Serum triamcinolone levels during intensive, inpatient wet-dressing therapy.

BACKGROUND: Wet dressings combined with topical corticosteroids are beneficial for patients with generalized and refractory dermatosis; however, to our knowledge, serum levels after topical corticosteroid absorption during intensive therapy have not been reported previously. AIM: To examine serum levels of triamcinolone acetonide (TAC) after topical corticosteroid application during intensive wet-dressing therapy. METHODS: We performed a retrospective study of adult patients admitted for inpatient wet-dressing therapy from 7 November 2015 to 24 June 2016. Data were collected on sex, age, body surface area, TAC serum levels, number of wet-dressing changes after 24 and 48 h, and type of wet dressing. RESULTS: In total, 29 patients (14 men, 15 women) were assessed. Median [interquartile range (IQR)] age was 57 years (51.5-67.0 years) and involved body surface area was 1.98 m2 (1.88-2.15) m2 . Before the 24-hour blood draw, patients had received 1-3 dressing changes. Median (IQR) TAC level at 24 h was 0.33 µg/dL (0.20-0.58 µg/dL), with no significant difference noted between the number of dressing changes and TAC serum level. At 48 h, results of a serum TAC test were available for 22 patients with 2-6 dressing changes. Mean (IQR) serum level was 0.30 µg/dL (0.30-0.87 µg/dL). For each additional dressing change, there was an estimated 0.21 µg/dL increase in TAC serum level (95% CI 0.11-0.31; P < 0.001). TAC serum level was not significantly associated with sex, age, body surface area or dressing type. CONCLUSIONS: Intensive, inpatient wet-dressing therapy is associated with detectable TAC serum levels. However, we suspect that topical TAC has a primarily local therapeutic effect on the skin.

Treatment of acne with spironolactone: a retrospective review of 395 adult patients at Mayo Clinic, 2007-2017.

BACKGROUND: Few large studies have assessed spironolactone treatment of adult female acne. OBJECTIVES: To explore the role of spironolactone in the treatment of adult female acne. METHODS: We performed a retrospective case series assessing the efficacy of spironolactone treatment of a cohort of women evaluated at Mayo Clinic in Rochester, Minnesota, from 2007 through 2017. RESULTS: In total, 395 patients (median age, 32 years) received a median spironolactone dose of 100 mg daily. Approximately two-thirds of patients (66.1%) had a complete response; 85.1% had a complete response or a partial response greater than 50%. Median times to initial response and maximum response were 3 and 5 months. Efficacy was observed across all severity subtypes of acne, including those with papulopustular and nodulocystic acne. Patients received long-term treatment with spironolactone (median duration, 13 months) and had few adverse effects. CONCLUSIONS: Spironolactone is a safe and effective treatment of acne for women.

Network meta-analysis of antibiotic prophylaxis for prevention of surgical-site infection after groin hernia surgery.

BACKGROUND: First-generation cephalosporins (such as cefazolin) are recommended as antibiotic prophylaxis in groin hernia repair, but other broad-spectrum antibiotics have also been prescribed in clinical practice. This was a systematic review and network meta-analysis to compare the efficacy of different antibiotic classes for prevention of surgical-site infection (SSI) after hernia repair. METHODS: RCTs were identified that compared efficacy of antibiotic prophylaxis on SSI after inguinal or femoral hernia repair from PubMed and Scopus databases up to March 2016. Data were extracted independently by two reviewers. Network meta-analysis was applied to assess treatment efficacy. The probability of being the best antibiotic prophylaxis was estimated using surface under the cumulative ranking curve (SUCRA) analysis. RESULTS: Fifteen RCTs (5159 patients) met the inclusion criteria. Interventions were first-generation (7 RCTs, 1237 patients) and second-generation (2 RCTs, 532) cephalosporins, ß-lactam/ß-lactamase inhibitors (6 RCTs, 619) and fluoroquinolones (2 RCTs, 581), with placebo as the most common comparator (14 RCTs, 2190). A network meta-analysis showed that ß-lactam/ß-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0·44 (95 per cent c.i. 0·25 to 0·75) and 0·62 (0·42 to 0·92) respectively. However, none of the antibiotic classes was significantly different from the others. SUCRA results indicated that ß-lactam/ß-lactamase inhibitors and first-generation cephalosporins were ranked first and second respectively for best prophylaxis. CONCLUSION: ß-Lactam/ß-lactamase inhibitors followed by first-generation cephalosporins ranked as the most effective SSI prophylaxis for adult patients undergoing groin hernia repair.

The association between dietary patterns and type 2 diabetes: a systematic review and meta-analysis of cohort studies.

BACKGROUND: Observational studies suggest that dietary pattern intake plays an important role in the development of type 2 diabetes. A meta-analysis was performed of existing cohort studies on the association between dietary patterns and the risk of type 2 diabetes. METHODS: Pertinent studies were identified by searching MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PROQUEST, MEDNAR and the Joanna Briggs Institute Library of Systematic Reviews, as well as the reference lists of all identified studies up to September 2012. A random-effects meta-analysis was performed to pool relative risk (RR) estimates from individual studies to assess the relationship between dietary pattern intake and the risk of type 2 diabetes. Statistical heterogeneity was assessed using I(2) and sensitivity analyses were conducted. Publication bias was evaluated by visual inspection of funnel plots and was formally assessed using Egger's test. RESULTS: There were fifteen cohort studies that met the inclusion criteria. There was evidence of a reduction in the risk of type 2 diabetes in the highest adherence compared to the lowest adherence to healthy dietary patterns [RR = 0.79, 95% confidence interval (CI) = 0.74-0.86, P < 0.005]. An increase in the risk of type 2 diabetes was evident for the highest adherence compared to the lowest adherence to unhealthy dietary patterns (RR = 1.44, 95% CI = 1.33-1.57, P < 0.005). CONCLUSIONS: The results of this systematic review and meta-analysis indicate that dietary patterns may be associated with the risk of type 2 diabetes.

Experience with the dermatology inpatient hospital service for adults: Mayo Clinic, 2000-2010.

BACKGROUND: There is a paucity of medical literature describing the role of dermatology inpatient hospital services for patients with severe dermatologic disease. A diminishing number of US hospitals have a dedicated dermatology inpatient service run by dermatologists. OBJECTIVES: To describe the role of a dermatology-run inpatient service in treatment of severe dermatologic disease from 2000 to 2010 at our institution. METHODS: We studied demographic characteristics, indications for admission and length of stay for the adult (age, >18 years) dermatology inpatient hospital service over the most recent decade. We compared data from the first 5.5 years with the subsequent 5.5 years and with previously published data. RESULTS: A total of 1732 patients had 2216 inpatient admissions to the adult service from 2000 to 2010. The mean (SD) age was 61.3 (17.7) years (age range 18-100 years). Median duration of admission was 3 days interquartile range (IQR), 2-5 days. The most common indications for admission were dermatitis (44.2%), psoriasis (17.4%) and cutaneous T-cell lymphoma (9.2%). We compared admissions from 2000 to mid-2005 (n = 1260) to admissions from mid-2005 to 2010 (n = 956). Statistically significant changes included median length of stay (decreased from 4 days [IQR, 3-6 days] to 3 days [IQR, 2-4 days] P < 0.01), admissions for psoriasis (decreased from 20.7% to 13.0%; P < .01) and admissions for dermatitis (increased from 41.6% to 47.6%; P < .01). CONCLUSION: The number of patients admitted and the median length of stay decreased between the 2 periods. Indications for admission have changed significantly across the two time periods.

Efficacy of Mitomycin C for postoperative endoscopic sinus surgery: a systematic review and meta-analysis.

BACKGROUND: Mitomycin C has recently been used to prevent nasal synechiae and sinus ostium stenosis after endoscopic sinus surgery. OBJECTIVE OF REVIEW: To compare nasal synechiae rate between topical Mitomycin C and saline or no treatment. TYPE OF REVIEW: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, SCOPUS, and Cochrane Register of Controlled Trials databases were used to identify studies up to January 2013. EVALUATION METHOD: Data were independently extracted by two reviewers (PN and KT). Studies which compared topical Mitomycin C with control where the outcomes of interest were nasal synechiae or sinus ostium stenosis were included. Baseline study characteristics, quality of study, numbers of patients between treatment and control groups, outcomes, and adverse events were extracted. A multivariate meta-analysis was separately applied for each outcome (nasal synechiae and maxillary sinus ostium stenosis). RESULTS: Among 11 included studies, most studies used Mitomycin C dose of 0.4-0.5 mg/mL 1-5 mL in the middle meatus for 5 min duration. Eight studies reported synechiae with 281 and 281 nasal cavities received Mitomycin C and saline, respectively. For outcome of nasal synechiae, a multivariate meta-analysis suggested that Mitomycin C was associated with a 66% (RR = 0.34, 95% CI: 0.18-0.65) lower risk of nasal synechiae with moderate heterogeneity (I(2) = 43%, 95% CI: 0-77%). Subgroup analyses by age and history of revision could reduce the degree of heterogeneity. Mitomycin C benefits were found in subgroups of age ≤ 40 years (RR = 0.27, 95% CI: 0.05-1.50) and patients without any history of revision (RR = 0.19, 95% CI: 0.06-0.58). Five studies with 134 and 140 nasal cavities for Mitomycin C and saline were included in pooling of maxillary sinus ostium stenosis. Mitomycin C was associated with 74% (RR = 0.26, 95% CI: 0.12-0.54) lower risk of maxillary sinus ostium stenosis when compared with saline with low heterogeneity (I(2) = 5%, 95% CI: 0-85%). There was no evidence of publication bias for both poolings. CONCLUSION: Applying Mitomycin C topically after endoscopic sinus surgery could reduce the risk of nasal synechiae and maxillary sinus ostium stenosis in short term by 66% and 74%, respectively. The treatment effects may be more beneficial in patients aged 40 years or younger or in patients without history of revision. However, our results were based on pooling trials with questionable methodological quality. Further trials with good research methodology and long-term follow-up should be conducted to confirm our results.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy.

BACKGROUND: Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial. METHODS: This was a systematic review and meta-analysis of studies comparing laparoscopic and open appendicectomy in pregnancy identified using PubMed and Scopus search engines from January 1990 to July 2011. Two reviewers independently extracted data on fetal loss, preterm delivery, wound infection, duration of operation, hospital stay, Apgar score and birth weight between laparoscopic and open appendicectomy groups. RESULTS: Eleven studies with a total of 3415 women (599 in laparoscopic and 2816 in open group) were included in the analysis. Fetal loss was statistically significantly worse in those who underwent laparoscopy compared with open appendicectomy; the pooled relative risk (RR) was 1·91 (95 per cent confidence interval (c.i.) 1·31 to 2·77) without heterogeneity. The pooled RR for preterm labour was 1·44 (0·68 to 3·06), but this risk was not statistically significant. The mean difference in length of hospital stay was - 0·49 (-1·76 to - 0·78) days, but this was not clinically significant. No significant difference was found for wound infection, birth weight, duration of operation or Apgar score. CONCLUSION: The available low-grade evidence suggests that laparoscopic appendicectomy in pregnant women might be associated with a greater risk of fetal loss.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation.

AIM: There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD: In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS: In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION: The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Disease severity and therapy as predictors of cardiovascular risk in psoriasis: a population-based cohort study.

BACKGROUND: Previous studies suggest an increased risk of cardiovascular disease in psoriasis, but the relative contributions of traditional risk factors and markers of disease severity are unclear. We examined the effect of psoriasis disease characteristics on cardiovascular risk after adjusting for traditional cardiovascular risk factors. METHODS: Study populations included (a) case-cohort sample of 771 patients nested within a population-based psoriasis incidence cohort, and (b) cohort of 1905 patients with incident and prevalent psoriasis patients. Both cohorts were followed-up to ascertain disease and treatment characteristics, traditional cardiovascular risk factors and cardiovascular outcomes. Cox proportional hazards regression models were used to identify predictors of cardiovascular outcomes. RESULTS: After adjusting for traditional risk factors, increasing number of psoriasis-affected body sites at disease onset (HR: 1.53 per additional site, 95% CI: 1.20, 1.95) was significantly associated with an increased risk of cardiovascular outcomes. Phototherapy (HR: 3.76, 95% CI: 2.45, 5.77) and systemic therapy (HR: 2.17, 95% CI: 1.50, 3.13) were associated with a higher risk of cardiovascular outcomes in univariate analyses, but these relatively strong associations disappeared after adjusting for cardiovascular risk factors. CONCLUSIONS: Increasing number of psoriasis-affected body sites may be a severity indicator in psoriasis and is associated with an increased cardiovascular risk. Due to low number of patients exposed to systemic therapy, this study had limited power to examine the effect of treatment on cardiovascular risk. Strong associations with phototherapy and systemic therapy suggest that the cardiovascular risk in psoriasis is confined to patients with severe disease.

Development and application of an economic ranking index for perennial ryegrass cultivars.

Economic values in euros (€) were calculated for traits of economic importance in Irish grass-based systems. The economically important traits selected were spring, midseason, and autumn grass dry matter (DM) yield (€/kg of DM per ha), grass quality (€ per unit DM digestibility), first- and second-cut silage DM yield (€/kg per ha), and sward persistency (€/% change in persistency per ha per yr). The economic value for each trait was calculated by changing the trait of interest while keeping all other traits constant, using the Moorepark Dairy Systems Model. Herd parameters (including cow numbers and calving pattern), milk production, energy demand, supplementary feeds, and land area were readjusted to calculate the economic value for the trait of interest. The base scenario assumed fixed cow numbers with 40 ha of land available, with full costs included. The results for the base scenario show the economic values were: €0.15/kg of DM spring yield, €0.03/kg of midseason yield, €0.10/kg of DM autumn yield, the quality value was €0.001, €0.008, €0.010, €0.009, €0.008, and €0.006 per unit change in DM digestibility/kg of DM yield for the months of April, May, June, July, August, and September, respectively; €0.036/kg of DM first-cut silage; €0.024/kg of DM second-cut silage; and -€4.961 per 1% decrease in persistency/ha per yr. Sensitivity of the economic values to changes in milk price and scenario were tested. The economic values were applied to experimental production data collected over 3 yr for 20 perennial ryegrass cultivars to establish the total economic merit for each cultivar and then to rank each cultivar based on its economic performance. Rank correlations between the base and alternative scenarios ranged from 0.90 to unity. This indicates that the economic values are reliable regardless of system, intensity, or price. The total merit index will identify the cultivars that can make the greatest economic contribution to a grass-based production system.

Virtual patients: an effective educational intervention to improve paediatric basic specialist trainee education in the management of suspected child abuse?

Child abuse is a particularly difficult subject to teach at both undergraduate and postgraduate level. Most doctors are dissatisfied with their training in child abuse recognition and management. We developed an interactive video based Virtual Patient to provide formal training for paediatric Basic Specialist Trainees in the recognition of suspected child abuse. The Virtual Patient case revolves around the management of suspected physical abuse in a seven month old child, who initially presents to the Emergency Department with viral upper respiratory tract symptoms. This Virtual Patient was used to facilitate a case discussion with Basic Specialist Trainees. A questionnaire was developed to determine their perception of the value of the Virtual Patient as an educational tool. Twenty five Basic Specialist Trainees completed the questionnaire. Upon completion of the case, 23/25 (92%) participants reported greater self confidence in their ability to recognize cases of suspected child abuse and 24/25 (96%) of participants reported greater self confidence in their ability to report cases of suspected child abuse. Basic Specialist Trainees perceived the Virtual Patient to be a useful educational tool. Virtual Patients may have a role to play in enhancing postgraduate training in the recognition of suspected child abuse.

Pedometer counts superior to physical activity scale for identifying health markers in older adults.

OBJECTIVE: Measuring physical activity is a key part of studying its health effects. Questionnaires and pedometers each have weaknesses but are the cheapest and easiest to use measurement methods for large-scale studies. We examined their capacity to detect expected associations between physical activity and a range of surrogate health measures. DESIGN: Cross-sectional analysis of 669 community-dwelling participants (mean age 63.3 (7.7) years) who completed the Physical Activity Scale for the Elderly (PASE) questionnaire and who, within 2 weeks, wore a pedometer for 7 days. RESULTS: PASE score and step count were only poorly correlated (r = 0.37 in women, r = 0.30 in men). Of 12 expected associations examined between activity and surrogate markers of health, 10 were detected as statistically significant by step counts but only 3 by PASE scores. Significant associations in the expected direction were found between step counts and high-density lipoprotein, body mass index, waist circumference, waist-to-hip ratio, blood glucose level, white cell count and fibrinogen. There was no association with either systolic or diastolic blood pressure. The association between PASE score and these markers was detected as significant only for body mass index and waist circumference in women and waist-to-hip ratio in both sexes. Associations were stronger for steps multiplied by stride length than for raw step count. CONCLUSIONS: Pedometer-derived step counts are a more valid measurement of overall physical activity in this sample than PASE score. Researchers should use objective measures of physical activity whenever possible.

Estrogen receptor polymorphisms and the risk of endometrial cancer.

OBJECTIVE: There is evidence that estrogens and some of their metabolites are involved in endometrial cancer pathogenesis. As estrogens mediate their effects via the estrogen receptors, ESR1 and ESR2, the objective of this investigation was to determine whether six single nucleotide polymorphisms (SNPs) in these two genes were over-represented in a population of endometrial cancer patients compared with a healthy matched control population, thereby associating differences in these genes with endometrial cancer. DESIGN: The study is a case-control investigation large enough to detect a two-fold increased risk, assuming a dominant genetic model, with P = 0.05 and 80% power. SETTING: The study and control populations were all from the Hunter-New England region of New South Wales, Australia collected between the years 1992 and 2005. POPULATION: The study consisted of 191 endometrial cancer patients and 291 healthy controls matched for gender and age. METHODS: Two SNPs in ESR1 and four SNPs in ESR2 were genotyped using PCR-based restriction fragment length polymorphism analysis and real-time PCR. Odds ratios were calculated using unconditional logistic regression and SIMHAP was used for haplotype analysis, adjusting for potential endometrial cancer risk factors. Kaplan-Meier survival analysis, Cox regression and t tests were used to examine the patient's age of diagnosis of endometrial cancer and genotype. MAIN OUTCOME MEASURES: Over-representation of ESR1 and ESR2 polymorphisms in the endometrial cancer population compared with the control population indicates an involvement in the development and/or progression of disease. RESULTS: Two ESR1 (rs2234693 and rs9340799) and two ESR2 (rs1255998 and rs944050) polymorphisms were associated with an increased risk of endometrial cancer. Following adjustment for risk factors, the association with the ESR1 and ESR2 polymorphisms (rs2234693, rs1255998 and rs944050) remained highly significant. Haplotype analysis revealed that carriers of the ESR1 haplotype (variant alleles; rs2234693 and rs9340799) and the ESR2 haplotype (variant allele; rs1255998 and wild-type alleles; rs944050, rs4986938 and rs1256049) were at an increased risk (OR 1.862, P = 0.013 and OR 1.918, P = 0.046 respectively). This risk was even greater in women carrying both risk haplotypes (OR 5.041, P = 0.007). CONCLUSIONS: Our data suggest that the ESR1 (rs2234693 and rs9340799) and the ESR2 (rs1255998 and rs944050) polymorphisms may be associated with an increased risk of developing endometrial cancer.

Effect of restricted access time to pasture on dairy cow milk production, grazing behavior, and dry matter intake.

The objective of this experiment was to investigate the effect of restricting pasture access time on milk production and composition, body weight and body condition score change, dry matter intake, and grazing behavior of autumn calving dairy cows in midlactation. Fifty-two (19 primiparous and 33 multiparous) Holstein-Friesian dairy cows (mean calving date, August 17 +/- 91.2 d) were randomly assigned to a 4-treatment (n = 13) randomized block design grazing study. The 4 grazing treatments were: (i) full-time access to pasture (22H; control), (ii) 9-h access to pasture (9H), (iii) two 4.5-h periods of access to pasture after both milkings (2 x 4.5H), and (iv) two 3-h periods of access to pasture after both milkings (2 x 3H). Experimental treatments were imposed from March 7 to April 6, 2007 (31 d). The pregrazing herbage mass of swards offered to all treatments was 1,268 kg of dry matter/ha, and sward organic matter digestibility was 86.4%, indicating high-quality swards conducive to high dry matter intake. Swards where animals had 22H and 2 x 4.5H access to pasture had the lowest postgrazing sward heights (3.5 cm), reflecting the greatest levels of sward utilization. After the experimental period, there were no differences in milk production; however, the 2 x 3H animals tended to have lower milk protein concentration (-0.17%) compared with 22H animals. Furthermore, dry matter intake of the 9H animals was lower than 22H animals. Although restricting access time to pasture decreased grazing time, animals compensated by increasing their intake/minute and intake/bite. Restricting pasture access time resulted in much greater grazing efficiency, because the 9H, 2 x 4.5H, and 2 x 3H treatments spent a greater proportion of their time at pasture grazing (81, 81, and 96%, respectively) than 22H animals (42%). Results of this study indicate that allocating animals restricted access to pasture does not significantly affect milk production. This study also found that the total access time should be greater than 6 h and that perhaps needs to be divided into 2 periods.

Fatty acid intake and milk fatty acid composition of Holstein dairy cows under different grazing strategies: herbage mass and daily herbage allowance.

The objective of this study was to investigate the effect of level of 1) pregrazing herbage mass (HM) and 2) level of daily herbage allowance (DHA) on the performance and fatty acid (FA) composition of milk from grazing dairy cows. Sixty-eight Holstein-Friesian dairy cows were allocated to either a high or low pregrazing HM (1,700 vs. 2,400 kg of DM/ha; >40 mm), and within HM treatment, cows were further allocated to either a high or low DHA (16 vs. 20 kg of DM/d per cow; >40 mm) in a 2 x 2 factorial design. Pregrazing HM did not affect dry matter intake (17.5 +/- 0.75 kg/d), milk production (22.1 +/- 0.99 kg/d), milk composition (milk fat, 3.88 +/- 0.114%; milk protein, 3.28 +/- 0.051%), body weight (525 +/- 16 kg), or body condition score (2.65 +/- 0.064). Increasing DHA increased dry matter intake (+1.5 kg/d) but did not affect any other variable measured. Cows grazing the low HM or high DHA had a higher daily intake of total FA (+0.12 and +0.09 kg/d, respectively, for the low HM and high DHA), alpha-linolenic acid (LNA; +0.08 and +0.05 kg/d, respectively, for the low HM and high DHA), and linoleic acid (+0.01 for both the low HM and high DHA) compared with either the high HM or low DHA. Milk conjugated linoleic acid (cis-9, trans-11 isomer) was not affected by treatment (13.0 +/- 0.77 g/kg of total FA); however, large variation was recorded between individual animals (range from 5.9 to 20.6 g/kg of total FA). Milk concentrations of LNA were higher for animals offered the low HM (5.3 g/kg of total FA), but across treatments, milk concentrations of LNA were low (4.9 +/- 0.33 g/kg of total FA). The present study indicates that changes in HM and DHA do not have a great effect on the milk FA composition of grazing dairy cows. Further enhancement of the beneficial FA content in milk purely from changes in grazing strategy may be difficult when pasture quality is already high.

Effect of pregrazing herbage mass and pasture allowance on the lactation performance of Holstein-Friesian dairy cows.

The objective of this study was to investigate the effect of pregrazing herbage mass (HM) and pasture allowance (PA) on the grazing management and lactation performance of spring-calving dairy cows. Sixty-eight Holstein-Friesian dairy cows (mean calving date, February 6) were randomly assigned across 4 treatments (n = 17) in a 2 x 2 factorial arrangement. The 4 treatments consisted of 2 pregrazing HM (>4 cm) and 2 PA (>4 cm): 1,700 kg of dry matter (DM)/ha (medium, M) or 2,200 kg of DM/ha (high, H), and 16 or 20 kg of pasture DM/cow per day. The experimental period lasted 30 wk. The experimental area was divided into 4 farmlets, with 1 farmlet per treatment. Mean HM throughout the experimental period was 1,767 kg of DM/ha (M HM) compared with 2,358 kg of DM/ha (H HM). Offering an M HM sward resulted in significantly greater milk protein yield (+31.7 g/d) and lower mean body weight (-12.8 kg). The body condition score change was significantly smaller (-0.21) with the M HM treatments compared with the H HM treatment (-0.34). Milk solids output per hectare was 6% greater on the M HM treatments compared with the H HM treatments. Increasing PA significantly increased milk (+0.9 kg/d), solids-corrected milk (+0.7 kg/d), protein (+43.9 g/d), and lactose (+52.7 g/d) yields. Mean body weight was also significantly greater for cows offered 20 kg of PA (+11.4 kg/cow). It was concluded that in rotational grazing systems, adapting the concept of grazing M HM pastures (1,700 kg of DM/ha) will result in increased sward quality and increased milk solids output per hectare. At medium levels of pregrazing HM, offering animals 20 kg of DM PA will result in increased milk yield per cow.