Protocolized screening and detection of occult alcohol use before and after liver transplant: Lessons learned from a quality improvement initiative.

INTRODUCTION: Detection of alcohol (ETOH) use with biomarkers provides an opportunity to intervene and treat patients with alcohol use disorder before and after liver transplant (LT). We describe our center's experience using urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) in alcohol screening protocols. METHODS: Single-center, retrospective review of patients presenting for LT evaluation, patients waitlisted for LT for alcohol-associated liver disease (ALD), and patients who received a LT for ALD over a 12-month period, from October 1, 2019 through September 30, 2020. Patients were followed from waitlisting to LT, or for up to 12 months post-LT. We monitored protocol adherence to screening for ETOH use- defined as completion of all possible tests over the follow-up period- at the initial LT visit, while on the LT waitlist and after LT. RESULTS: During the study period, 227 patients were evaluated for LT (median age 57 years, 58% male, 78% white, 54.2% ALD). Thirty-one patients with ALD were placed on the waitlist, and 38 patients underwent LT for ALD during this time period. Protocolized adherence to screening for alcohol use was higher for PEth for all LT evaluation patients (191 [84.1%] vs. 146 [67%] eligible patients, p < .001), in patients with ALD waitlisted for LT (22 [71%] vs. 14 (48%] eligible patients, p = .04) and after LT for ALD, 20 (33 [86.8%] vs. 20 [52.6%] eligible patients, p < .01). Few patients with a positive test in any group completed chemical dependency treatment. CONCLUSIONS: When screening for ETOH use in pre- and post-LT patients, protocol adherence is higher using PEth compared to EtG. While protocolized biomarker screening can detect recurrent ETOH use in this population, engagement of patients into chemical dependency treatment remains challenging.

Leaf trait modification in European beech trees in response to climatic and edaphic drought.

Leaf morphological and physiological traits control the carbon and water relations of mature trees and are determinants of drought tolerance, but it is not well understood how they are modified in response to water deficits. We analysed five sun-canopy leaf traits (mean leaf size (LS), specific leaf area (SLA), Huber value (HV), water potential at turgor loss point (Ψtlp ) and foliar carbon isotope signature (δ13 C)) in European beech (Fagus sylvatica L.) across three precipitation gradients sampled in moist (2010), dry (2019) and very dry (2018) summers, and tested their response to short-term water deficits (climatic water balance (CWB) preceding sample collection) and long-term water availability (mean annual precipitation (MAP), plant-available soil water capacity (AWC) and neighbourhood competition). Across the 34 sites, LS varied seven-fold (3.9-27.0 cm2 ), SLA four-fold (77.1-306.9 cm²·g-1 ) and HV six-fold (1.0-6.65 cm2 ·m-2 ). In the 2018 dataset, LS showed a negative and HV a positive relationship to MAP, which contradicts relations found in multi-species samples. Average Ψtlp ranged from -1.90 to -2.62 MPa and decreased across the sites with decreasing CWB in the month prior to measurement, as well as with decreasing MAP and AWC in 2019. Studied leaf traits varied considerably between years, suggesting that mast fruiting and the severe 2018 drought caused the formation of smaller leaves. We conclude that sun-canopy leaf traits of European beech exhibit considerable plasticity in response to climatic and edaphic aridity, and that osmotic adjustment may be an important element in the drought response strategy of this anisohydric tree species.

[Diagnoses of thyroid disorders in ENT and general practices in Germany between 2008 and 2016]. / Diagnosen von Schilddrüsenerkrankungen in HNO-Praxen und Hausarztpraxen in Deutschland 2008­2016.

OBJECTIVE: The aim of this study was to investigate thyroid disorder diagnoses in otorhinolaryngologic (ENT) practices in Germany compared to general (GP) practices using data from a representative Germany-wide practice database. METHODS: The database was retrospectively searched for diagnoses of thyroid disorders made in ENT and GP practices between January 2008 and December 2016. Data were collected on the most common three-character disease classes (categories) from the "Disorders of thyroid gland" (E00-E07) group as well as the "Benign neoplasm of thyroid gland" (D34) and "Malignant neoplasm of thyroid gland" (C73) categories. The periods 2008-2010, 2011-2013, and 2014-2016 were evaluated. RESULTS: The database included 71 ENT and 506 GP practices with continuous participation from 2008 to 2016. The relative frequency (patients/practice) of diagnoses from the "Disorders of thyroid gland" group was 4.4-times higher in GP than in ENT practices. The relative frequency of benign neoplasms of the thyroid gland was 5­times higher in GP than in ENT practices. The relative frequency of malignant neoplasms of the thyroid gland was almost identical in GP and ENT practices. The most frequent diagnoses in both ENT and GP practices were found in the categories "Other nontoxic goiter" (E04) and "Other hypothyroidism" (E03). Diagnoses in the categories "Hyperthyroidism" (E05) and "Thyroiditis" (E06) were less frequent. Diagnoses of thyroid neoplasms were the least frequent, with benign neoplasms diagnosed more frequently in GP practices and malignant neoplasms diagnosed more frequently in ENT practices. During the study period, the diagnostic frequency of thyroid diseases decreased in ENT practices, whereas it increased in GP practices. CONCLUSION: Despite the increasing interest in establishing thyroid surgery in ENT clinics in Germany in recent years, thyroid diagnoses in ENT practices in Germany have been continuously declining, whereas they have considerably increased in GP practices. The reason for this may be health insurance provider-related differences in reimbursement practices for GPs and specialists.

Comparison of pregnancy outcomes using either an Ovsynch or a Cosynch protocol for the first timed AI with liquid or frozen semen in lactating dairy cows.

The objective of this study was to evaluate fertility to the first timed AI (TAI) using either liquid semen or frozen semen after an Ovsynch or a Cosynch protocol in lactating dairy cows. The hypothesis was that there is an increase in fertility to the first TAI when cows are inseminated with liquid semen compared to that when frozen semen is used in a Cosynch protocol. Lactating dairy cows (n = 1724; 540 primiparous, 1184 multiparous) from 9 commercial dairy farms were enrolled on a weekly basis to facilitate first timed AI. Two experiments were conducted. In experiment 1, all cows received GnRH, 7 d later PGF2α, and then received one of the following treatments: 1) GnRH + TAI with liquid semen 56 h after PGF2α; 2) GnRH + TAI with frozen semen 56 h after PGF2α; 3) GnRH 56 h after PGF2α + TAI with liquid semen 12-16 h after the second GnRH; 4) GnRH 56 h after PGF2α + TAI with frozen semen 12-16 h after the second GnRH. In experiment 2, all cows received GnRH, 7 d later PGF2α, and then received treatments 3 or 4 as described for experiment 1. Number of sperm per straw was 20 × 106 sperm/straw and 10 × 106 sperm/straw for frozen and liquid semen, respectively. Pregnancy diagnosis was performed by ultrasound scanning at 39 d after TAI. In experiment 1 (n = 1263), there was an interaction of semen preservation method by TAI protocol. Cows inseminated with liquid semen concurrently with the second GnRH (Cosynch-56) achieved greater pregnancy per AI (P/AI) than cows inseminated with frozen semen using the same synchronization protocol (20.0% vs. 27.5%; P = 0.032). There was no effect of semen preservation method (liquid semen 32.3% vs. frozen semen 28.6%; P = 0.330) when cows were inseminated approximately 16 h after the second GnRH injection (Ovsynch-56). Parity affected P/AI with primiparous having a greater P/AI than multiparous cows (34.8% vs. 20.2%; P = 0.001). In experiment 2 (n = 377), there was no effect of semen preservation method (liquid semen 26.5% vs. frozen semen 25.5%; P = 0.846) when cows were inseminated approximately 16 h after the second GnRH injection (Ovsynch-56). Parity affected P/AI with primiparous having a greater P/AI than multiparous cows (37.0% vs. 17.3%; P = 0.001). The results of this study provide evidence that liquid semen achieved greater P/AI in a TAI protocol with a long time interval between insemination and ovulation (Cosynch-56) compared with frozen semen indicating that liquid semen might have a longer viability in the reproductive tract.

Impact of heat stress on estrus expression and follicle size in estrus under field conditions in dairy cows.

The objective of this study was to investigate the impact of heat stress on the expression of estrus signs and follicular diameter at the day of estrus in dairy cows under farm conditions. Cows reported in estrus (i.e., by an automated activity monitoring system or by the herd manager) were examined by a veterinarian. Uterine contractility and the largest diameter of all ovarian structures was determined by transrectal palpation and ultrasonography, respectively. The amount of estrus discharge, mounting traces and the color of the vaginal mucosa were determined in an external examination and scored on 3-point scales. Blood samples were obtained for analysis of serum progesterone concentrations. Cows with a high uterine contractility and high amount of estrus discharge were 4.05 and 1.72 times more likely to have an estrus follicle (large, presumptive preovulatory follicle ≥ 12 mm) than cows expressing low amount of the estrus sign, respectively. The likelihood for a pink vaginal mucosa, clear stringy estrus discharge and mounting traces at the cows back decreased continuously with increasing temperature-humidity index (THI) at the day of estrus. The likelihood for a serum progesterone concentration < 1 ng/ml at the day of estrus decreased continuously with increasing THI ≥74. Follicular size decreased 0.1 mm for each incremental THI point at the day of estrus. The results of this study indicate, that heat stress at the day of estrus significantly reduces the intensity of external estrus signs and the size of estrus follicle decreases with increasing THI.

Effect of short- and long-term heat stress on the conception risk of dairy cows under natural service and artificial insemination breeding programs.

The objectives of this retrospective study were to examine the effect of heat stress on natural service and artificial insemination (AI) breeding methods. We investigated the influence of short- and long-term heat stress on the conception risk (CR) of dairy cows bred by natural service or by AI with frozen-thawed or fresh semen. In addition, the relationship between breeding method and parity was determined. Cows bred by AI with frozen-thawed semen exposed to long-term heat stress (mean temperature-humidity index ≥73 in the period 21d before breeding) were 63% less likely to get pregnant compared with cows not exposed to heat stress. Cows bred by AI with fresh semen were 80% less likely to get pregnant during periods of short-term heat stress than during periods without heat stress. Furthermore, multiparous cows bred by AI with frozen-thawed or fresh semen were 22 and 67% less likely to get pregnant, respectively, than primiparous cows. No influence of heat stress or parity was noted on the CR of cows bred by natural service. The present study indicates that the likelihood of dairy cows becoming pregnant is reduced by short- and long-term heat stress depending on the type of semen employed. In particular, CR of cows inseminated with fresh semen is negatively affected by short-term heat stress and CR of cows inseminated with frozen-thawed semen is negatively affected by long-term heat stress.

Impact of heat stress on conception rate of dairy cows in the moderate climate considering different temperature-humidity index thresholds, periods relative to breeding, and heat load indices.

The objectives of this retrospective study were to investigate the relationship between temperature-humidity index (THI) and conception rate (CR) of lactating dairy cows, to estimate a threshold for this relationship, and to identify periods of exposure to heat stress relative to breeding in an area of moderate climate. In addition, we compared three different heat load indices related to CR: mean THI, maximum THI, and number of hours above the mean THI threshold. The THI threshold for the influence of heat stress on CR was 73. It was statistically chosen based on the observed relationship between the mean THI at the day of breeding and the resulting CR. Negative effects of heat stress, however, were already apparent at lower levels of THI, and 1 hour of mean THI of 73 or more decreased the CR significantly. The CR of lactating dairy cows was negatively affected by heat stress both before and after the day of breeding. The greatest negative impact of heat stress on CR was observed 21 to 1 day before breeding. When the mean THI was 73 or more in this period, CR decreased from 31% to 12%. Compared with the average maximum THI and the total number of hours above a threshold of more than or 9 hours, the mean THI was the most sensitive heat load index relating to CR. These results indicate that the CR of dairy cows raised in the moderate climates is highly affected by heat stress.

Short communication: Comparison of ambient temperature, relative humidity, and temperature-humidity index between on-farm measurements and official meteorological data.

The objectives of the study were to compare the climate conditions of 7 dairy farms with the climate recorded at the closest official meteorological station. Specifically, we set out to compare the ambient temperature, relative humidity, and the resulting temperature-humidity index (THI) from 7 different barns with those data obtained from the closest official meteorological stations and to compare the climate conditions between 4 different locations within 1 barn. Measures of correlation and agreement demonstrated that climate conditions differ significantly between the barn and the corresponding official meteorological stations as well as between 4 different locations inside 1 barn. The ambient temperature was higher (6.4±3.6°C) in the barn than at the official meteorological station. The relative humidity was higher at the official meteorological station (0.2±7.2%) than in the barn. The THI was higher (11.1±6.5) in the barn than at the official meteorological station. Days with an average THI≥72 were 64 and 4 out of 756 experimental d in the barn and at the official meteorological station, respectively. Also, in a comparison of 7 different barns, ambient temperature and THI were significantly higher than at the closest corresponding official meteorological station. These results indicate that climate conditions should be obtained from on-farm measurements to evaluate potential heat stress and to develop effective measures to abate heat stress of dairy cows.

[Changes in therapy for breast cancer patients as a result of mammography screening. An analysis of Bavarian cancer registry data from 2000 to 2008]. / Veränderungen der Therapie des Mammakarzinoms in Bayern seit Einführung des Mammografie-Screenings. Eine Analyse bayerischer Krebsregisterdaten der Jahre 2000 bis 2008.

PURPOSE: A quality controlled mammography screening programme was initiated at the end of 2003 in Bavaria, a region with 12.5 million inhabitants, and transferred over to the national screening programme at the end of 2006. The purpose of this study was to evaluate immediate population-based consequences of mammography screening on breast cancer therapy. METHODS: Data from 75 475 breast cancer cases, diagnosed between 2000 and 2008 and registered in one of the 6 Bavarian clinical cancer registries were analysed. 51.4% of these patients were between 50 and 69 years of age and therefore the target population for screening. Trends of prognostic factors and standard therapies were calculated for 3 age groups (≤49 years, 50-69 years, ≥70 years) by means of annual percentages as well as 95%-confidence intervals for the percent difference between 2000 and 2008 (year of diagnosis). For interpretation of therapy trends, logistic regression models were calculated. RESULTS: Therapy trends showed that the increasingly favourable stage distribution may have resulted in the reduction of more radical surgical methods such as mastectomy (2000: 32.6%; 2008: 19.6%) or axillary dissection (89.0% vs. 37.0%), especially for women aged 50-69. An increase of radiation therapies (59.7% vs. 66.6%) can be explained to some extent by the increase in breast conserving surgeries. The shift to more favourable prognostic factors led, in accordance with the guidelines, to an increase of the proportion of singular endocrine therapies (28.5% vs. 40.7%), a decrease of chemotherapies (20.4% vs. 13.1%) and therefore to more gentle systemic therapies overall. These trends strengthened in the years following the introduction of screening, with a simultaneous rise of screening participants in the target population. CONCLUSION: The introduction of mammography screening in Bavaria has already shown the expected trend towards more favourable prognostic factors. Among other things, this could be a reason for the increasing use of more gentle therapies. Whether the screening in Bavaria leads to a mortality reduction, has to be analysed on the basis of an initial comparison of participation status followed by the trends in mortality thereafter.

Education in end-of-life care: bridging disciplinary and institutional boundaries.

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

Interpretation of atypical patterns encountered when using a flow cytometry-based method to detect residual leukocytes in leukoreduced red blood cell components.

BACKGROUND: Universal leukoreduction of blood components is becoming the standard of care. Flow cytometry methods are being used for quality control of the leukoreduction process. METHODS: We provide an atlas of atypical flow cytograms generated by a commercial LeucoCOUNT assay that was used to enumerate residual leukocytes in leukoreduced red blood cell components. Numeric results are derived from a flow cytogram generated by the assay. RESULTS: Three types of atypical flow cytogram patterns were observed during process validation or routine quality control of leukoreduced red blood cell components. (a) Fixation artifact: Fixation of control or test samples can alter the staining intensity compared with fresh cells. (b) "Rain" pattern: Flow cytometry methods count slightly damaged leukocytes not removed during leukoreduction. Slightly damaged leukocytes appear on a flow cytogram like "rain" falling from a well-defined "cloud" of intact residual leukocytes. Discrepancies between automated flow cytometry results and subjective manual counting methods can occur. (c) Autofluorescence-debris pattern: Cell debris and age-related changes in the sample can cause shifts in the fluorescence staining pattern, resulting in erroneous test results. CONCLUSION: Review of flow cytograms is essential for accurate reporting of flow cytometry-based methods for enumerating residual leukocytes in leukoreduced blood components.