Genome-wide association studies and Mendelian randomization analyses provide insights into the causes of early-onset colorectal cancer.

BACKGROUND: The incidence of early-onset colorectal cancer (EOCRC; diagnosed <50 years of age) is rising globally; however, the causes underlying this trend are largely unknown. CRC has strong genetic and environmental determinants, yet common genetic variants and causal modifiable risk factors underlying EOCRC are unknown. We conducted the first EOCRC-specific genome-wide association study (GWAS) and Mendelian randomization (MR) analyses to explore germline genetic and causal modifiable risk factors associated with EOCRC. PATIENTS AND METHODS: We conducted a GWAS meta-analysis of 6176 EOCRC cases and 65 829 controls from the Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO), the Colorectal Transdisciplinary Study (CORECT), the Colon Cancer Family Registry (CCFR), and the UK Biobank. We then used the EOCRC GWAS to investigate 28 modifiable risk factors using two-sample MR. RESULTS: We found two novel risk loci for EOCRC at 1p34.1 and 4p15.33, which were not previously associated with CRC risk. We identified a deleterious coding variant (rs36053993, G396D) at polyposis-associated DNA repair gene MUTYH (odds ratio 1.80, 95% confidence interval 1.47-2.22) but show that most of the common genetic susceptibility was from noncoding signals enriched in epigenetic markers present in gastrointestinal tract cells. We identified new EOCRC-susceptibility genes, and in addition to pathways such as transforming growth factor (TGF) ß, suppressor of Mothers Against Decapentaplegic (SMAD), bone morphogenetic protein (BMP) and phosphatidylinositol kinase (PI3K) signaling, our study highlights a role for insulin signaling and immune/infection-related pathways in EOCRC. In our MR analyses, we found novel evidence of probable causal associations for higher levels of body size and metabolic factors-such as body fat percentage, waist circumference, waist-to-hip ratio, basal metabolic rate, and fasting insulin-higher alcohol drinking, and lower education attainment with increased EOCRC risk. CONCLUSIONS: Our novel findings indicate inherited susceptibility to EOCRC and suggest modifiable lifestyle and metabolic targets that could also be used to risk-stratify individuals for personalized screening strategies or other interventions.

The MOBILISE study: utilisation of ambulatory pumps in the inpatient setting to administer continuous antibiotic infusions-a randomised controlled trial.

In the inpatient setting, antibiotics are generally administered via bedside pumps with multiple daily dosing. Utilisation of a continuous antibiotic infusion (CAI) instead might have patient and nursing satisfaction, workflow efficiencies and infection control benefits. We aimed to study the utilisation of CAI in the inpatient setting for routine antibiotic administration. Patients receiving a peripherally inserted central venous catheter (PICC) for antibiotic administration were screened for the study. The patients were randomised to either (1) standard pump and intermittent antibiotic administration (IAA) or (2) CAI via an ambulatory pump. An accelerometer placed on the ankle was used to assess patient activity. Nursing and patient satisfaction surveys were also carried out. Forty patients met the study criteria for enrolment with 21 patients being enrolled in the CAI arm of the study. One hundred and five days of accelerometer recordings were available for analysis. The geometric mean activity was 45 min/day in the standard arm and 64 min/day in the CAI arm. This represented a 42% (95% CI: -14 to 133%, p = 0.16) difference in activity between the two groups. Nursing staff reported that they spent less time throughout their shift attending the antibiotic line or pump in patients who were in the CAI arm of the study (p < 0.001). In addition, patients in this arm of the study were more likely to recommend this method of administration of antibiotics to a family member (p =0.0001). The MOBILISE study showed nursing and patient satisfaction when CAI were utilised in the inpatient setting. A statistically non-significant difference in mobility was seen. The trial was registered (28/03/2018) with the Australia New Zealand Clinical Trials Registry (ACTRN12618000452291).

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study.

BACKGROUND: The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19. METHODS: Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease. RESULTS: Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56). CONCLUSIONS: Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Herb species inclusion in grazing swards for dairy cows-A systematic review and meta-analysis.

A systematic review and meta-analysis were conducted to estimate the effect of herb species on milk production and urinary nitrogen (UN) excretion from grazing dairy cows. Grazing swards consisting of herb species grown with either a grass species or a grass and legume (multispecies swards) were compared with non-herb-containing swards consisting of a grass species grown as a monoculture or grass-legume swards (simple swards). A literature search was completed using the online databases CAB Direct, Web of Science, and Google Scholar, using the search strategy "dairy cow", "herb OR forb OR phorb", and "grazing". Milk production data, variance, and sample size were required for eligibility. In all, 116 studies were identified. Following eligibility screening, 11 papers from 6 journals, published between 2006 and 2018, were available for analysis. Studies were from New Zealand (N = 7), Australia (N = 3), and the United States (N = 1). The population was either Holstein Friesian or Holstein Friesian × Jersey dairy cows, with a range in mean daily milk yield (MY) from 12.1 kg to 34.7 kg (mean = 18.6 kg). A total of 25 comparisons were used for milk production analysis, with 324 and 284 cows included in multispecies and simple sward groups respectively. Data analysis was conducted in R using a random effects, robust variance estimation model (R Foundation for Statistical Computing, Vienna, Austria). Heterogeneity was reported using the I2 statistic. Milk production was significantly increased. Analysis of MY resulted in a weighted mean difference (WMD) of +1.20 kg/d (95% CI = 0.90, 1.49; I2 = 4%). Fat and protein kg were also significantly increased (WMD +0.06 kg/d; CI = 0.01, 0.11). Urinary nitrogen excretion was estimated from milk urea nitrogen when reported (n = 6). A WMD of -28.1 g of N/d (95% CI = -81.1, 24.9) was generated, with heterogeneity high among studies (I2 = 75%). This meta-analysis shows the potential benefits of multispecies swards. Although we saw no significant difference in UN excretion, an increase in milk production was found.

Septic arthritis post anterior cruciate ligament reconstruction due to Clostridioides difficile.

Clostridioides difficile is an obligate anaerobe ubiquitous in the environment and is of particular interest in the healthcare setting as a cause of healthcare associated infection usually presenting with colitis. Extracolonic manifestations of C. difficile infection are less common with only rare reports of septic arthritis primarily in the setting of relative or overt immunocompromise. This report details the case of a 31-year-old immunocompetent male presenting with clinical features of septic arthritis, three weeks post right knee anterior cruciate ligament (ACL) reconstruction using a native hamstring tendon graft. C. difficile was isolated from two different samples of the synovial tissue from a subsequent arthroscopic washout and synovectomy. The ACL graft was retained. The isolate underwent whole genome sequencing and was found to be tcdA and tcdB gene deficient. Susceptibility testing showed susceptibility to benzylpenicillin and metronidazole. The patient received a two-week course of intravenous benzylpenicillin and four weeks of oral metronidazole. At one-year post cessation of antibiotics the patient has no clinical evidence of recurrence. This is the first known reported case of C. difficile septic arthritis in an immunocompetent patient. It demonstrates successful treatment of post-ACL septic arthritis with a graft retention strategy.

Outcomes of patients with a history of injecting drug use and receipt of outpatient antimicrobial therapy.

People who inject drugs (PWID) are susceptible to endovascular and deep-seated infections which require prolonged antibiotic therapy. There are concerns regarding this cohort's suitability for outpatient parenteral antimicrobial therapy (OPAT), but relatively little published data. Our aim is to publish our outcomes in this setting, to inform other clinicians' decisions regarding PWID in OPAT. We reviewed case records of all PWID in our OPAT service from July 2015 to December 2017. Successful completion of OPAT care was defined as completing the duration of parenteral therapy as planned at the outset, with expected clinical improvement. Data was collected on complications including hospital re-admission, new blood stream infections, patient non-compliance including ongoing non-prescribed intravenous drug use, and staff safety compromise. Twenty-eight of 38 (76.2%) episodes of OPAT care for PWID were completed successfully, with 724 bed days of care provided. The cohort was labour intensive to manage with high rates of re-admission, non-attendance and line-associated infections. There were no adverse events for staff safety, and no patient deaths on the programme. OPAT can be a viable option for PWID provided there is careful patient selection, good patient engagement and sufficient resources allocated for patient management.

Slow Acceptance of Universal Antiretroviral Therapy (ART) Among Mothers Enrolled in IMPAACT PROMISE Studies Across the Globe.

The PROMISE trial enrolled asymptomatic HIV-infected pregnant and postpartum women not eligible for antiretroviral treatment (ART) per local guidelines and randomly assigned proven antiretroviral strategies to assess relative efficacy for perinatal prevention plus maternal/infant safety and maternal health. The START study subsequently demonstrated clear benefit in initiating ART regardless of CD4 count. Active PROMISE participants were informed of results and women not receiving ART were strongly recommended to immediately initiate treatment to optimize their own health. We recorded their decision and the primary reason given for accepting or rejecting the universal ART offer after receiving the START information. One-third of participants did not initiate ART after the initial session, wanting more time to consider. Six sessions were required to attain 95% uptake. The slow uptake of universal ART highlights the need to prepare individuals and sensitize communities regarding the personal and population benefits of the "Treat All" strategy.

Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study.

BACKGROUND: frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages. METHODS: a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period. RESULTS: the cohort included 2,279 patients (median age 54 years [IQR 36-72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40's to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61-2.01) supporting a linear dose-response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days. CONCLUSIONS: worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

Listeria Meningitis in an Immunocompetent Child: Case Report and Literature Review

We present a case of a 23 month-old boy presenting with fever, irritability and diarrhea who subsequently developed symptoms of photophobia and lethargy. Cerebrospinal fluid culture grew Listeria monocytogenes. Immunology investigations were normal. This patient had a complete and uncomplicated recovery. Listeria meningitis is a rare presentation in immunocompetent children, but should be considered in the setting of diarrhea, failure to respond to cephalosporin therapy, or suspected immunodeficiency.

Varicella Related Hospital Admissions in Ireland

Aim The aim of this study was to evaluate trends in admissions for patients with primary varicella infection in Irish hospitals. Methods The Hospital Inpatient Enquiry System was evaluated from Irish hospitals from 2005-2016 for patients with primary varicella infection. Results There were 2717 admissions with primary varicella infection. The average annual number of admissions was 226 for an incidence of 4.87/100,000. Average length of stay (ALOS) was 5-days. Sixty-two (2.5%) patients required intensive-care with an ALOS of 26-days. The most common secondary diagnoses were cellulitis, volume-depletion and streptococcal infection. The number of admissions due to streptococcal infection and cellulitis significantly increased over the period. Conclusion Chickenpox places a consistent burden on Irish healthcare, accounting for in excess of 1100 acute and 160 intensivecare bed days annually. This study adds weight to the argument that universal varicella vaccine should be considered and provides baseline epidemiology to determine vaccine effectiveness in the future.

P. aeruginosa blood stream infection isolates: A "full house" of virulence genes in isolates associated with rapid patient death and patient survival.

We have recently characterised the epidemiology of P. aeruginosa blood stream infection (BSI) in a large retrospective multicentre cohort study [1]. Utilising corresponding patient BSI isolates we aimed to characterise the genotypic virulence profile of the P. aeruginosa isolates that were associated with rapid death in the non-neutropenic host. Five P. aeruginosa BSI episodes were identified from a larger cohort of P. aeruginosa BSI episodes previously described by McCarthy et al. [1]. The genotypic profile of another 5 isolates from this cohort in whom the non-neutropenic host had survived one year post the BSI was also analysed for comparison. These isolates underwent Illumina whole genome sequencing, de novo assembly and annotation. A comprehensive suite of virulence genes was collated from the Pseudomonas Genome Database (http://www.pseudomonas.com/) and were searched by BLAST based analysis in assemblies of all BSI isolates [2]. There was extensive conservation of virulence genes across all of the BSI isolates studied. The exoU gene was found in two isolates from patients who died rapidly and in one isolate from a patient that survived one year post BSI. The higA and higB genes were detected in all isolates. The exlA gene was not detected in any of the isolates studied. These findings suggest that to cause a BSI that it is only the virulent P. aeruginosa isolate that succeeds. The virulence gene profile seen was independent of patient outcome. Further phenotypic correlation is required to determine if there is any difference in genotypic expression by the BSI isolates that were associated with rapid death of the host and those BSI isolates associated with host survival at one year.

Waterborne outbreak of gastroenteritis on the KwaZulu-Natal Coast, South Africa, December 2016/January 2017.

An unexpected increase in gastroenteritis cases was reported by healthcare workers on the KwaZulu-Natal Coast, South Africa, January 2017 with >600 cases seen over a 3-week period. A case-control study was conducted to identify the source and risk factors associated with the outbreak so as to recommend control and prevention measures. Record review identified cases and controls and structured-telephonic interviews were conducted to obtain exposure history. Stool specimens were collected from 20 cases along with environmental samples and both screened for enteric pathogens. A total of 126 cases and 62 controls were included in the analysis. The odds of developing gastroenteritis were 6.0 times greater among holiday makers than residents (95% confidence interval (CI) 2.0-17.7). Swimming in the lagoon increased the odds of developing gastroenteritis by 3.3 times (95% CI 1.06-10.38). Lagoon water samples tested positive for norovirus (NoV) GI.6, GII.3 and GII.6, astrovirus and rotavirus. Eleven (55%) stool specimens were positive for NoV with eight genotyped as GI.1 (n = 2), GI.5 (n = 3), GI.6 (n = 2), and GI.7 (n = 1). A reported sewage contamination event impacting the lagoon was the likely source with person-to-person spread perpetuating the outbreak. Restriction to swimming in the lagoon was apparently ineffective at preventing the outbreak, possibly due to inadequate enforcement, communication and signage strategies.

Antimicrobial stewardship in the neonatal unit reduces antibiotic exposure.

AIM: Antimicrobial stewardship plays an important role in ensuring that the appropriate drug, dose, route and duration are employed to provide adequate treatment while minimising the risks of unnecessary antibiotic use. Surveillance of antibiotic use with prescriber feedback is recommended as a high-impact stewardship intervention. The aim of this study was to reduce unnecessary antimicrobial use in a neonatal unit. METHODS: A prospective audit was performed to assess compliance with antimicrobial guidelines. Following this, educational interventions were applied, electronic prescribing was introduced to the neonatal unit, and re-audit was performed. The primary outcome was a reduction in days of therapy (DOT). RESULTS: There were 312 neonatal admissions. There was a significant overall reduction in the primary outcome of DOT/1000 patient days from 572 to 417 DOT. This represents a 27% reduction in total antibiotic use. Prolonged antibiotic treatment courses >36 hours in negative sepsis evaluations were reduced from 82 DOT to 7.5 DOT. Similarly, treatment courses greater than five days for culture-negative sepsis were reduced from 46.5 DOT to 7 DOT. CONCLUSION: Monitoring antibiotic prescribing data can provide useful insights into the trends of antibiotic use and also inform clinicians of potential areas where antibiotic use may be safely reduced.

Observation of Oscillatory Radial Electric Field Relaxation in a Helical Plasma.

Measurements of the relaxation of a zonal electrostatic potential perturbation in a nonaxisymmetric magnetically confined plasma are presented. A sudden perturbation of the plasma equilibrium is induced by the injection of a cryogenic hydrogen pellet in the TJ-II stellarator, which is observed to be followed by a damped oscillation in the electrostatic potential. The waveform of the relaxation is consistent with theoretical calculations of zonal potential relaxation in a nonaxisymmetric magnetic geometry. The turbulent transport properties of a magnetic confinement configuration are expected to depend on the features of the collisionless damping of zonal flows, of which the present Letter is the first direct observation.

Community-acquired Pseudomonas aeruginosa bloodstream infection: a classification that should not falsely reassure the clinician.

Pseudomonas aeruginosa bloodstream infection (BSI) is predominantly acquired in the hospital setting. Community-onset infection is less common. Differences in epidemiology, clinical features, microbiological factors and BSI outcomes led to the separation of bacterial community-onset BSI into the categories of healthcare-associated infection (HCAI) and community-acquired infection (CAI). Community-acquired P. aeruginosa BSI epidemiology is not well defined in the literature. In addition, it is also not clear if the same factors separate CAI and HCAI BSI caused by P. aeruginosa alone. A retrospective multicentre cohort study was performed looking at P. aeruginosa BSI from January 2008 to January 2011. Strict definitions for HCAI and CAI were applied. Extensive epidemiological, clinical and outcome data were obtained. Thirty-four CAI episodes and 156 HCAI episodes were analysed. The CAI group could be characterised into seven distinct categories based on comorbidities and clinically suspected source of infection. A pre-morbidly healthy group could not be identified. On multivariate analysis, the presence of a rheumatological or a gastrointestinal comorbidity were significantly associated with CAI. There was no significant difference in length of stay or rates of mortality between HCAI or CAI. The clinician should not be falsely reassured regarding outcome by the diagnosis of a community-acquired P. aeruginosa BSI.

Pseudomonas aeruginosa blood stream infection isolates from patients with recurrent blood stream infection: Is it the same genotype?

The type identity of strains of Pseudomonas aeruginosa from primary and recurrent blood stream infection (BSI) has not been widely studied. Twenty-eight patients were identified retrospectively from 2008 to 2013 from five different laboratories; available epidemiological, clinical and microbiological data were obtained for each patient. Isolates were genotyped by iPLEX MassARRAY MALDI-TOF MS and rep-PCR. This showed that recurrent P. aeruginosa BSI was more commonly due to the same genotypically related strain as that from the primary episode. Relapse due to a genotypically related strain occurred earlier in time than a relapsing infection from an unrelated strain (median time: 26 vs. 91 days, respectively). Line related infections were the most common source of suspected BSI and almost half of all BSI episodes were associated with neutropenia, possibly indicating translocation of the organism from the patient's gut in this setting. Development of meropenem resistance occurred in two relapse isolates, which may suggest that prior antibiotic therapy for the primary BSI was a driver for the subsequent development of resistance in the recurrent isolate.

An isolated outbreak of diphtheria in South Africa, 2015.

An outbreak of respiratory diphtheria occurred in two health districts in the province of KwaZulu-Natal in South Africa in 2015. A multidisciplinary outbreak response team was involved in the investigation and management of the outbreak. Fifteen cases of diphtheria were identified, with ages ranging from 4 to 41 years. Of the 12 cases that were under the age of 18 years, 9 (75%) were not fully immunized for diphtheria. The case fatality was 27%. Ninety-three household contacts, 981 school or work contacts and 595 healthcare worker contacts were identified and given prophylaxis against Corynebacterium diphtheriae infection. A targeted vaccination campaign for children aged 6-15 years was carried out at schools in the two districts. The outbreak highlighted the need to improve diphtheria vaccination coverage in the province and to investigate the feasibility of offering diphtheria vaccines to healthcare workers.

Outcomes for Patients with apparent Chronic Idiopathic Pelvic Pain and associated Pelvic Floor Disorders undergoing Laparoscopic Ventral Mesh Rectopexy.

This article has been temporarily withdrawn, with the agreement of all authors and the journal editor, whilst an investigated is being carried out by the North Bristol NHS Trust and the General Medical Council following some concerns raised.

Milk fat threshold determination and the effect of milk fat content on consumer preference for fluid milk.

Milk consumption in the United States has been in decline since the 1960s. Milk fat plays a critical role in sensory properties of fluid milk. The first objective of this study was to determine the change in percent milk fat needed to produce a detectable or just noticeable difference (JND) to consumers in skim, 1%, 2%, and whole milks. The second objective was to evaluate how milk fat affected consumer preferences for fluid milk. Threshold tests were conducted to determine the JND for each reference milk (skim, 1%, 2%, and whole milk), with a minimum of 60 consumers for each JND. The JND was determined for milks by visual appearance without tasting and tasting without visual cues. Serving temperature effect (4, 8, or 15°C) on tasting JND values were also investigated. The established JND values were then used to conduct ascending forced-choice preference tests with milks. Consumers were assigned to 3 groups based on self-reported milk consumption: skim milk drinkers (n = 59), low-fat milk drinkers (consumed 1% or 2% milk, n = 64), and whole milk drinkers (n = 49). Follow-up interviews were conducted where consumers were asked to taste and explain their preference between milks that showed the most polarization within each consumer segment. Descriptive sensory analysis was performed on the milks used in the follow-up interviews to quantify sensory differences. Visual-only JND were lower than tasting-only JND values. Preference testing revealed 3 distinct preference curves among the consumer segments. Skim milk drinkers preferred skim milk and up to 2% milk fat, but disliked milk higher in fat due to it being "too thick," "too heavy," "flavor and texture like cream," "too fatty," and "looks like half and half." Low-fat milk drinkers preferred 2% milk up to 3.25% (whole milk), but then disliked higher milk fat content. Whole milk drinkers preferred whichever milk was higher in milk fat regardless of how high the fat content was, distinct from skim and low-fat milk drinkers. The findings of this study provide insights on sensory characteristics of milk fat in fluid milk and consumer sensory perception of these properties. These results also provide insights on how the industry might adjust milk fat references for adjusting milk sensory properties to increase milk preference and remain within the standards of identity of milk.

Drivers of choice for fluid milk versus plant-based alternatives: What are consumer perceptions of fluid milk?

Fluid milk consumption has declined for decades while consumption of nondairy alternatives has increased. A better understanding of why consumers purchase fluid milk or nondairy alternatives is needed to assist increased sales of milk or maintain sales without further decline. The objective of this study was to determine the extrinsic attributes that drive purchase within each product category. The second objective was to determine the personal values behind the purchase of each beverage type to give further understanding why particular attributes are important. An online conjoint survey was launched with 702 dairy consumers, 172 nondairy consumers, and 125 consumers of both beverages. Individual means-end chain interviews were conducted with fluid milk consumers (n = 75), plant-based alternative consumers (n = 68), and consumers of both beverages (n = 78). Fat content was the most important attribute for dairy milk followed by package size and label claims. Consumers of fluid milk preferred 1 or 2% fat content, gallon, or half-gallon packaging, conventionally pasteurized store-brand milk. Sugar level was the most important attribute for plant-based beverages, followed by plant source and package size. Almond milk was the most desirable plant source, and half-gallon packaging was the most preferred packaging. Means-end chain interviews results suggested that maintaining a balanced diet and healthy lifestyle was important to all consumer groups. Lactose free was an important attribute for plant-based alternative consumers and consumers of both dairy and nondairy. A distinguishing characteristic of those who only drank nondairy plant-based alternatives was that plant-based beverages contributed to a goal to consume less animal products, beliefs about animal mistreatment, and perceived lesser effect on the environment than fluid milk. Unique to fluid milk consumers was that fluid milk was perceived as a staple food item. These results suggest that the dairy industry should focus on the nutrition value of milk and educating consumers about misconceptions regarding dairy milk. Future beverage innovation should include the development of lactose-free milk that is also appealing to consumers in flavor.