Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis.

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Habitual protein intake, protein distribution patterns and dietary sources in Irish adults with stratification by sex and age.

BACKGROUND: Given the importance of habitual dietary protein intake, distribution patterns and dietary sources in the aetiology of age-related declines of muscle mass and function, the present study examined these factors as a function of sex and age in Irish adults aged 18-90 years comprising The National Adult Nutrition Survey (NANS). METHODS: In total, 1051 (males, n = 523; females, n = 528) undertook a 4-day semi-weighed food diary. Total, body mass relative intake and percentage contribution to total energy intake of dietary protein were determined in addition to protein distribution scores (PDS), as well as the contribution of food groups, animal- and plant-based foods to total protein intake. RESULTS: Total and relative protein intake [mean (SD)] were highest in those aged 18-35 years [96 (3) g day-1 , 1.32 (0.40) g kg-1  day-1 ], with lower protein intakes with increasing age (i.e. in adults aged ≥65 years [82 (22) g, 1.15 (0.34) g kg-1  day-1 , P < 0.001 for both]. Differences in protein intake between age groups were more pronounced in males compared to females. Protein distribution followed a skewed pattern for all age groups [breakfast, 15 (10) g; lunch, 30 (15) g; dinner, 44 (17) g]. Animal-based foods were the dominant protein source within the diet [63% (11%) versus 37% (11%) plant protein, P < 0.001]. CONCLUSIONS: Protein intake and the number of meals reaching the purported threshold for maximising post-prandial anabolism were highest in young adults, and lower with increasing age. For main meals, breakfast provided the lowest quantity of protein across all age categories and may represent an opportunity for improving protein distribution, whereas, in older adults, increasing the number of meals reaching the anabolic threshold regardless of distribution pattern may be more appropriate.

Estrous detection intensity and accuracy and optimal timing of insemination with automated activity monitors for dairy cows.

The objectives of this observational study were to assess the ability of automated activity monitoring (AAM) to detect estrus for first insemination, the accuracy of detection, and the optimum interval from the estrus alert from the AAM system to insemination. Four commercial farms using 1 of 2 commercial AAM systems were studied over 1 yr. Cows were inseminated between 55 and 80 d in milk (DIM) based on AAM only, then by a combination of AAM and timed artificial insemination (AI). Blood progesterone was measured in 1,014 cows at wk 5, 7, and 9 postpartum; purulent vaginal discharge (PVD) was assessed at wk 5; and lameness and BCS at wk 7. Overall, AAM detected 83% of cows in estrus by 80 DIM. Cows that had 3 serum progesterone <1 ng/mL, had PVD, or were both lame and had BCS ≤2.5 has lesser odds of being detected in estrus by 80 DIM (62, 68, and 53%, respectively). Blood samples were collected on the day of 445 AI based on AAM and 323 timed AI. The proportion of cows not in estrus (progesterone >1 ng/mL) on the day of AI was similar between AAM (4 ± 1.8%) and timed AI (3 ± 1.2%). Managers elected, based on subjective criteria, not to inseminate 17% of cows for which an AAM estrus alert was issued, of which 43% were not in estrus. Activity data were extracted from AAM software for 1,399 AI. Onset of estrus was calculated using the same or similar data processing criteria as the AAM system. Producers recorded the time of AI. The interval from onset of estrus to AI was categorized as 0 to 8, 8 to 16, or 16 to 24 h. We found no effect of AAM system on the probability of pregnancy per AI, but noted an interaction of interval with parity. For multiparous cows, the probability of pregnancy per AI was 31%, which did not differ with the interval to AI. For primiparous cows, the odds of pregnancy were greater if AI occurred 0 to 8 h (49%) than 8 to 16 (36%) or 16 to 24 h (31%) after the estrus alert from the AAM. Automated activity monitoring can detect estrus for first AI in just over the length of 1 estrous cycle for over 80% of cows, but the remainder would likely require intervention for timely insemination. For multiparous cows, performing AI based on AAM once per day would not affect pregnancy per AI, but for primiparous cows AI within 8 h of the onset of estrus may be advantageous.

Dietary strategies for achieving adequate vitamin D and iron intakes in young children in Ireland.

BACKGROUND: Inadequate intakes of vitamin D and iron have been reported in young children in Ireland. The present study aimed to identify the main foods determining vitamin D and iron intakes and to model the impact of dietary strategies to improve adequacy of these micronutrients in young children. METHODS: The present study is based on the Irish National Pre-School Nutrition Survey (NPNS), which estimated food and nutrient intakes in a representative sample (n = 500) of children (aged 1-4 years) using a 4-day weighed food record. Dietary strategies were modelled using DaDiet© software (Dazult Ltd, Co. Kildare, Republic of Ireland) and the usual intake distribution, prevalence of inadequate intakes and risk of excessive intakes were estimated using the National Cancer Institute method. RESULTS: Fortified foods and nutritional supplements were the key foods influencing the intakes of vitamin D and iron. Adding a 5 µg day-1 vitamin D supplement, fortifying cow's milk (CM) with vitamin D or replacing CM with growing-up milk (GUM) would modestly increase intakes of vitamin D. A combined strategy of fortifying CM with vitamin D or replacing CM with GUM plus a 5 µg day-1 vitamin D supplement would increase mean intakes of vitamin D (from 3.5 µg day-1 at baseline to ≥11 µg day-1 ) and substantially reduce the prevalence of inadequate intakes (from >95% to 12-36%). Fortifying CM with iron or replacing CM with GUM would increase mean intakes of iron (from 7.3 mg day-1 to >10 mg day-1 ), achieving adequate intakes across all ages. CONCLUSIONS: Based on real food consumption data in a representative sample of Irish children, we have shown that through targeted dietary strategies adequate intakes of iron are achievable and intakes of vitamin D could be greatly improved.

Nutrient intakes and compliance with nutrient recommendations in children aged 1-4 years in Ireland.

BACKGROUND: The early childhood years represent a period of rapid growth and development characterised by unique requirements for energy and individual nutrients. METHODS: The present study uses data from the National Pre-School Nutrition Survey, a nationally representative sample of Irish children (1-4 years) (n = 500), aiming to estimate energy and nutrient intakes across age and compliance with recommendations (UK and European). A 4-day weighed food-record was used to collect dietary data and statistical modelling (National Cancer Institute method) was applied to estimate usual nutrient intakes. RESULTS: Intakes of carbohydrate [48-50% energy (E)], protein (15-16%E), total fat (32-34%E), dietary fibre (2.5 g MJ-1 ), α-linolenic acid (0.45%E) and most micronutrients were in good compliance with recommendations. However, intakes of long chain polyunsaturated fatty acids (LCPUFA) (65-80 mg) were low and significant proportions of children had inadequate intakes (< estimated average requirement) of vitamin D and iron. Small proportions of children with intakes exceeding the upper level for retinol, folic acid, zinc, copper and iodine, are unlikely to give rise to adverse health effects. Mean intakes of free sugars (12%E) and salt (3.1 g day-1 ) exceeded recommendations and increased with age, whereas mean intake of saturated fat (15%E) decreased with age. By the age of 4 years, patterns established for intakes of salt, saturated fat and free sugars were unfavourable and similar to those observed in the diets of older children. CONCLUSIONS: Further research is needed to identify dietary strategies that improve the quality of the diet in young children, particularly in relation to excess of saturated fat, free sugars and salt, as well as inadequacy of iron, vitamin D and LCPUFA.

A review of sugar consumption from nationally representative dietary surveys across the world.

BACKGROUND: Government and health organisations worldwide have recently reviewed the evidence on the role of dietary sugars in relation to health outcomes. Hence, it is timely to review current intakes of dietary sugars with respect to this guidance and as a benchmark for future surveillance. METHODS: This review collates data from nationally representative dietary surveys across the world and reports estimates of intakes of total and added sugars, and sucrose in different population subgroups. Total sugars includes all mono- and disaccharides; namely, glucose, fructose, lactose, sucrose and maltose. Added and free sugars differ in the quantity of natural sugars included in their definitions. Free sugars include sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates, whereas added sugars typically only refer to those added during processing. RESULTS: Most countries reported intakes of total sugars, with fewer reporting intakes of added sugars and sucrose. No country reported intakes of free sugars. The available data suggest that total sugars as a percentage of energy were highest in the infant (<4 years), with mean values ranging from 20.0% to 38.4%, and decreased over the lifespan to 13.5-24.6% in adults. Intakes of added sugars were higher in school-aged children and adolescents (up to 19% of total energy) compared to younger children or adults. CONCLUSIONS: Further research into the dietary patterns contributing to added sugars intake in children and adolescents is warranted. It would also be beneficial to policy guidance if future dietary surveys employed a uniform way of expressing sugars that is feasible to measure and has public health significance.

Student ePortfolios to develop reflective skills and demonstrate competency development: Evaluation of a curriculum pilot project.

INTRODUCTION: The University of British Columbia Faculty of Dentistry developed a longitudinal curriculum pilot project to assess the usefulness of portfolios for dental students to develop reflective skills and demonstrate competency development, and to examine relationships between portfolio grades and clinical success. MATERIALS AND METHODS: Students in one dental class created portfolios with reflections on examples relevant to eight selected competency statements each year of the program. As part of our program evaluation, we set out to look at trends in portfolio grades, meta-reflection skills, student and faculty views of the project, and relationships among portfolio grades, 4th year clinical grades and faculty rankings. RESULTS: Portfolio grades improved from years 1 to 3, dropping off slightly in year 4. The highest level of internal consistency for grades within and between years occurred with Competency 42, while the lowest level occurred with Competency 4. Most students were able to demonstrate meta-reflection by 4th year. Students generally agreed with portfolios and reflection in concept, but suggested a looser structure, and they shared concerns with faculty about the workload involved. Portfolio grades did not correlate with clinical course grades (P = 0.092), but they did correlate significantly with faculty rankings except for year 1. CONCLUSION: While portfolio grades for reflections were not consistent, and they did not quite correlate with clinical course grades, they correlated strongly with faculty rankings. Future use of portfolios at UBC Dentistry will be enhanced by increasing curricular support regarding both competency development and the importance of reflection for professionals, decreasing workload by focusing on five Key Competencies, incorporating more formative and face-to-face feedback, and providing greater opportunities for peer sharing.

Nutritional quality of the school-day diet in Irish children (5-12 years).

BACKGROUND: The European Commission has identified schools as a priority setting for health promotion, including nutrition education and intervention. The present study examined the school-day diet of Irish primary-school children with the aim of identifying opportunities for dietary improvement. METHODS: Data from The National Children's Food Survey (2003-2004) were used to establish a dataset of school-days. Dietary intake data were collected from 594 children (5-12 years) using a 7-day weighed food-record. The nutritional quality of the diet was examined for the total school-day and for food eaten 'before school', 'at school' and 'after school'. RESULTS: Examination of dietary intake on school-days has highlighted nutritional imbalances for intakes of fat, saturated fat, added sugars, sodium and dietary fibre (DF). Mean energy (E) intake for the overall school-day was 7.1 MJ, with 16% of energy provided from food eaten 'before school', 33%E from food eaten 'at school' and 53% of energy from food eaten 'after school'. Relative to the overall school-day, food eaten 'before school' was lower in saturated fat and sodium, and higher in DF and many micronutrients. Food eaten 'at school' was relatively high in added sugars and sodium; lower in DF and micronutrients; and similar in saturated fat compared to the overall school-day. Food eaten 'after school' was relatively high in DF and vitamin A; similar in saturated fat, magnesium and sodium; and lower in added sugars and other micronutrients compared to the overall school-day. CONCLUSIONS: To improve the overall nutritional quality of the school-day diet, food eaten at school should be targeted.

A unified perspective on the nature of bonding in pairwise interatomic interactions.

Different classes of ground electronic state pairwise interatomic interactions are referenced to a single canonical potential using explicit transformations. These approaches have been applied to diatomic molecules N2, CO, H2(+), H2, HF, LiH, Mg2, Ca2, O2, the argon dimer, and one-dimensional cuts through multidimensional potentials of OC-HBr, OC-HF, OC-HCCH, OC-HCN, OC-HCl, OC-HI, OC-BrCl, and OC-Cl2 using accurate semiempirically determined interatomic Rydberg-Klein-Rees (RKR) and morphed intermolecular potentials. Different bonding categories are represented in these systems, which vary from van der Waals, halogen bonding, and hydrogen bonding to strongly bound covalent molecules with binding energies covering 3 orders of magnitude from 84.5 to 89,600.6 cm(-1) in ground state dissociation energies. Such approaches were then utilized to give a unified perspective on the nature of bonding in the whole range of diatomic and intermolecular interactions investigated.

Water intakes and dietary sources of a nationally representative sample of Irish adults.

BACKGROUND: Despite evidence that even mild dehydration is associated with various morbidities, water intake estimates in free-living populations are lacking. The present study aimed to estimate water intakes and dietary sources in a nationally representative sample of the Irish adult population. METHODS: A 4-day semi-weighed food record was used to collect dietary intake data from 1500 free-living adults aged 18-90 years in the Irish National Adult Nutrition Survey (NANS) (2008-2010) from which water intake was estimated. To enable fluid intake estimation, additional questions on how water and milk were consumed were incorporated. Total water intake was calculated as drinking water plus water from other beverages and food moisture. RESULTS: The mean (SD) daily total water intake for Irish adults was 2.31 (0.92) L day(-1) [males 2.52 (1.00) L day(-1) ; females 2.09 (0.79) L day(-1)]. Intakes were lowest in elderly adults, as well as in those with less education, a lower social class, less energy expenditure and a higher body mass index and body fat percentage. In total, 67% of water came from beverages and 33% came from food moisture. Alcoholic beverages and teas individually contributed to total water intake in amounts similar to the drinking water contribution. CONCLUSIONS: These data may be used as a foundation for further research in the area of the effect of under consumption of water on health outcomes to guide public health messages regarding adequate water intakes.

Association of Exclusive Breast Milk Intake and Outcomes in Infants With Uncomplicated Gastroschisis: A National Cohort Study.

BACKGROUND: Enteral feeding is an essential part of the management of infants with gastroschisis. We hypothesized that exclusive breast milk is associated with improved neonatal outcomes. METHODS: We conducted a retrospective review of infants with uncomplicated gastroschisis through the Canadian Pediatric Surgery Network (CAPSNet) and Canadian Neonatal Network (CNN). The primary outcome was time to full enteral feeds. RESULTS: We identified 411 infants with gastroschisis treated at CAPSNet centres from 2014 to 2022. 144 patients were excluded due to gestational age <32 weeks, birth weight <1500 g, other congenital anomalies, or complicated gastroschisis. Of the remaining 267 participants, 78% (n = 209) received exclusive breast milk diet in the first 28 days of life, whereas 22% (n = 58) received supplemental or exclusive formula. Infants who received exclusive breast milk experienced higher time to reach full enteral feeding (median 24 vs 22 days, p = 0.047) but were more likely to have undergone delayed abdominal closure (32% vs 17%, p = 0.03). After adjustment, there were no significant differences between groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay. Infants who received supplemental or exclusive formula had a similar risk of necrotizing enterocolitis (4% vs 3%) but were less likely to transition to exclusive breast milk at discharge (73% vs 11%, p < 0.001). CONCLUSION: Early use of exclusive breast milk in infants with uncomplicated gastroschisis is associated with similar outcomes compared to supplemental or exclusive formula. Patients who received supplemental or exclusive formula were unlikely to transition to exclusive breastfeeding by discharge. LEVEL OF EVIDENCE: Level IIb (Individual Cohort Study).

Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP).

BACKGROUND: In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE: The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN: This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION: This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT05678244, Registered December 6, 2022.

The effects of a community-based partnership, Project Access Dallas (PAD), on emergency department utilization and costs among the uninsured.

BACKGROUND: Approximately 19% of non-elderly adults are without health insurance. The uninsured frequently lack a source of primary care and are more likely to use the emergency department (ED) for routine care. Improving access to primary care for the uninsured is one strategy to reduce ED overutilization and related costs. METHODS: A comparison group quasi-experimental design was used to evaluate a broad-based community partnership that provided access to care for the uninsured-Project Access Dallas (PAD)-on ED utilization and related costs. Eligible uninsured patients seen in the ED were enrolled in PAD (n = 265) with similar patients not enrolled in PAD (n = 309) serving as controls. Study patients were aged 18-65 years, <200% of the federal poverty level and uninsured. Outcome measures include the number of ED visits, hospital days and direct and indirect costs. RESULTS: PAD program enrollees had significantly fewer ED visits (0.93 vs. 1.44; P < 0.01) and fewer inpatient hospital days (0.37 vs. 1.07; P < 0.05) than controls. Direct hospital costs were ∼60% less ($1188 vs. $446; P < 0.01) and indirect costs were 50% less ($313 vs. $692; P < 0.01). CONCLUSIONS: A broad-based community partnership program can significantly reduce ED utilization and related costs among the uninsured.

Determining the optimal method for proteinuria detection in chronic spinal cord injury.

STUDY DESIGN: A retrospective analysis. OBJECTIVES: The objective of this study is to determine whether dipstick protein analysis (DSP) or random urine protein:creatinine ratios (UPC) are accurate in predicting clinical proteinuria in the chronic spinal cord injury (SCI) population. METHODS: A retrospective analysis was performed in 219 veterans with SCI, comparing DSP and 24-h urine protein excretion. Sensitivity, specificity, predictive values (PV) and receiver-operator characteristic (ROC) curves of DSP in predicting clinical proteinuria were calculated with and without correction for specific gravity (SG). A prospective study was also performed in 62 SCI patients, comparing the UPC and 24-h urines. Sensitivity, specificity, PV and ROC curves of UPC in predicting clinical proteinuria were calculated. RESULTS: Any level of positive DSP had high specificity, but low sensitivity, for detecting the presence of clinical proteinuria. ROC curves of DSP for identifying clinical proteinuria yielded area under the curve of 0.749 (95% confidence interval 0.699-0.794), and adjustment for SG did not significantly improve accuracy. A UPC of <0.3 was sensitive with a high negative PV for ruling out clinical proteinuria, whereas a ratio >0.8 was specific with a high positive PV. A UPC between 0.3-0.8 had an intermediate sensitivity and specificity. CONCLUSION: Urine collections of 24-h are still needed in the chronic SCI population for accurate detection of clinically significant proteinuria. DSP may not reliably detect low-grade clinical proteinuria, whereas a UPC below 0.3 may be used to rule out clinical range proteinuria.

Risk factors and effects of postpartum anovulation in dairy cows.

The objectives were to identify risk factors for and to quantify the effect of postpartum anovulation on reproductive performance in dairy cows. Data from 2,178 Holstein cows in 6 commercial herds enrolled in a randomized clinical trial were used. Data on periparturient disease incidence, calving history, and body condition score were collected. Cows were examined at wk 5 postpartum for reproductive tract disease; cytological endometritis was defined as ≥6% polymorphonuclear cells in endometrial cytology, and purulent vaginal discharge was defined as the presence of mucopurulent or purulent vaginal discharge. Cows were followed until 300 d in milk (DIM) for reproductive performance. Serum nonesterified fatty acids (NEFA) concentration was measured once during the week before expected calving. Serum ß-hydroxybutyrate, NEFA, and haptoglobin were measured at wk 1, 2, and 3 postpartum. Serum progesterone (P4) was measured at wk 3, 5, 7, and 9 postpartum. The end of the postpartum anovulation period was defined as the first sampling time at which P4 was >1 ng/mL. Statistical analyses were performed using logistic regression models and Cox proportional hazard models. The prevalence of anovulation was 72, 44, 26, and 17% at wk 3, 5, 7, and 9, respectively. Cows were classified according to their ovulatory status as having luteal function at 21 DIM (Cyc21), as having low P4 at 21 DIM but having luteal function at least once at 35 or 49 or 63 DIM (Cyc63), or being anovulatory at 63 DIM (Anov63; no samples with P4 >1 ng/mL). Factors associated with early ovulation (Cyc21) included season, parity, decreased haptoglobinemia, and decreased serum NEFA concentration before and after parturition. Risk factors for prolonged anovulation (Anov63) included cytological endometritis, increased haptoglobinemia, and greater serum NEFA concentrations before and after parturition. Cows classified as Anov63 had an increased median time to first breeding compared with Cyc63 (74.1 vs. 73.2 d). The effect of prolonged postpartum anovulation on median time to pregnancy was conditional on parity group; a detrimental effect was present in cows of parity ≥3 (129 d for Cyc21, 151 d for Cyc63, and 180 d for Anov63), but no effect was observed in cows of parity ≤2. Overall, these findings suggest that postpartum anovulation was associated with indicators of energy balance and uterine inflammation, and with detrimental effects on reproductive performance.

Reproductive performance with an automated activity monitoring system versus a synchronized breeding program.

The objective was to compare reproductive performance with management programs based on an automated activity monitoring (AAM) system or a synchronized breeding program under field conditions. In total, 1,429 Holstein cows from 3 commercial herds in Ontario, Canada, were enrolled over 1 yr in a randomized controlled trial. At each farm, primiparous and multiparous animals were housed in separate pens. At the pen level, cows were assigned to reproductive management primarily using an AAM system based on monitoring activity levels (Heatime, SCR Engineers Ltd., Netanya, Israel) or a timed artificial insemination (TAI) program. A crossover occurred after 6 mo of the trial to avoid confounding treatment with parity. Insemination based on additional detection of estrus by visual observation was practiced in all pens. At the individual cow level, time to pregnancy throughout the study (n=1,985 cow-6 mo periods), time to first service, and time to second service were analyzed with a Cox proportional hazards models accounting for herd, and did not differ overall between the AAM and TAI treatment groups. However, we observed an interaction between herd and breeding program, such that association of AAM- or TAI-based program with these outcomes differed between farms. Time to pregnancy was not different in herd A [median=151 and 136 d; hazard ratio (HR) = 0.93] and herd C (median=99 and 124, HR = 1.24), whereas herd B had a median time to pregnancy of 119 d and 146 d (HR = 1.3) in the AAM and TAI groups, respectively. Under conditions in which 19 to 32% of artificial inseminations in both groups were based on visually detected estrus, herd pregnancy rate and cow-level time to pregnancy did not differ overall between TAI- and AAM-based programs, but the effect of reproductive management approach depended on herd. Considering 924 cow-6 mo periods with artificial inseminations only by the assigned program, we also found an interaction between herd and breeding program. Stratified analysis showed no difference in time to pregnancy in herd A (HR = 1.3), whereas in herds B (HR = 1.7) and C (HR = 2.8), cows in the AAM treatment group became pregnant sooner compared with those in the TAI group. Factors that influence the variability in relative performance of these management systems between herds require further investigation. Our study used one commercial activity monitoring system and the results cannot necessarily be generalized to other systems.

Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now?

PURPOSE: Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia. METHODS: Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant. RESULTS: Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample. CONCLUSION: Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study.

BACKGROUND: Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy. METHODS: We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality. RESULTS: We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037). CONCLUSION: Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.