10, herd 1) and the fresh lactating herd (10 < days in milk < 120, herd 2) including a small lame herd fed separately. The transition cows were fed 2 kg dry matter triticale per cow per day and hay with an estimated total dry matter intake of 4.8 kg per cow per day. The lactating cow diet included 6.75 kg dry matter triticale per cow per day with total concentrate fed being 8.1 kg dry matter per cow per day in the milking parlour. Silage, lucerne cubes, hay and pasture (herd 2 only) was also fed to the lactating cows with the estimated total dry matter intake for cows in herds 1 and 2 being 13.7 kg and 20.8 kg per cow per day respectively. Three primiparous and five multiparous cows in early lactation (< 100 days in milk) were randomly selected from each of two lactating herds: herds 1 and 2. Rumen fluid was sampled from each cow by both rumenocentesis and stomach tube. The rumenocentesis samples were tested for pH at the time of sampling. Stomach tube samples were frozen and subsequently tested for volatile fatty acid, ammonia, and D- and L-lactate concentration. RESULTS: In the very fresh herd, there was a high prevalence of severe lameness and scouring, coupled with a mean rumen pH 5.67, low mean total volatile fatty acid concentration 71.0 mM and high mean concentrations of L- and D-lactate, (7.71 mM and 7.31 mM), respectively. Cows in the fresh herd had moderate signs of scouring and lameness. A lame herd comprising approximately 50 cows separated from the fresh herd was also present on the farm. The mean rumen pH of the fresh herd was 5.74 and mean rumen concentrations of volatile fatty acids, ammonia, L- and D-lactate were within ranges considered normal. CONCLUSIONS: The transition diet failed to supply sufficient energy and protein for maintenance of cows of this live weight in late gestation. The diet fed to the very fresh herd was low in effective fibre and contained an excessive content of non-structural carbohydrate in the form of processed, rapidly fermentable grain. The sudden change from the transition diet to the diet fed to the very fresh herd probably also precipitated the outbreak of acidosis. This case report provides unique detail, including information on diets and rumen parameters, of an outbreak of acidosis in a pasture-fed herd.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

PURPOSE: Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome. SUBJECTS AND METHODS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data. RESULTS: Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients. CONCLUSIONS: Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.

Changing pattern of organ dysfunction in early human sepsis is related to mortality.

OBJECTIVE: We examined the pattern of organ system dysfunction, the evolution of this pattern over time, and the relationship of these features to mortality in patients who had sepsis syndrome. DESIGN: Prospective, multicenter, observational study. SETTING: Intensive care units in tertiary referral teaching hospitals. PATIENTS: A total of 287 patients who had sepsis syndrome were prospectively identified in intensive care units. MATERIALS AND MEASUREMENTS: Cardiovascular, pulmonary, neurologic, coagulation, renal, and hepatic dysfunction were assessed at onset and on day 3 of sepsis syndrome. Organ dysfunction was classified as normal, mild, moderate, severe, and extreme dysfunction. We calculated the occurrence rate and associated 30-day mortality rate of organ dysfunction at the onset of sepsis syndrome. We then measured the change in organ dysfunction from onset to day 3 of sepsis syndrome and determined, for individual organ systems, the associated 30-day mortality rate. RESULTS: At the onset of sepsis syndrome, clinically significant pulmonary dysfunction was the most common organ failure, but was not related to 30-day mortality. Clinically significant cardiovascular, neurologic, coagulation, renal, and hepatic dysfunction were less common at the onset of sepsis syndrome but were significantly associated with the 30-day mortality rate. Worsening neurologic, coagulation, and renal dysfunction from onset to day 3 of sepsis syndrome were associated with significantly higher 30-day mortality than with improvement or no change in organ dysfunction. CONCLUSIONS: Increased mortality rate in sepsis syndrome is associated with a pattern characterized by failure of nonpulmonary organ systems and, in particular, worsening neurologic, coagulation, and renal dysfunction over the first 3 days. Although initial pulmonary dysfunction is common in patients with sepsis syndrome, it is not associated with an increased mortality rate.

Effects of ibuprofen on the physiology and survival of hypothermic sepsis. Ibuprofen in Sepsis Study Group.

OBJECTIVES: The objective was to compare the clinical and physiologic characteristics of febrile septic patients with hypothermic septic patients; and to examine plasma levels of cytokines tumor necrosis factor alpha (TNF-alpha and interleukin 6 (IL-6) and the lipid mediators thromboxane B2 (TxB2) and prostacyclin in hypothermic septic patients in comparison with febrile patients. Most importantly, we wanted to report the effect of ibuprofen treatment on vital signs, organ failure, and mortality in hypothermic sepsis. SETTING: The study was performed in the intensive care units (ICUs) of seven clinical centers in the United States and Canada. PATIENTS: Four hundred fifty-five patients admitted to the ICU who met defined criteria for severe sepsis and were suspected of having a serious infection. INTERVENTION: Ibuprofen at a dose of 10 mg/kg (maximum 800 mg) was administered intravenously over 30 to 60 mins every 6 hrs for eight doses vs. placebo (glycine buffer vehicle). MEASUREMENTS AND MAIN RESULTS: Forty-four (10%) septic patients met criteria for hypothermia and 409 were febrile. The mortality rate was significantly higher in hypothermic patients, 70% vs. 35% for febrile patients. At study entry, urinary metabolites of TxB2, prostacyclin, and serum levels of TNF-alpha and IL-6 were significantly elevated in hypothermic patients compared with febrile patients. In hypothermic patients treated with ibuprofen, there was a trend toward an increased number of days free of major organ system failures and a significant reduction in the 30-day mortality rate from 90% (18/20 placebo-treated patients) to 54% (13/24 ibuprofen-treated patients). CONCLUSIONS: Hypothermic sepsis has an incidence of approximately 10% and an untreated mortality twice that of severe sepsis presenting with fever. When compared with febrile patients, the hypothermic group has an amplified response with respect to cytokines TNF-alpha and IL-6 and lipid mediators TxB2 and prostacyclin. Treatment with ibuprofen may decrease mortality in this select group of septic patients.

Performance of an algorithm to detect Pneumocystis carinii pneumonia in symptomatic HIV-infected persons. Pulmonary Complications of HIV Infection Study Group.

STUDY OBJECTIVES: To determine whether an algorithm consisting of a chest radiograph and the diffusing capacity of the lung for carbon monoxide (D(LCO)) is effective in detecting Pneumocystis carinii pneumonia (PCP) in symptomatic HIV-infected persons; and to establish a benchmark for future comparisons of alternative algorithms. DESIGN: Prospective, 64-month study. SETTING: Multicenter, ambulatory care. PATIENTS: 306 HIV-infected subjects enrolled in the Pulmonary Complications of HIV Infection Study who developed 467 episodes of new or worsening respiratory symptoms. MEASUREMENTS: Chest radiography followed by D(LCO) measurement, if the radiograph was normal or unchanged. RESULTS: An algorithm combining a chest radiograph followed by a D(LCO) measurement, if the radiograph was normal or unchanged, was effective and detected abnormalities that led to a diagnosis of PCP in 78 of 80 evaluable episodes (97.5%). The radiograph (specific parenchymal abnormality, number of lung zones involved) and the D(LCO) (degree of decrease, degree of decrease from baseline) also provided additional information on the probability of PCP. CONCLUSIONS: In symptomatic HIV-infected patients suspected of having PCP, the diagnostic evaluation should begin with a chest radiograph, followed by a D(LCO) measurement, if the radiograph is normal or unchanged. If both of these tests are normal, it may be reasonable to conclude the evaluation rather than to proceed on to additional testing. This algorithm can serve as a benchmark for future comparisons.

Effect of genetic merit and concentrate feeding on reproduction of grazing dairy cows in a subtropical environment.

This study was conducted to determine the effects of genetic merit for milk production and concentrate feeding on the intervals to the onset of postpartum cyclic ovarian activity, first insemination, and establishment of pregnancy. Other factors considered included biochemical measures of energy balance, liveweight, and measures of production. A farmlet study was conducted with two lines of cattle that differed in Australian Breeding Value by 735 L milk and 47 kg of fat plus protein that were fed 300 or 2000 kg of concentrate per cow per year in a subtropical grazing system based on ryegrass, clover, and kikuyu pasture. Milk yield was higher in cows fed 2000 kg of concentrate per cow per year (23.6 L/d) than those fed 300 kg/cow per year (18.2 L/d), and cows of medium genetic merit (19.6 L/d) produced less milk than those of high genetic merit (22.2 L/d). Plasma glucose concentration was lower in the cows of high genetic merit (3.11 mmol/L), than in the cows of medium genetic merit (3.39 mmol/L). The cumulative probabilities of ovulation, insemination, and establishment of pregnancy by any day postpartum were determined by a Weibull distribution. Medium genetic merit cows in winter were more likely to ovulate by any day postpartum than in summer and more likely than high genetic merit cows in either summer or winter. The cumulative probability of insemination was lower in primipara than multipara and in summer than in winter. Primiparous cattle had a lower cumulative probability of pregnancy by any day postpartum.

Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults.

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.

Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. SUPPORT Investigators. The Study to Understand Prognoses and Preferences for Outcome and Risks of Treatments.

OBJECTIVE: To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects. DESIGN: Prospective, multicenter study. SETTING: Five tertiary care medical centers in the United States. PATIENTS: Patients > or = 18 yrs of age who had one of nine illnesses of sufficient severity to anticipate a 6-month mortality rate of 50% were enrolled at five participating sites in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were asked their current height and weight as part of the demographic data. Stratifying body mass index by percentile rank (< or = 15, 15 to 85, and > or = 85th percentiles), risk ratios for mortality were calculated by Cox Proportional Hazards using the 15th to 85th percentile of body mass index as the reference group while controlling for multiple variables such as prior weight loss, albumin, and Acute Physiology Score. A body mass index in the < or = 15th percentile was associated with an excess risk of mortality (risk ratio = 1.23; p < .001) within 6 months. High body mass index (> or = 85th percentile) was not significantly related to risk of mortality. CONCLUSIONS: Body mass index, a simple anthropometric measure of nutrition employed in community epidemiologic studies, has now been demonstrated to be a predictor of mortality in an acutely ill population of adults at five different tertiary centers. Even when controlling for multiple disease states and physiologic variables and removing from the analysis all patients with significant prior weight loss, a body mass index below the 15th percentile remained a significant and independent predictor of mortality. Examination of patient vs. proxy data did not change the results. Future studies examining variables predictive of mortality should include body mass index, even in acutely ill populations with a poor probability of survival.

A prognostic model for patients with end-stage liver disease.

BACKGROUND & AIMS: Survival of patients with end-stage liver disease is variable and difficult to predict. A two-phase prospective cohort study was conducted at five teaching hospitals to develop and evaluate a model for prediction of death. METHODS: Five hundred thirty-eight hospitalized patients with a history of chronic liver disease and two or more signs of decompensation were studied. RESULTS: The cumulative incidence of death was 30% at 30 days and 50% at 6 months. In 295 patients in phase I, time till death was independently associated (P < 0.01) with five factors measured on study day 3: renal insufficiency, cognitive dysfunction, ventilatory insufficiency, age > or = 65 years, and prothrombin time > or = 16 seconds. These risk factors stratified 243 patients in phase II into three groups with cumulative incidences of death at 30 days of 12%, 40%, and 74%, respectively. Integration of the prognostic model with physicians' predictions led to improved estimates of the probability of death. Although performance of liver transplantation after study entry was independently associated with enhanced survival, the intensity of other acute therapies was not. CONCLUSIONS: Five risk factors were associated with the risk of death in patients with end-stage liver disease and provided a quantitative basis to complement physicians' prognostic estimates.

Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Renal failure requiring dialysis in the setting of hospitalization for serious illness is a poor prognostic sign, and dialysis and aggressive care are sometimes withheld. OBJECTIVE: To evaluate the clinical outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care for seriously ill hospitalized patients. DESIGN: Prospective cohort study and cost-effectiveness analysis. SETTING: Five geographically diverse teaching hospitals. PATIENTS: 490 patients (median age, 61 years; 58% women) enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) in whom dialysis was initiated. MEASUREMENTS: Survival, functional status, quality of life, and health care costs. Life expectancy was estimated by extrapolating survival data (up to 4.4 years of follow-up) using a declining exponential function. Utilities (quality-of-life weights) were estimated by using time-tradeoff questions. Costs were based on data from SUPPORT and published Medicare data. RESULTS: Median duration of survival was 32 days, and only 27% of patients were alive after 5 months. Survivors reported a median of one dependency in activities of daily living, and 62% rated their quality of life as "good" or better. Overall, the estimated cost per quality-adjusted life-year saved by initiating dialysis and continuing aggressive care rather than withholding dialysis and allowing death to occur was $128,200. For the 103 patients in the worst prognostic category, the estimated cost per quality-adjusted life-year was $274,100; for the 94 patients in the best prognostic category, the cost per quality-adjusted life-year was $61,900. CONCLUSIONS: For the few patients who survived, clinical outcomes were fairly good. With the exception of patients with the best prognoses, however, the cost-effectiveness of initiating dialysis and continuing aggressive care far exceeded $50,000 per quality-adjusted life-year, a commonly cited threshold for cost-effective care.

Right heart catheterization in acute respiratory failure.

OBJECTIVE: To review the literature addressing the use of the pulmonary artery catheter (PAC) in patients with respiratory failure. DATA SOURCE: All pertinent English language articles dealing with pulmonary artery catheterization in patients with respiratory failure were retrieved from 1983 through 1996. STUDY SELECTION: Articles were chosen for review if the use of pulmonary artery catheterization in patients with respiratory failure was studied or reviewed. DATA EXTRACTION: From the articles selected, information was obtained about changes in therapy and changes in outcome associated with PAC use in patients with respiratory failure. DATA SYNTHESIS: Evidence exists to suggest that use of the PAC in patients with respiratory failure often results in a change in diagnosis and therapy. Inadequate evidence exists to accurately determine benefit or harm from PAC use in patients with respiratory failure. CONCLUSION: The optimal role of the PAC as a diagnostic and monitoring device in different types of respiratory failure has not been clearly defined. Research is needed to determine the role of the PAC in very carefully defined groups of patients with respiratory failure.

Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self-Determination Act (PSDA) and enhanced by the effort to improve decision-making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation. DESIGN: Observational cohort study conducted for 2 years before (PRE) and for 2 years after (POST) the PSDA, with a randomized, controlled trial of an additional intervention to improve decision-making after PSDA (POST+SUPPORT). SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 seriously ill patients treated in five teaching hospitals. INTERVENTIONS: The PSDA mandated patient education about ADs at hospital entry and documentation of ADs in the medical record. The SUPPORT intervention, in addition, provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatment alternatives and, when clinically appropriate, to encourage completion and utilization of ADs. MEASUREMENTS: Interviews were conducted with patients, surrogates, and attending physicians about awareness, completion, and impact of ADs. Medical records were reviewed for discussion about preferences concerning resuscitation, timing and writing of "Do Not Resuscitate" (DNR) orders, evidence of ADs, and the use or forgoing of resuscitation at the time of death. RESULTS: In the three cohorts, PRE, POST, and POST+SUPPORT, average age was 63. One-quarter of patients died during the initial hospitalization, one-half were dead within 6 months, and one-half were unconscious for their last 3 days. Before the PSDA (PRE), 62% were familiar with a living will, and 21% had an AD. These rates were similar for the POST and POST+SUPPORT cohorts. Just 36 (6%) of these directives were mentioned in the medical records for PRE, but a stable 35% were documented for POST, and POST+SUPPORT had an increasing rate averaging 78% (P < .001). As previously reported for PRE patients, the POST patients with and without ADs had no significant differences in the rates of medical record documentation of discussions about resuscitation (33% vs 38%, POST without AD vs POST with AD), DNR orders among those who wanted to forgo resuscitation (54% vs 58%), and attempted resuscitations at death (17% vs 9%). The POST+SUPPORT patients had similar results, with no evidence that the intervention enhanced the effect of ADs on these three measures of resuscitation decision-making. Patients with ADs more often reported that preferences about resuscitation were discussed with a physician (e.g., for POST patients, 30% for those with no AD and 43% for those with an AD, P < .05). Only 12% of patients with ADs had talked with a physician when completing the AD. Only 42% reported ever having discussed the AD with their physician. By the second study week, only one in four physicians was aware of patients' ADs. CONCLUSIONS: In these seriously ill patients, ADs did not substantially enhance physician-patient communication or decision-making about resuscitation. This lack of effect was not altered by the PSDA or by the enhanced efforts in SUPPORT, although these interventions each substantially increased documentation of existing ADs. Current practice patterns indicate that increasing the frequency of ADs is unlikely to be a substantial element in improving the care of seriously ill patients. Future work to improve decision-making should focus upon improving the current pattern of practice through better communication and more comprehensive advance care planning.

Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents. DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives. SETTINGS: Five teaching hospitals in the United States. PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes. RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff. CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.