Graduate Student Literature Review: The use of integrated sensor data for the detection of hyperketonemia in pasture-based dairy systems during the transition period.

This review evaluates research regarding the use of sensors to predict and manage hyperketonemia (HYK) in dairy cows during the transition period, with a focus on pasture-based systems. By doing so, we assessed the accuracy of HYK detection models, noting that no studies thus far have produced models with sufficient accuracy for practical use. Sensors have been validated for their use in dairy farming, proving they produce reliable and useful information. Research is beginning to focus on the analysis of multiple sensors together as a sensor system, discovering the potential for these technologies to be a valuable aid in decision making and farm management. Of the studies that use sensors to predict and manage disease in dairy cows, few studies use data integration (the process of combining data from multiple sensors which in turn improves model accuracy), highlighting a gap in the literature. Recently published research has focused on the detection of mastitis and lameness in pasture-based systems, with less focus toward the detection of metabolic disease. This is reflected in the lack of studies that report the prevalence of metabolic diseases, such as HYK, in pasture-based systems, especially in Australia and New Zealand. It is suggested that further research focuses on (1) determining the prevalence and impact of HYK in pasture-based systems; (2) exploring the use of sensors for HYK detection in pasture-based systems; (3) improving model accuracy with data integration; and (4) confirming the economic benefit of sensors to justify the cost of investing in sensor systems.

The effectiveness of a virtual fencing technology to allocate pasture and herd cows to the milking shed.

Virtual fencing technology provides an opportunity to rethink the management of intensive grazing systems in general, yet most studies have used products developed and applied to more extensive livestock systems. This research aimed to assess the application of a virtual fencing technology developed for the intensive pastoral dairy industry. The Halter system uses 2 primary cues (sound and vibration) and one aversive secondary cue (a low-energy electrical pulse) to confine cows to a pasture allocation and remotely herd cows. We studied 2 groups of 40 mid-lactation multiparous dairy cows (Bos taurus, predominantly Friesian and Friesian × Jersey, parity 1-8). Cows were milked twice per day and provided 9 kg of pasture DM/d in a 24-h allocation, supplemented with 7 kg of silage and 6 kg of grain DM/d. Training to the Halter system occurred over 10 d, after which cows were managed with the technology for a further 28 d. The type and time of cues delivered were recorded by each collar and communicated via a base station to cloud data storage. Cows took less than a day to start responding to the sound cues delivered while held on a pasture allocation and were moving to the milking parlor without human intervention by d 4 of training. On training d 1, at least 60% of sound cues resulted in an electrical pulse. Across training d 2 to 10, 6.4% of sound cues resulted in a pulse. After the 10-d training period, 2.6% of sound cues resulted in a pulse. During the management period, 90% of cows spent ≤1.7 min/d beyond the virtual fence, received ≤0.71 pulses/d in the paddock and received ≤1 pulse/d during virtual herding to the parlor. By the final week of the management period, 50% of cows received 0 pulses/week in the paddock and 35% received 0 pulses/week during virtual herding. The number of pulses delivered per day and the pulse/sound cue ratio was lower in this study than that previously reported using other virtual fencing technologies. We conclude that the Halter technology is successful at containing lactating dairy cows in an intensive grazing system as well as at remotely herding animals to the milking parlor.

Investigating how nitrogen nutrition and pruning impacts on CBD and THC concentration and plant biomass of Cannabis sativa.

Precise crop fertilization requires an in-depth understanding of plant uptake and utilisation to optimise sustainable production. This study investigated the influence of nitrogen (N) nutrition and pruning on the cannabinoid concentrations and biomass of a commercial cannabis cultivar; the rationale for this study is how N supply and pruning affect cannabinoid yields and concentration in a commercial setting. Clones of a Cannabis sativa L. (CBD-type) were grown in a controlled-environment glasshouse in pots with coarse sand. After five weeks of vegetative growth under 210 mg/L N and an 18 h light regime, rates of 30, 60, 210, and 500 mg/L N were applied to plants for twelve weeks and a light regime set at 12 h. Double stem pruning was applied as an additional treatment to investigate efficacy on biomass increase. Biomass, N concentrations, and cannabinoid concentrations were measured after the final harvest. Pruning treatment did not increase cannabinoid concentrations or affect biomass. It was coincidentally found that plants on the glasshouse edge with higher exposure to sunlight developed more biomass and higher cannabinoid concentrations. Only biomass in leaves was increased significantly via higher nitrogen nutrition. Cannabinoid concentration, as well as cannabinoid yield per plant were decreased with the increase in N supply. High rates of fertilizer are not recommended because of reduced cannabinoid concentration and biomass yield: the ideal N supply is likely to be between 60 and 210 mg/L. This research will benefit growers and advisors in understanding the complexity of effects of nitrogen fertiliser and pruning practices on plant biomass and secondary metabolite production in medicinal cannabis.

Modelling growth of Bacillus cereus in paneer by one-step parameter estimation.

Bacillus cereus phylogenetic group III and IV strains are commonly associated with food products and cause toxin mediated foodborne diseases. These pathogenic strains have been identified from milk and dairy products, such as reconstituted infant formula and several cheeses. Paneer is a fresh, soft cheese originating from India that is prone to foodborne pathogen contamination, such as by Bacillus cereus. However, there are no reported studies of B. cereus toxin formation in paneer or predictive models quantifying growth of the pathogen in paneer under different environmental conditions. This study assessed enterotoxin-producing potential of B. cereus group III and IV strains, isolated from dairy farm environments, in fresh paneer. Growth of a four-strain cocktail of toxin-producing B. cereus strains was measured in freshly prepared paneer incubated at 5-55 °C and modelled using a one-step parameter estimation combined with bootstrap re-sampling to generate confidence intervals for model parameters. The pathogen grew in paneer between 10 and 50 °C and the developed model fit the observed data well (R2 = 0.972, RMSE = 0.321 log10 CFU/g). The cardinal parameters for B. cereus growth in paneer along with the 95% confidence intervals were: µopt 0.812 log10 CFU/g/h (0.742, 0.917); Topt is 44.177 °C (43.16, 45.49); Tmin is 4.405 °C (3.973, 4.829); Tmax is 50.676 °C (50.367, 51.144). The model developed can be used in food safety management plans and risk assessments to improve safety of paneer while also adding to limited information on B. cereus growth kinetics in dairy products.

Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: A randomized equivalence trial.

STUDY DESIGN: Multi--center randomized controlled trial with two intervention parallel groups. An equivalence trial. INTRODUCTION: Relative motion extension (RME) orthoses are widely used in the postoperative management of finger extensor tendon repairs in zones V-VI. Variability in orthotic additions to the RME only (without a wrist orthosis) approach has not been verified in clinical studies. PURPOSE OF THE STUDY: To examine if two RME only approaches (with or without an additional overnight wrist-hand-finger orthosis) yields clinically similar outcomes. METHODS: Thirty-two adult (>18 years) participants (25 males, 7 females) were randomized to one of two intervention groups receiving either 1) a relative motion extension orthosis for day wear and an overnight wrist-hand-finger orthosis ('RME Day' group), or 2) a relative motion extension orthosis to be worn continuously ('RME 24-Hr' group); both groups for a period of four postoperative weeks. RESULTS: Using a series of linear mixed models we found no differences between the intervention groups for the primary (ROM including TAM, TAM as a percentage of the contralateral side [%TAM], and Millers Criteria) and secondary outcome measures of grip strength, QuickDASH and PRWHE scores. The models did identify several covariates that are correlated with outcome measures. The covariate 'Age' influenced TAM (P = .006) and %TAM (P = .007), with increasing age correlating with less TAM and recovery of TAM compared to the contralateral digit. 'Sex' and 'Contralateral TAM' are also significant covariates for some outcomes. DISCUSSION: With similar outcomes between both intervention groups, the decision to include an additional night orthosis should be individually tailored for patients rather than protocol-based. As the covariates of 'Age' and 'Sex' influenced outcomes, these should be considered in clinical practice. CONCLUSIONS: A relative motion extension only approach with or without an additional overnight wrist-hand-finger orthosis yielded clinically similar results whilst allowing early functional hand use, without tendon rupture.

IVIg-exposure and thromboembolic event risk: findings from the UK Biobank.

BACKGROUND: Arterial and venous thromboembolic events (TEEs) have been associated with intravenous Ig use, but the risk has been poorly quantified. We aimed to calculate the risk of TEEs associated with exposure to intravenous Ig. METHODS: We included participants from UK Biobank recruited over 3 years, data extracted September 2020.The study endpoints were incidence of myocardial infarction, other acute ischaemic heart disease, stroke, pulmonary embolism and other venous embolism and thrombosis.Predictors included known TEE risk factors: age, sex, hypertension, smoking status, type 2 diabetes mellitus, hypercholesterolaemia, cancer and past history of TEE. Intravenous Ig and six other predictors were added in the sensitivity analysis.Information from participants was collected prospectively, while data from linked resources, including death, cancer, hospital admissions and primary care records were collected retrospectively and prospectively.  FINDINGS: 14 794 of 502 492 individuals had an incident TEE during the study period. The rate of incident events was threefold higher in those with prior history of TEE (8 .7%) than those without previous history of TEE (3.0%).In the prior TEE category, intravenous Ig exposure was independently associated with increased risk of incident TEE (OR=3.69 (95% CI 1.15 to 11.92), p=0.03) on multivariate analysis. The number needed to harm by exposure to intravenous Ig in those with a history of TEE was 5.8 (95% CI 2.3 to 88.3).Intravenous Ig exposure did not increase risk of TEE in those with no previous history of TEE. INTERPRETATION: Intravenous Ig is associated with increased risk of further TEE in individuals with prior history of an event with one further TEE for every six people exposed. In practice, this will influence how clinicians consent for and manage overall TEE risk on intravenous Ig exposure.

Genome-Wide Association Study Reveals Marker Trait Associations (MTA) for Waterlogging-Triggered Adventitious Roots and Aerenchyma Formation in Barley.

Waterlogging is an environmental stress, which severely affects barley growth and development. Limited availability of oxygen in the root zone negatively affects the metabolism of the whole plant. Adventitious roots (AR) and root cortical aerenchyma (RCA) formation are the most important adaptive traits that contribute to a plant's ability to survive in waterlogged soil conditions. This study used a genome-wide association (GWAS) approach using 18,132 single nucleotide polymorphisms (SNPs) in a panel of 697 barley genotypes to reveal marker trait associations (MTA) conferring the above adaptive traits. Experiments were conducted over two consecutive years in tanks filled with soil and then validated in field experiments. GWAS analysis was conducted using general linear models (GLM), mixed linear models (MLM), and fixed and random model circulating probability unification models (FarmCPU model), with the FarmCPU showing to be the best suited model. Six and five significant (approximately -log10 (p) ≥ 5.5) MTA were identified for AR and RCA formation under waterlogged conditions, respectively. The highest -log10 (p) MTA for adventitious root and aerenchyma formation were approximately 9 and 8 on chromosome 2H and 4H, respectively. The combination of different MTA showed to be more effective in forming RCA and producing more AR under waterlogging stress. Genes from major facilitator superfamily (MFS) transporter and leucine-rich repeat (LRR) families for AR formation, and ethylene responsive factor (ERF) family genes and potassium transporter family genes for RCA formation were the potential candidate genes involved under waterlogging conditions. Several genotypes, which performed consistently well under different conditions, can be used in breeding programs to develop waterlogging-tolerant varieties.

An Evaluation of an Online Brief Mindfulness-Based Intervention in Higher Education: A Pilot Conducted at an Australian University and a British University.

Mental ill health among higher education students is a well-established problem; therefore, it is imperative to implement preventative approaches to support wellbeing. Blended and fully online education programmes widens access for mature or returning students; however, the psychological wellbeing of this sub-group of students is under-researched. Finally, evaluating wellbeing interventions that meet the needs of university students as well as accessible for online students is required. The aim of this study was to evaluate a brief, online and mindfulness-based intervention to assist the self-management of wellbeing and stress for both online and on-campus higher education students. The total sample included 427 participants (96% psychology students) at Monash University, Australia (n=283) and King's College London (n=144), with 152 participants completing the whole study. Participants were allocated to a brief, self-guided, online and mindfulness-based intervention (over the course of one study period; n=297), or to a wait-list control group (n=148). Baseline and end of semester questionnaires included the 14-item Warwick-Edinburgh Mental Wellbeing Scale, 10-item Perceived Stress Scale and the 15-item Mindful Attention Awareness Scale. Regression modelling revealed the intervention condition accounted for up to 12% of the variability in change in student wellbeing, stress and mindfulness between the start and end of semester (when controlling for baseline). These findings support the implementation of a brief, online and asynchronous mindfulness-based intervention for supporting student mental health and psychological wellbeing. An on-going challenge in practice includes engaging and maintaining student engagement in wellbeing initiatives.

Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

Acute Diaphragmatic Injuries Associated with Traumatic Rib Fractures: Experiences of a Major Trauma Centre and the Importance of Intra-Pleural Assessment.

BACKGROUND: Diaphragmatic injuries following blunt or penetrating thoraco-abdominal trauma are rare, but can be life-threatening. Rib fractures are the most common associated injury in patients with a traumatic diaphragmatic injury (TDI). We hypothesized that the pattern of rib fracture injuries could dictate the likelihood of acute TDIs. METHODS: A retrospective study was carried out between April 2014 and October 2018 to analyze patients with TDIs and rib fractures at a major trauma center in London, United Kingdom. RESULTS: Over the study period, 1,560 patients had rib fractures, of whom 14 had associated diaphragmatic injuries. Left-sided diaphragmatic injuries were found in 8 patients (57%) . A significant proportion of the rib fractures were located posterolaterally (44.9%). The highest frequency of fractures was found in ribs 5-10, which accounted for 74% of all the fractures. Ten patients underwent surgery, of whom 7 were diagnosed with a diaphragmatic injury intraoperatively after video-assisted thoracoscopic surgery assessment of the pleural cavity. Two patients died due to severe injuries of other organs and the remaining 2 patients were managed conservatively. CONCLUSION: Our series of patients demonstrates a relationship between significant rib fractures and diaphragmatic injuries in trauma patients, and the diagnostic difficulties in identifying the condition. We found that the location of the rib fractures and the pattern of injury in patients with TDIs were much lower and posterolateral in the chest wall without a preference for laterality. We suggest using a thoracoscope in patients undergoing chest wall surgery post-trauma to aid in diagnosing this condition.

The Role of Computer-Aided Design Implant Insertion in Revision Pectus Surgery.

Pectus excavatum affects about 1 in 500 people. Several surgical procedures have been proposed, including correction of the chest wall through a Nuss or modified Ravitch procedure. Further corrective revision operations remain challenging, and certainly potential life-threatening complications are described with less predictable outcomes. Secondary surgical procedures with a deep customized 3-dimensional elastomer implant are an elegant, effective, and safe solution compared with further corrective revision surgery.

Elective Lung Resections in the Elderly: Where Do We Draw the Line?

INTRODUCTION: The increasing longevity of the Western population means patients with a more advanced age are being diagnosed with resectable disease. With improvements in imaging and diagnostic capabilities, this trend is likely to develop further. As a unit operating on a higher proportion of older patients and with limited literature regarding the population of older than 85 years, we retrospectively compared the outcomes of patients older than 85 years in our unit treated with elective lung resection for non-small cell lung cancer (NSCLC) with those between the age of 80 and 84 years inclusive. METHODS: All patients who underwent elective lung cancer resection between the years 2012 and 2015 were identified from the National Thoracic Surgical Database. RESULTS: A total of 701 elective lung resections were performed during this time frame; 76 patients between the ages of 80 and 84 years and 18 patients older than 85 years. The follow-up period was 3 to 7 years. There was a significant increase in the Thoracic Surgery Scoring System (2.04; 2.96%, p = 0.0015) and a significant reduction in the transfer factor (94.7; 69.5%, p = 0.0001) between the younger and older groups. There were three (3.9%) in-hospital deaths in the 80 to 84 years age group and no in-hospital deaths in the 85 years and older age group. CONCLUSION: This study demonstrates that surgery for early NSCLC can be safely performed in 85 years and older population. This is a higher risk population and parenchymal-sparing procedures should be considered.

Thoracic Surgery during Coronavirus Disease 2019 (COVID-19): The Experience of a Level 1 Trauma Center.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus primarily affecting the respiratory system, was initially diagnosed in Wuhan, China, in late 2019. Identified as coronavirus disease 2019 (COVID-19) by the World Health Organization, the virus rapidly became a global pandemic. The effects on health care worldwide were unprecedented as countries adapted services to treat masses of critically ill patients.The aim of this study is to analyze the effect that the COVID-19 pandemic had on thoracic surgery at a major trauma center during peak prevalence. METHODS: Prospective unit data were collected for all patients who underwent thoracic surgery during March 2020 until May 2020 inclusive. Retrospective data were collected from an earlier comparable time period as a comparison. RESULTS: In the aforementioned time frame, 117 thoracic surgical operations were performed under the care of four thoracic surgeons. Six operations were performed on three patients who were being treated for SARS-CoV-2. One operation was performed on a patient who had recovered from SARS-CoV-2. There were no deaths due to SARS-CoV-2 in any patient undergoing thoracic surgery. CONCLUSION: This study demonstrates that during the first surge of SARS-CoV-2, it was possible to adapt a thoracic oncology and trauma service without increase in mortality due to COVID-19. This was only possible due to a significant reduction in trauma referrals, cessation of benign and elective work, and the more stringent reprioritization of cancer surgery. This information is vital to learn from our experience and prepare for the predicted second surge and any similar future pandemics we might face.

Tophaceous gout in the sternoclavicular joint.

Gouty arthritis commonly occurs in peripheral synovial joints and involvement in the thoracic cage is extremely rare. We report a case of a 52-year-old presenting with a painful bony mass in her sternal notch. Imaging demonstrated a lobulated calcified and necrotic lesion causing mass effect on adjacent structures. Excision biopsy confirmed a benign cystic lesion with amorphous material containing needle-shaped refractile crystals suggestive of uric acid. Tophaceous gout was diagnosed. Presence of a periarticular mass with characteristics of gout should warrant investigation with biopsy and imaging. This can prevent misdiagnosis of malignancy and avoid unnecessary surgery in asymptomatic lesions.

Are non-radiation-based imaging modalities effective for objectively assessing and monitoring patients with pectus deformities?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'What is the role of non-radiation-based imaging modalities in the management of pectus deformities?'. Altogether 29 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that non-radiation-based imaging modalities provide a safe and easily implemented alternative to traditional computed tomography scan assessment for pectus deformities. This is particularly true for deformities on the more severe end of the spectrum and as an aid in providing an on-going assessment tool particularly in treatment modalities requiring a high degree of compliance (external bracing or vacuum bell therapy).

Prediction of extubation success using the diaphragmatic electromyograph results in ventilated neonates.

Objectives Extubation failure is common in infants and associated with complications. Methods A prospective study was undertaken of preterm and term born infants. Diaphragm electromyogram (EMG) was measured transcutaneously for 15-60 min prior to extubation. The EMG results were related to tidal volume (Tve) to calculate the neuroventilatory efficiency (NVE). Receiver operating characteristic curves (ROC) were constructed and areas under the ROCs (AUROC) calculated. Results Seventy-two infants, median gestational age 28 (range 23-42) weeks were included; 15 (21%) failed extubation. Infants successfully extubated were more mature at birth (p=0.001), of greater corrected gestational age (CGA) at extubation (p<0.001) and heavier birth weight (p=0.005) than those who failed extubation. The amplitude and area under the curve of the diaphragm EMG were not significantly different between those who were and were not successfully extubated. Those successfully extubated required a significantly lower inspired oxygen and had higher expiratory tidal volumes (Tve) and NVE. The CGA and Tve had AUROCs of 0.83. A CGA of >29.6 weeks had the highest combined sensitivity (86%) and specificity (80%) in predicting extubation success. Conclusions Although NVE differed significantly between those who did and did not successfully extubate, CGA was the best predictor of extubation success.

Initial reduction of flexible pectus carinatum with outpatient manipulation as an adjunct to external compressive bracing: technique and early outcomes at 12 weeks.

INTRODUCTION: Our aim was to assess whether initial reduction with outpatient soft-tissue manipulation of flexible pectus carinatum deformity prior to external compressive bracing was associated with improved compliance and patient satisfaction compared to reported outcomes of external brace with progressive tightening. MATERIALS AND METHODS: From our observational cohort of 227 patients, 177 were felt appropriate to undergo initial reduction and soft tissue manipulation prior to immediate custom fitting of an external compressive brace. These patients then followed a prescriptive schedule of 12 weeks of continuous external bracing with subsequent follow-up in clinic. RESULTS: The reduction in Haller Index was maintained throughout the period of external bracing without the need for progressive tightening of the external brace. The treatment was associated with high levels of patient satisfaction and high patient concordance compared to other protocols. There were no major complications and minor complications included only skin irritation. CONCLUSIONS: Out-patient initial reduction with manipulation prior to external compressive bracing is a novel technique which resulted in excellent concordance and high rates of patient satisfaction and should be considered as an adjunct to standard external bracing techniques. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level II.