IDENTIFYING ECONOMIC RISK IN CATTLE FEEDING

Closeout data from two western Kansas commercial feedlots are examined to determine how cattle prices, feed costs, and animal performance impact the variability of cattle feeding profits. The relative impacts of these factors are studied across sex, placement weight, and placement month using standardized beta coefficients. Feeder cattle prices have a greater impact on profit variability for spring and fall placements. The effect of animal performance on variability of cattle feeding profits is greater for fall placements. Results suggest that fed cattle and feeder cattle prices should be emphasized in managing the overall risk in cattle feeding because they are the largest contributors to profit variability.cattle finishing profitability, cattle performance, feedlot closeouts, standardized beta coefficients, Livestock Production/Industries,

Portion control for the treatment of obesity in the primary care setting

<p>Abstract</p> <p>Background</p> <p>The increasing prevalence of obesity is a significant health threat and a major public health challenge. A critical need exists to develop and evaluate practical methods for the treatment of obesity in the clinical setting. One of the factors contributing to the obesity epidemic is food portion sizes. Limited data are available on the efficacy of visual or tactile devices designed to enhance patient understanding and control of portion sizes. A portion control plate is a commercially-available product that can provide visual cues of portion size and potentially contribute to weight loss by enhancing portion size control among obese patients. This tool holds promise as a useful adjunct to dietary counseling. Our objective was to evaluate a portion control intervention including dietary counseling and a portion control plate to facilitate weight loss among obese patients in a primary care practice.</p> <p>Findings</p> <p>We randomized 65 obese patients [body mass index (BMI) ≥ 30 and < 40] to an intervention including counseling by a dietitian incorporating a portion control plate or to usual care. Following initial consultation, patients in the intervention arm were contacted at 1, 3, and 5 months by the dietician for brief follow-up counseling. Usual care subjects received instructional handouts on diet and exercise. Forty-two (65%) subjects returned to have weight assessed at 6 months. Subjects in the portion control intervention had a greater percentage change (± SD) in weight from baseline at 3 months (-2.4% ± 3.7% <it>vs</it>. -0.5% ± 2.2%; p = 0.041) and a non significant trend in weight change from baseline at 6 months (-2.1% ± 3.8% vs. -0.7% ± 3.7%; p = 0.232) compared with usual care. Nearly one-half of patients assigned to the portion control intervention who completed the study reported the overall intervention was helpful and the majority would recommend it to others.</p> <p>Conclusions</p> <p>Our findings suggest that a portion control intervention incorporating dietary counseling and a portion control plate may be effective for enhancing weight loss among obese subjects. A portion control intervention deserves further evaluation as a weight control strategy in the primary care setting.</p> <p>Trial registration</p> <p>Current controlled trials <a href="http://clinicaltrials.gov/ct2/show/NCT01451554">NCT01451554</a></p

Pediatric surgical extracorporeal membrane oxygenation - a case series

Objective. To review demographic and procedural factors and their association with weaning rate and survival from extracorporeal membrane oxygenation (ECMO) in pediatric patients undergoing repair of cardiac malformations. Methods. The hospital records of children requiring ECMO during cardiac operation due to failure to wean from cardio-pulmonary by pass (CPB) were retrospectively reviewed, and an analysis of variables affecting survival was performed. Results. Thirty-five pediatric patients between January 1, 2000 and December 31, 2006 required ECMO for cardiopulmonary support during cardiac operations. ECMO survival was 54.3% and was comparable across all age groups. The lowest pH during ECMO treatment was the only predictor of mortality (P = 0.006). No other patient, surgical or anesthetic, factor was associated with either weaning from ECMO or hospital survival. Conclusions. No clear risk factor could be identified for survival from ECMO in our pediatric patients who underwent cardiac surgery and failed weaning from cardiopulmonary bypass

Survey of self-assessed preparedness for clinical practice in one Croatian medical school

<p>Abstract</p> <p>Background</p> <p>The Croatian higher education system is in the process of reforming its medical curricula to comply with European Union standards. We conducted a survey of students enrolled at the University of Zagreb (Croatia) asking them to rate their perception of preparedness for clinical practice prior to initiation of the reform process. The purpose of the survey was to identify self-perceived deficiencies in education and to establish a reference point for the later assessment of ongoing educational reform.</p> <p>Findings</p> <p>One-hundred and forty seven (N = 147) graduates reported the levels of perceived preparedness on 30 items grouped into 8 educational domains. Main domains were: understanding science, practical skills/patient management, holistic care, prevention, interpersonal skills, confidence/coping skills, collaboration, and self-directed learning. For each item, graduates self assessed their preparedness on a scale ranging from 1 to 4, with 1 = "Very inadequate", 2 = "Somewhat inadequate", 3 = "Somewhat adequate", and 4 = "Very adequate". In 7 out of 8 domains the achieved median score was ≥ 3. Students expressed low confidence (defined when ≥ 25% of respondents supplied a rating for the survey question as: "very inadequate" or "somewhat inadequate") with interpersonal skills (discussing terminal disease, counseling distraught patients, balancing professional and personal life), and in performing certain basic semi-invasive or invasive procedures.</p> <p>Conclusion</p> <p>Zagreb medical graduates identified several deficiencies within educational domains required for standard clinical practice. Ongoing educational efforts need to be directed towards the correction of these deficiencies in order to achieve standards required by the European Union.</p

Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases

BACKGROUND: The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. ----- METHODS: We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. ----- RESULTS: Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. ----- CONCLUSION: The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates

Survival of outborns with congenital diaphragmatic hernia: the role of protective ventilation, early presentation and transport distance: a retrospective cohort study

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a congenital malformation associated with life-threatening pulmonary dysfunction and high neonatal mortality. Outcomes are improved with protective ventilation, less severe pulmonary pathology, and the proximity of the treating center to the site of delivery. The major CDH treatment center in Croatia lacks a maternity ward, thus all CDH patients are transferred from local Zagreb hospitals or remote areas (outborns). In 2000 this center adopted protective ventilation for CDH management. In the present study we assess the roles of protective ventilation, transport distance, and severity of pulmonary pathology on survival of neonates with CDH. ----- METHODS: The study was divided into Epoch I, (1990-1999, traditional ventilation to achieve normocapnia), and Epoch II, (2000-2014, protective ventilation with permissive hypercapnia). Patients were categorized by transfer distance (local hospital or remote locations) and by acuity of respiratory distress after delivery (early presentation-occurring at birth, or late presentation, ≥ 6 h after delivery). Survival between epochs, types of transfers, and acuity of presentation were assessed. An additional analysis was assessed for the potential association between survival and end-capillary blood CO2 (PcCO2), an indirect measure of pulmonary pathology. ----- RESULTS: There were 83 neonates, 26 in Epoch I, and 57 in Epoch II. In Epoch I 11 patients (42%) survived, and in Epoch II 38 (67%) (P = 0.039). Survival with early presentation (N = 63) was 48 % and with late presentation 95% (P <0.001). Among early presentation, survival was higher in Epoch II vs. Epoch I (57% vs. 26%, P = 0.031). From multiple logistic regression analysis restricted to neonates with early presentation and adjusting for severity of disease, survival was improved in Epoch II (OR 4.8, 95%CI 1.3-18.0, P = 0.019). Survival was unrelated to distance of transfer but improved with lower partial pressure of PcCO2 on admission (OR 1.16, 95%CI 1.01-1.33 per 5 mmHg decrease, P = 0.031). ----- CONCLUSIONS: The introduction of protective ventilation was associated with improved survival in neonates with early presentation. Survival did not differ between local and remote transfers, but primarily depended on severity of pulmonary pathology as inferred from admission capillary PcCO2

Postoperative respiratory depression after hysterectomy

To investigate if sex-specific physiologic characteristics could impact postoperative respiratory depression risks in women, we studied incidence and risk factors associated with postoperative respiratory depression in a gynecologic surgical cohort. Only hysterectomies performed under general anesthesia from 2012 to 2017 were included to minimize interprocedural variability. Respiratory depression was defined as episodes of apnea, hypopnea, hypoxemia, pain-sedation mismatch, unplanned positive airway pressure device application, or naloxone administration in the post-anesthesia care unit. Multivariable logistic regression was used to explore the association with clinical characteristics. From 1,974 hysterectomies, 253 had postoperative respiratory depression, yielding an incidence of 128 (95% confidence interval, 114–144) per 1,000 surgeries. Risk factors associated with respiratory depression were older age (odds ratio 1.22 [95% confidence interval 1.02–1.46] per decade increase, p = 0.03), lower body weight (0.77 [0.62–0.94] per 10 kg/m2, p = 0.01), and higher intraoperative opioid dose (1.05 [1.01–1.09] per 10 mg oral morphine equivalents, p = 0.01); while sugammadex use was associated with a reduced risk (0.48 [0.30–0.75], p = 0.002). Respiratory depression was not associated with increased hospital stay, postoperative complications, or mortality. Postoperative respiratory depression risk in women increased with age, lower weight, and higher intraoperative opioids and decreased with sugammadex use; however, it was not associated with postoperative pulmonary complications

Influence of tobacco use on postoperative opiate analgesia requirements in patients undergoing coronary artery bypass graft surgery

Introduction. The objective of this study was to test the hypothesis that tobacco use status is independently associated with postoperative opioid requirements in patients undergoing coronary artery bypass grafting (CABG) when important demographic variables such as age and gender are taken into account. Methods. A retrospective chart review of patients who underwent CABG surgery over a one year period at Mayo Clinic in Rochester, MN was performed. Tobacco users (N=69) were compared to nonusers (N=345) with regards to opiate requirements and the occurrence of severe pain during the first 48 hours postoperatively. For comparison, all postoperative opiates were converted to oral morphine equivalents (OME). Adjusted analysis for age and gender was also performed. Results. Tobacco users were younger than nonusers (P < 0.001), and a greater proportion of former users were male compared to never users (P = 0.003). Tobacco users had greater mean opiate requirements 401 ± 284 than nonusers 314 ± 240 mg OME, (P = 0.009). However, the association between tobacco use and greater postoperative opiate requirements lost significance after adjustment for age and gender. Tobacco use was not associated with increased risk of the development of severe pain (P = 0.51). Conclusions. Although current tobacco users undergoing CABG surgery utilize more opioid analgesics in the first 48 hours following extubation than nonusers of tobacco, when adjusted for age and gender, tobacco use was not independently associated with differences in postoperative opioid use

Solid malignancies among etanercept‐treated patients with granulomatosis with polyangiitis (Wegener's): Long‐term followup of a multicenter longitudinal cohort

Objective An association between therapeutic inhibition of tumor necrosis factor (TNF) and solid malignancies was observed during the Wegener's Granulomatosis Etanercept Trial (WGET), which included 180 patients with granulomatosis with polyangiitis (Wegener's) (GPA). The present study was conducted to determine the malignancy risk beyond the time of exposure to study therapy. Methods The occurrence and type of solid malignancies were ascertained using a standardized data form. Data collected included vital status, histologic findings, and therapeutic interventions. The Surveillance, Epidemiology, and End‐Results database was used to estimate a standardized incidence rate (SIR) for solid malignancies. Results Post‐trial followup data were available for 153 patients (85% of the original cohort), with a median followup time of 43 months. Fifty percent of these patients had received etanercept. There were no differences in demographic characteristics between the etanercept and placebo groups. Thirteen new solid malignancies were detected, 8 in the etanercept group and 5 in the placebo group. Compared to the general population, the risk of solid malignancies in the etanercept group was increased (SIR 3.92 [95% confidence interval 1.69–7.72]), but was not different from the risk in the placebo group compared to the general population (SIR 2.89 [95% confidence interval 0.94–6.73]). All solid malignancies occurred in patients who had been exposed to cyclophosphamide. The overall duration of disease and a history of malignancy before trial enrollment were associated with the development of malignancy during post‐trial followup. Conclusion The incidence of solid malignancy remained increased during long‐term followup of the WGET cohort. However, this could not be attributed solely to etanercept exposure during the trial. Anti‐TNF therapy with etanercept appears to further increase the risk of malignancy observed in patients with GPA treated with cytotoxic agents and should be avoided in these patients.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87143/1/30394_ftp.pd

Sugammadex and urinary retention after hysterectomy: A propensity-matched cohort study

Postoperative urinary retention (POUR) is a well-known complication after gynecologic surgery. Our objective was to investigate whether the choice of pharmacologic agent for reversing neuromuscular blockade at the end of a hysterectomy is a risk factor for POUR. Among adult patients undergoing hysterectomy with general anesthesia from 2012 to 2017, those who received aminosteroid nondepolarizing neuromuscular agents followed by pharmacologic reversal were identified, and electronic health records were reviewed. The cohort was dichotomized into two groups by reversal agent: 1) sugammadex and 2) neostigmine with glycopyrrolate. The primary outcome, POUR, was defined as unplanned postoperative bladder recatheterization. A propensity-adjusted analysis was performed to investigate the association between POUR and reversal agent by using inverse probability of treatment weighting to adjust for potential confounders. We identified 1,974 patients, of whom 1,586 (80.3%) received neostigmine-glycopyrrolate and 388 (19.7%) received sugammadex for reversal of neuromuscular blockade. The frequency of POUR was 24.8% (393/1,586) after reversal with neostigmine-glycopyrrolate and 18.3% (71/388) with sugammadex. Results from the propensity-adjusted analysis showed that sugammadex was associated with a lower POUR risk than neostigmine-glycopyrrolate (odds ratio 0.53, 95% confidence interval [CI] 0.37 - 0.76, P < 0.001). A post hoc analysis of sugammadex recipients who received glycopyrrolate for another indication showed a higher POUR risk than among those who did not receive glycopyrrolate (odds ratio 1.86, 95% CI 1.07 - 3.22, P = 0.03). Use of sugammadex to reverse aminosteroid neuromuscular blocking agents is associated with decreased risk of POUR after hysterectomy. A potential mechanism is the omission of glycopyrrolate, which is coadministered with neostigmine to mitigate unwanted cholinergic effects