Evaluation of traditional targeted axillary dissection eligibility criteria for node-positive breast cancer after neoadjuvant chemotherapy in a prospective multicenter registry.

INTRODUCTION: Targeted axillary dissection (TAD) is performed after neoadjuvant systemic therapy (NST) to decrease the rate of non-therapeutic axillary dissection (ALND) for patients with node-positive breast cancer. In order to ensure the oncologic safety of TAD, eligibility criteria resulting in a low false negative rate (FNR) have been proposed. The purpose of this study was to evaluate the utility of the traditional criteria. METHODS: Data was collected from a prospective multicenter registry. In order to ascertain FNRs, pathologic findings in the sentinel lymph nodes (LN)s, malignant clipped LN, and axillary contents were determined. The FNRs within TAD eligibility criterion groups were compared. RESULTS: A total of 110 patients underwent TAD and ALND, and were therefore eligible for analysis. TAD retained a low FNR in advanced clinical T-N stage compared with earlier disease (T stage: 95% CI 0.00-11.93, p = 0.42; N stage: 95% CI 0.00-8.76, p = 0.31). Presentation with ≥4 abnormal LNs on axillary ultrasound did not predict a high TAD FNR (95% CI 0.00-5.37, p = 0.16). No significant differences were noted in TAD FNR when single was compared with dual tracer (blue dye vs dual tracer 95% CI 0.72-52.49, p = 0.13; radiotracer vs dual tracer 0.04-20.11, p = 0.51). Excision of the clipped LN and only one SLN was as accurate as excision of the clipped LN and ≥2 SLNs (95% CI 0.00-10.61, p = 0.38). CONCLUSIONS: TAD retained a low FNR among patients traditionally considered ineligible for this technique. However, excision of the clipped LN and at least one SLN remained essential to a low FNR.

An exploratory metabolomic comparison of participants with fast or absent functional progression from 2CARE, a randomized, double-blind clinical trial in Huntington's disease.

Huntington's disease (HD) is increasingly recognized for diverse pathology outside of the nervous system. To describe the biology of HD in relation to functional progression, we previously analyzed the plasma and CSF metabolome in a cross-sectional study of participants who had various degrees of functional impairment. Here, we carried out an exploratory study in plasma from HD individuals over a 3-year time frame to assess whether differences exist between those with fast or absent clinical progression. There were more differences in circulating metabolite levels for fast progressors compared to absent progressors (111 vs 20, nominal p < 0.05). All metabolite changes in faster progressors were decreases, whereas some metabolite concentrations increased in absent progressors. Many of the metabolite levels that decreased in the fast progressors were higher at Screening compared to absent progressors but ended up lower by Year 3. Changes in faster progression suggest greater oxidative stress and inflammation (kynurenine, diacylglycerides, cysteine), disturbances in nitric oxide and urea metabolism (arginine, citrulline, ornithine, GABR), lower polyamines (putrescine and spermine), elevated glucose, and deficient AMPK signaling. Metabolomic differences between fast and absent progressors suggest the possibility of predicting functional decline in HD, and possibly delaying it with interventions to augment arginine, polyamines, and glucose regulation.

Medicare Reimbursement in Hand and Upper Extremity Procedures: A 20-Year Analysis.

PURPOSE: Concern exists that Medicare physician fees for procedures have decreased over the past 20 years. The Centers for Medicare & Medicaid Services (CMS) is set to re-evaluate these physician fees in the near future for concern that these procedures are overvalued. Our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2019 for the top 20 most billed hand and upper extremity surgical procedures at our institution. METHODS: The financial database of a single academic tertiary care center was queried to identify the Current Procedural Terminology codes most frequently utilized in orthopedic hand and upper extremity procedures in 2019. The Physician Fee Schedule Look-Up Tool from the CMS was queried for annual physician fee data. Monetary data were adjusted for inflation using the consumer price index of Urban Research Series (CPI-U-RS) and expressed in 2019 constant US dollars (USD). The average annual and total percent change in reimbursement were calculated via linear regression for all procedures (P < .05). RESULTS: Accounting for inflation, the total average physician reimbursement decreased by 20.9% from 2000 to 2019, with 12 of 20 codes decreasing by more than 20%. The greatest decrease pertained to arthrodesis of the wrist at 33.9%. Upon linear regression, all procedures were found to decrease annually, with arthrodesis of the wrist decreasing by an average of 2.3% annually over this period. CONCLUSIONS: Over the past 2 decades, physician reimbursement for hand and upper extremity procedures has significantly decreased.

The effects of stocking density on behavior and biological functioning of penned sheep under continuous heat load conditions.

Stocking density may impact sheep welfare during live export voyages that occur under hot and humid conditions. The aim of this study was to assess the welfare implications for sheep housed at three allometric stocking densities (k = 0.030, 0.033, 0.042), while exposed to hot and humid climatic conditions. For 21 d, Merino wethers (n = 216) were housed in 12 pens of 18 wethers, in two climate-controlled rooms where wet-bulb temperature (TWB) mimicked the conditions of a live export voyage with high heat and humidity, and limited diurnal variation. Scan sampling of standing and lying behaviors was conducted on days 2, 5, 8, 11, 15, 18, and 20, at hourly intervals. Agonistic interactions were scored continuously on the same days between 1750 and 1800 h. Liveweights were recorded at the start and end of the study. For a subset of focal wethers (3 per pen), whole blood variables were assessed at the start and end of the experiment, along with fecal glucocorticoid metabolites (FGCM), which were also assessed on days 7 and 14. Rumen temperatures (TRUM) of focal wethers were recorded at 10-min intervals, and their respiration rates (RR) were measured every 2 h on days 1, 3, and from days 7 to 21. Focal wethers were slaughtered for necropsy after the study, and both adrenal glands were excised and weighed. The expression of some lying positions was impaired at high stocking densities, and lying with outstretched legs increased at high TWB. For respiration rates, there was an interaction between stocking density and TWB, such that RR was reduced by the provision of additional space at high TWB. TRUM was relatively unaffected by stocking density but increased at higher TWB, and any effects of stocking density on FGCM concentrations, liveweights (LW), adrenal gland weights or blood variables were minimal. Necropsy examination showed no indication that the wethers had experienced ongoing respiratory distress. These results suggest that the wethers were able to cope with these increases in stocking density under the conditions imposed. However, based on this evidence, the provision of additional space under hot conditions may be beneficial to facilitating the expression of some lying positions. Whilst the experiment was designed to emulate certain conditions relevant during live export voyages, other factors that may induce stress during this mode of transport were not present, and so the conclusions must be interpreted in the context of the experimental conditions.

There is a high demand for Australian sheep to be exported to the Middle East, and for live export voyages which depart during an Australian winter, heat, and humidity increase rapidly as ships cross the equator and approach destination countries. Concern about sheep becoming heat stressed during these voyages has increased, and industry attention has focused on the potential role of stocking density in determining heat stress risk in this context. High stocking densities limit the body surface area available for heat loss and can increase heat exchange between individual sheep. This study aimed to assess the welfare implications of three stocking densities, for sheep exposed to climatic conditions similar to those experienced during a live export voyage to the Middle East. Higher stocking densities restricted the ability of sheep to lie in some positions, but stocking density had limited effects on heat stress indicators or the physiology of the sheep. These results suggested that the sheep were able to cope with these increases in stocking density under the conditions imposed, but the conclusions must be interpreted in the context of the controlled experimental conditions.

The availability and type of lesbian, gay, bisexual, transgender, and queer content on sperm, oocyte, and embryo provider websites.

PURPOSE: To evaluate and quantify the character and amount of lesbian, gay, bisexual, transgender, and queer (LGBTQ +) content on sperm, oocyte, and embryo provider websites in the USA. METHODS: Websites with LGBTQ + information were categorized into "minimal," "moderate," and "significant" content. The presence and type (category) of LGBTQ + content were assessed in its relationship to geographic regions, in vitro fertilization (IVF) cycles/year, and website types. Interobserver reliability was assessed for the categorization system created. RESULTS: Out of 373 unique websites, 191 (51.2%) had LGBTQ + content of any kind. Regarding the amount of content, websites were categorized as "none" (48.8%), "minimal" (8.0%), "moderate" (28.4%), and "significant" (14.8%). "Private fertility clinic" websites were more likely to have LGBTQ + content and a significantly increased amount of content compared to other website types ("academic hospital" and "sole sperm, oocyte, and embryo provider" websites) (p < 0.0001). Fertility clinics with more IVF cycles/year were more likely to have increased amount of LGBTQ + content compared to those with fewer IVF cycles/year (OR = 4.280; 95% CI, 1.952-9.388). Northeast, West, South, and Midwest regions showed no statistically significant difference in presence and type of content (p = 0.06 and p = 0.13, respectively). CONCLUSION: Approximately half of websites had LGBTQ + content. Private fertility clinics and fertility clinics with increased IVF cycles/year show a positive relationship to the presence and type of LGBTQ + content, while LGBTQ + website content was similar across four geographic regions.

Socioeconomic Influence on Speech Rehabilitation After Total Laryngectomy.

OBJECTIVE: Speech rehabilitation following a total laryngectomy significantly impacts the quality of life. Indwelling prosthetic voice restoration provides optimal outcomes; however, the long-term maintenance of these devices carries considerable financial costs, which are not universally covered by insurance. This investigation aimed to analyze associations between socioeconomic factors and outcomes in postlaryngectomy speech rehabilitation. STUDY DESIGN: Retrospective cohort analysis. SETTING: Academic tertiary-care center from May 2014 to September 2021. METHODS: In patients undergoing total laryngectomy, the incidence of tracheoesophageal puncture with indwelling vocal prostheses (TEP-VP) placement within the first postoperative year was compared among household income, demographic factors, and disease characteristics. Functional and maintenance outcomes served as secondary endpoints. RESULTS: Seventy-seven patients were included. Forty-five (58%) underwent indwelling TEP-VP (41 primaries). Eighty-nine percent of patients with annual incomes greater than $50k underwent TEP-VP compared to only 35% with incomes less than $50k/year. TEP-VP was performed in 85% of patients with commercial insurance, 70% with Medicare, 42% with Medicaid, and 0% with no insurance. On multivariate analysis, annual household incomes greater than $50k were predicted for TEP-VP placement (odds ratio: 12.7 [2.45-65.8], p = .002). The utilization of postoperative speech therapy and functional communication outcomes were similar among socioeconomic groups. Twelve patients were unable to afford supplies within the first year, with differences noted among insurance (p = .015) and income status (p = .003). CONCLUSION: Disparities in vocal and speech rehabilitation following laryngectomy may disproportionally affect underserved patients.

Heat stress in horses: a literature review.

Healthy adult horses can balance accumulation and dissipation of body heat to maintain their body temperature between 37.5 and 38.5 °C, when they are in their thermoneutral zone (5 to 25 °C). However, under some circumstances, such as following strenuous exercise under hot, or hot and humid conditions, the accumulation of body heat exceeds dissipation and horses can suffer from heat stress. Prolonged or severe heat stress can lead to anhidrosis, heat stroke, or brain damage in the horse. To ameliorate the negative effects of high heat load in the body, early detection of heat stress and immediate human intervention is required to reduce the horse's elevated body temperature in a timely manner. Body temperature measurement and deviations from the normal range are used to detect heat stress. Rectal temperature is the most commonly used method to monitor body temperature in horses, but other body temperature monitoring technologies, percutaneous thermal sensing microchips or infrared thermometry, are currently being studied for routine monitoring of the body temperature of horses as a more practical alternative. When heat stress is detected, horses can be cooled down by cool water application, air movement over the horse (e.g., fans), or a combination of these. The early detection of heat stress and the use of the most effective cooling methods is important to improve the welfare of heat stressed horses.

Automated Quantification of the Behaviour of Beef Cattle Exposed to Heat Load Conditions.

Cattle change their behaviour in response to hot temperatures, including by engaging in stepping that indicates agitation. The automated recording of these responses would be helpful in the timely diagnosis of animals experiencing heat loading. Behavioural responses of beef cattle to hot environmental conditions were studied to investigate whether it was possible to assess behavioural responses by video-digitised image analysis. Open-source automated behavioural quantification software was used to record pixel changes in 13 beef cattle videorecorded in a climate-controlled chamber during exposure to a simulated typical heat event in Queensland, Australia. Increased digitised movement was observed during the heat event, which was related to stepping and grooming/scratching activities in standing animals. The 13 cattle were exposed in two cohorts, in which the first group of cattle (n = 6) was fed a standard finisher diet based on a high percentage of cereal grains, and the second group of cattle (n = 7) received a substituted diet in which 8% of the grains were replaced by lucerne hay. The second group displayed a smaller increase in digitised movements on exposure to heat than the first, suggesting less discomfort under hot conditions. The results suggest that cattle exposed to heat display increased movement that can be detected automatically by video digitisation software, and that replacing some cereal grain with forage in the diet of feedlot cattle may reduce the measured activity responses to the heat.

Features of mixed medullary thyroid tumors: An NCDB analysis of clinicopathologic characteristics and survival.

BACKGROUND: Mixed medullary-papillary thyroid carcinoma (MMPTC) and mixed medullary-follicular thyroid carcinoma (MMFTC) are rare variants with little known regarding behavior and prognosis. METHODS: Using the National Cancer Database (NCDB), demographics, clinicopathologic features, treatment, and overall survival (OS) from patients with MMPTC and MMFTC were compared to more prevalent subtypes. RESULTS: There were 296,101 patients: 421 MMPTC (0.14%), 133 MMFTC (0.04%), 263,140 PTC (88.87%), 24,208 FTC (8.18%) and 8,199 MTC (2.77%). Compared to PTC, MMPTC and MMFTC patients were older (p < 0.001) with a higher Charlson-Deyo comorbidity index (p < 0.001). Mixed tumors exhibited lower rates of nodal disease but more distant metastases compared to PTC (p < 0.001). MMPTC demonstrated lower estimated 10-year OS than PTC and FTC (76.04%vs 89.04% and 81.95%,p < 0.001), yet higher than MTC (70.29%,p < 0.001). MMFTC had a worse OS compared to all groups (63.32%,p < 0.001). CONCLUSION: Patients with MMFTC had significantly worse OS compared to DTC, portending a worse prognosis.

Trauma Incidence During the New Jersey COVID-19 Stay-At-Home Order: A Multicenter Study.

INTRODUCTION: Given the early surge of COVID-19 in New Jersey (NJ), a statewide executive order (EO) to stay-at-home was instituted on March 22, 2020. We hypothesized that the EO would result in a decreased number of trauma admissions, length of stay, and resources utilized in trauma patients at NJ trauma centers. METHODS: In an institutional review board-approved, retrospective, multicenter study, trauma registries at three level one trauma centers in NJ were queried from March 22 to June 14 in 2020 and compared to the same timeframe the year prior. Epidemiological and clinical data were obtained including demographics, select preexisting conditions, mechanism of injury, injury severity score, resources utilized, and outcomes. RESULTS: 1859 trauma patients were evaluated during the EO versus 2201 the year prior. During the EO, trauma patients were less likely to be transferred from another hospital (21% versus 29% P < 0.05), more likely to have a penetrating mechanism (16% versus 12% P < 0.05), were equally likely to require a procedure (P = 0.44) and had similar injury severity score (5 [interquartile range [IQR] 1-9] versus 5 [IQR 1-9], P = 0.73). There was no significant difference in ventilator days (0 [IQR 0-1] versus 0 [IQR 0-2] P = 0.08), intensive care unit days (2 [IQR 0-4] versus 2 [IQR 0-3] P = 0.99), or length of stay (2 [IQR 1-5] versus 2 [IQR 1-6] P = 0.73). Patients were more likely to be sent home than to rehabilitation or long-term acute care hospital during the EO (81% versus 78%, P = 0.02). CONCLUSIONS: The 2020 COVID-19 EO was associated with a significantly different epidemiology with a higher rate of penetrating injury during the EO, and similar volume of injured patients evaluated.

Improving Outpatient Follow-Up Rates for New In-Hospital Consults.

OBJECTIVE(S): This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence. METHODS: Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge. RESULTS: Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio [OR]: 3.69 [95% confidence interval [CI]: 2.29-5.96], p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 [1.92-5.64], p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 [1.02-3.69], p = 0.045) or Pediatrics (OR: 3.36 [1.41-7.98], p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001). CONCLUSION: Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540-2545, 2023.

Gastric Neuroendocrine Tumor Treatment and Survival Outcome Depends on Facility Type.

BACKGROUND: Gastric neuroendocrine tumors (gNETs) are rare cancers for which surgery may improve survival. We aim to determine if facility type affects treatment and survival outcomes. METHODS: The NCDB was queried for patients with gNET from 2004-2016 and stratified into Academic/Research Program (ARP), Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), or Integrated Network Cancer Program (INCP). Overall survival along with clinical and demographic features was compared. RESULTS: Median survival was improved in patients treated at an academic program: 137.3 months versus 88.0, 96.3, and 100.2 for CCP, CCCP, INCP, respectively (P < .0001). Patients treated at academic centers were more likely to have surgery (64.2% vs 59.1%, 57.5%, 51.4%, P < .0001). After propensity matching for age, race, grade, stage, insurance status, and comorbidity score, survival benefit from treatment at an academic center remained (P = .03), particularly for patients undergoing surgery (P < .0001) and chemotherapy (P = .04). CONCLUSION: Patients with gNET treated at an academic hospital had improved median survival after propensity matching and may benefit from treatment at academic rather than community medical centers.

Is Calcium Score in the Abdominal Aorta or Renal Arteries Predictive of Acute Kidney Injury After Cardiopulmonary Bypass: An Exploratory Study.

Introduction Acute kidney injury (AKI) remains a serious complication after surgery with cardiopulmonary bypass (CPB). A relationship similar to the one between coronary artery calcification and increased incidence of cardiac complications is hypothesized to exist for aortic calcification and the development of AKI. Elevated pulse pressure (PP) hypertension has been shown to be a predictor of AKI-CPB (AKI after CPB surgery), and calcium deposition and stiffening of the body's conduit arteries may be part of this process. We hypothesized that calcium scores obtained from non-contrast computed tomography (CT) scans of the infrarenal aorta and renal arteries would be independently and significantly associated with AKI-CPB. Methods We conducted a retrospective study of 65 subjects who underwent non-emergent open heart surgery with CPB in a tertiary healthcare center. AKI-CPB was diagnosed using the Acute Kidney Injury Network criteria. Aortic and renal artery calcium (Agatston) scores were obtained and entered into a multivariable logistic regression model alongside other significant predictors of AKI-CPB from a univariable analysis. Results Pulse pressure, body surface area, and pre-operative serum creatinine were significantly associated with the development of AKI-CPB, but the calcium scores were not. For PP, the odds ratio (OR) was 1.062, (95% Wald confidence interval {CI}=1.012 - 1.114). The OR for the calcium score in the aorta was 1.0000 (95% CI=1.0 - 1.0). Conclusions Agatston calcium scores in the renal arteries and infrarenal aorta were not independently associated with AKI-CPB, but arterial stiffening, as indicated by elevated pulse pressure, was predictive of AKI-CPB.

Resident physician outlook on death, dying and end-of-life care during the COVID-19 pandemic: effect of religion and burnout.

OBJECTIVES: Religion and spirituality are important aspects of many physicians and patients' lives and may impact their views of death and the way they interact with terminally ill patients, specifically comfort discussing end-of-life care and death and dying. This study explores the religious and spiritual beliefs of resident physicians, if they affect interactions with their patients and if burnout impedes this interaction. METHODS: A 28-item questionnaire was administered to residents and fellows at an urban academic hospital. RESULTS: 65 residents and fellows answered the survey. Religiosity but not spirituality correlated with reported comfort interacting with patients dealing with death or dying. Resident specialty, biological sex and spirituality were not associated with comfort and conversations about religion and end-of-life care. The majority (60%) reported that the pandemic has not affected how they speak to their patients about death and dying. Caring for a higher volume of terminally ill patients was not associated with high levels of burnout though 71% reported increased burnout due to COVID-19. CONCLUSION: Further research can be done to determine whether additional training or resources should be provided to resident physicians to cope with death and dying in the setting of a pandemic.

Outcomes of catheter ablation for ventricular tachycardia in patients with sarcoidosis: Insights from the National Inpatient Sample database (2002-2018).

INTRODUCTION: Data on utilization, major complications, and in-hospital mortality of catheter ablation (CA) for sarcoidosis-related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis-related VT, and incidence and predictors of complications associated with the CA procedure. METHODS: We queried the 2002-2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. A 1:3 propensity score-matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in-hospital mortality and procedural complications associated with the CA procedure. RESULTS: Of 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior myocardial infarction, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in-hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs. 6.6%, p = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture periprocedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in-hospital mortality and procedural complications among the CA group included congestive heart failure (odds ratio [OR], 13.2; 95% confidence interval [CI], 1.7-104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1-13.3). CONCLUSIONS: Compared to patients with sarcoidosis-related VT who received medical therapy alone, those who underwent CA have a trend for a lower mortality rate despite procedure-related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group.

Effect of Strength-Based Resilience on Patient's Length of Stay at the Renfrew Center for Eating Disorders.

Objective: Throughout past decades, physicians have sought to understand factors that contribute to severity of an eating disorder (ED). There is a potential relationship between patients' resilience and the recovery course of their disorder. The objective of this study is to examine the correlation between resilience, measured by indicators of mindfulness and restraint, and length of stay (LOS) at Renfrew Center for Eating Disorders. Materials and Methods: Data were obtained from Renfrew's database. Secondary analysis was conducted from this database. The database included women aged 13-75 years admitted to Renfrew. The database excluded males and individuals of ages <13 or >75 years old. Resilience was analyzed through Southampton Mindfulness Questionnaire (SMQ) and ED restraint. The dependent variable, LOS at Renfrew, was analyzed by multivariable linear regression, and multivariable logistic regression for LOS >45 days. Results: A sample of 2901 subjects was analyzed. There were significant associations between increased mindfulness scores and decreased restraint scores and a decreased LOS at Renfrew. For every 13-point increase in SMQ, the LOS was associated with a decrease by ∼1 day, and for every 1-point decrease in the restraint score (increased restraint), the LOS was associated with a decrease by ∼1 day. Higher restraint scores were independently associated with an increase in likelihood of LOS >45 days by 22.8%. Conclusions: The Renfrew data support the relationship between a patient's resilience and LOS. This information holds promise for future treatment approaches to improve strength-based modalities in patients suffering from EDs.

Challenges and Opportunities of Using a National Database to Evaluate Racial/Ethnic Disparities and Breastfeeding Effects on Sudden Unexpected Infant Death.

Background: Sudden unexpected infant death (SUID) rates remain higher in American Indian/Alaska Native (AI/AN) and non-Hispanic Black (NHB) infants than other demographic groups. Racial disparities are also evident in breastfeeding, which is associated with reduced risk of SUID. Objective: To assess the relationship between racial/ethnic disparities in SUID and breastfeeding beyond the newborn period using U.S. nationally reported public databases. Methods: Data were extracted from Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) and the National Immunization Surveys (NISs) 2009-2017. WONDER data were restricted to full-term infants and sorted by death year, race/ethnicity, and other characteristics. NIS breastfeeding data included ever breastfed, breastfed at 6 months, and exclusive breastfeeding at 3 and 6 months. Breastfeeding rates and mortality data were aggregated based on race/ethnicity, and mortality rates were analyzed by weighted (number of births) multivariable linear regression. Results: SUID rates were highest among NHB and AI/AN infants who also had the lowest breastfeeding rates. When breastfeeding and race/ethnicity were included in the analyses, race/ethnicity confounded the relationship between breastfeeding and SUID. When race was excluded, ever breastfeeding and any breastfeeding at 6 months were associated with significantly decreased SUID rates. Conclusion: Race/ethnicity confounded the relationship between breastfeeding and SUID. Analysis was limited because individual SUID rates were available for maternal/birth characteristics but not for breastfeeding. Our study showed a need for adding additional data points to other national databases to better understand the role that breastfeeding plays in the racial/ethnic disparities in SUID.

Application of infrared thermal technology to assess the level of heat stress and milk yield reduction of cows in tropical smallholder dairy farms.

Panting score (PS) is a common research tool used to assess the physiological state of cows exposed to heat stress, but it is subjective. Infrared temperature (IRT), measured by either infrared thermometers or cameras, may be a more objective and reliable alternative. Very few studies thus far have evaluated the associations between PS, IRT, and milk production. We investigated the applicability of IRT compared with PS as a means of assessing heat stress and milk yield reduction in dairy cows in tropical smallholder dairy farms (SDF). In autumn 2017, SDF located across 4 typical dairy regions of Vietnam were each visited once to collect farm (n = 32) and individual cow data (n = 344). For each SDF, heat load index (HLI) inside the cowsheds, an indicator of environmental heat load calculated from ambient temperature, humidity, and wind speed, was measured. For each cow, PS (0 indicates a cow breathing normally, not panting; 4.5 indicates an extremely heat-stressed cow with excessive panting, tongue fully extended, and excessive drooling), IRT of the cow's body, single-day energy-corrected milk yield (ECM), body weight, and body condition score were measured. Cow genotype, age, lactation number, and days in milk were recorded. The IRT of the cows' inner vulval lip (IVuT) were measured with an infrared thermometer; and the IRT of the cows' vulval surface (OVuT), inner tail base surface (ITBT), ocular area, muzzle, armpit area, paralumbar fossa area, fore udder, rear udder, fore hoof, and hind hoof were also measured with an infrared camera. Multivariate mixed-effects models were used to assess the associations between HLI with PS and IRT, and associations between PS and IRT with ECM while accounting for the effects of other cow variables. All IRT correlated positively with PS (Pearson correlation, r = 0.23-0.50). Each unit increase in HLI was associated with increases of 0.07 units in PS and 0.09 to 0.23°C in IRT. Each degree (°C) increase in IVuT, OVuT, and ITBT was associated with decreases of 0.75, 0.87, and 0.70 kg/cow per day in ECM, respectively, whereas PS and other IRT were not significantly associated with ECM. Thus, all IRT showed potential to assess the heat stress level of cows; and IVuT, OVuT, and ITBT, but not PS and other IRT, showed potential to predict ECM reduction in cows during heat stress. First cross (F1) Holstein Brown Swiss and F1 Holstein Jersey showed lower PS and yielded higher ECM than the third backcross (B3) Holstein Zebu (7/8 Holstein + 1/8 Zebu) and pure Holstein. Thus, F1 Holstein Brown Swiss and F1 Holstein Jersey could be more suitable for tropical SDF than B3 Holstein Zebu and pure Holstein.

Multivariate analysis identifying the main factors associated with cow productivity and welfare in tropical smallholder dairy farms in Vietnam.

This study aimed to rank potential drivers of cow productivity and welfare in tropical smallholder dairy farms (SDFs) in Vietnam. Forty-one variables were collected from 32 SDFs located in four geographically diverse dairy regions, with eight SDFs per region. Twelve variables, including milk yield (MILK), percentages of milk fat (mFA), protein (mPR), dry matter (mDM), energy-corrected milk yield (ECM), heart girth (HG), body weight (BW), ECM per 100 kg BW (ECMbw), body condition score (BCS), panting score (PS), inseminations per conception (tAI), and milk electrical resistance (mRE) of cows, were fitted as outcome variables in the models. Twenty-one other variables describing farm altitude, housing condition, and diet for the cows, cow genotypes, and cow physiological stage were fitted as explanatory variables. Increased farm altitude was associated with increases in ECM and mRE and with decreases in PS and tAI (P < 0.05). Increases in roof heights and percentage of shed side open were associated with increases in ECM, mFA, and mDM (P < 0.05). Increased dry matter intake and dietary densities of dry matter and fat were associated with increased MILK, ECM, and ECMbw and decreased tAI (P < 0.05). Increased dietary lignin density was associated with increased PS. Increased genetic proportion of Brown Swiss in the herd was associated with increased MILK, ECM, and ECMbw (P < 0.05). Thus, to improve cow productivity and welfare in Vietnamese SDFs, the following interventions were identified for testing in future cause-effect experiments: increasing floor area per cow, roof heights, shed sides open, dry matter intake, dietary fat density, and the genetic proportion of Brown Swiss and decreasing dietary lignin density.

Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center.

OBJECTIVES: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.