Gradual Weaning Research Articles

Effects of Combined Respiratory Physiotherapy with High-Flow Nasal Cannula and Venturi Mask in Spinal Cord Injury: A Single-Subject Research Study and Literature Review.

The level of spinal cord injury affects the severity of respiratory impairment and the alteration of respiratory pattern and gas exchanges. Lesions at the C3-C5 level (phrenic nerve nucleus) cause disruption of descending input with paralysis of the main inspiratory muscle, often requiring tracheostomy and prolonged mechanical ventilation. Oxygen therapy is essential to switch from ventilatory support to removal of the endotracheal tube to correct residual difficulties in oxygenation management. A 58-year-old man had tracheostomy and tetraparesis as complication of tonsillectomy and adenoidectomy treatment for a history of obstructive sleep apnea. A respiratory rehabilitation program with protocol of oxygen therapy with high flow cannula alternated with a low-flow system by Venturi mask during daytime hours only was started. The patient was constantly monitored with capillary partial oxygen saturation to obtain adequate oxygenation (≥ 94%) and registered every 15 minutes in the clinical chart. There was gradual improvement of respiratory function. Oxygen by Venturi mask was gradually reduced due to improvement of partial pressure oxygen values. Over the course of days, the optimal results of respiratory parameters led to a gradual weaning from the Venturi mask until the complete discontinuation of the low-flow system during daytime and decreased of the high-flow fraction of inspired oxygen to the maximal tolerated level during nighttime. Implementing a combined protocol of nighttime oxygen with high flow cannula and daytime Venturi mask improves intensive motor training of patients by promoting the acquisition of ability to perform chair/bed transitions and to be able to achieve standing and begin gait training. More research is needed whether or noted to determine the role of this promising approach in patients with severe SCI and in other critically ill patients. This is a presentation of a new respiratory training protocol of combined oxygen therapy by high flow cannula and Venturi mask in a patient with cervical spinal cord injury and respiratory failure.Due to this new respiratory training, from the weaning of ventilation devices the patient had greater independence and improved quality of life, with more intensive motor training in the gym, improvement of the motor program and the patient tolerance to training.Oxygen therapy with high flow cannula and Venturi mask could be valid and reliable combined respiratory training to improve the respiratory pattern in severely hypoxemic and hypercapnic patients, without adverse events.

Anaesthesia considerations in heart transplantation: A comprehensive review

In over 56 years since the first heart transplant, the science of heart transplantation has evolved from an experimental procedure to an established standard of care for end-stage heart failure. The process involves appropriate patient selection, the listing of recipients, pre-operative optimization, intraoperative management, post-operative care, and follow-up. A robust transplant team, strong government backing, and positive support from the population are essential criteria for the success of any transplant program. Management of heart transplant recipients from the Anaesthesia perspective is challenging due to a myriad of patient risk factors; and the urgent nature of surgery due to the unpredictable nature of donor heart availability. The intraoperative aim is safe induction of anaesthesia, strict asepsis, immunosuppressive therapy, anticipation of major vascular injury, managing pulmonary vascular resistance, ventricular support, optimal ventilatory strategy, and good haemostasis. The postoperative goal is preventing infection, haemodynamic management, gradual weaning of supports, adequate analgesia, monitoring for complications, physiotherapy, and early discharge of the patient from the intensive care unit. There is an increased complexity of heart transplant recipients, due to the increasing use of pre-transplantation mechanical circulatory support devices. The cardiac anaesthesiologist needs to have knowledge of the modern changes in the field of Heart Transplant. The goal of this paper is to provide an overview of the heart transplant origins in India, donor pre-operative workup, intra-operative anaesthesia care, and early post-operative management of heart transplant patients.

Implementation of Nasal CPAP Weaning Guidelines in Preterm Infants.

Continuous positive airway pressure (CPAP) benefits preterm infants with respiratory distress, including reduced bronchopulmonary dysplasia (BPD) incidence, surfactant use, and extubation failure. Successful CPAP weaning also promotes oral feeding. However, there is no consensus on the optimal weaning of CPAP in neonates. This study aims to determine the effects of CPAP (CPAP) weaning guideline implementation on neonatal outcomes. CPAP gradual pressure weaning guidelines were implemented in the Penn State Children's Hospital NICU in 2020. We included baseline data from infants (Epoch1) before bubble CPAP implementation in 2018-19. We included infants (Epoch2) after implementing the guidelines during 2020-21. The inclusion criteria were infants <32 weeks gestation with CPAP support. Compliance with the CPAP weaning guidelines was the primary process measure. Primary outcome measures included successful CPAP wean on the first attempt. Balancing measures used were total days on respiratory support and length of hospital stay. 195 infants were included in this study, 95 infants in Epoch 1 before bubble CPAP implementation and 100 infants in Epoch 2 after implementing guidelines. Infants in the two Epochs were similar in median gestational age at 29 vs 30 weeks (p=0.47) and were similar in median birth weight at 1190 vs 1130 grams (p=0.73). After implementing weaning guidelines, the successful weaning off CPAP improved from 9.5% to 54% (p<0.001). The total days needed to achieve full oral feeds decreased by 7 days (29 vs 22 median days, p<0.001). The BPD incidence was not significantly different between the two Epochs at 17% vs 16%, p= 0.87. There was no difference in total days of respiratory support, total length of stay, the number of infants discharged on home nasogastric feeding, and demographic variables. The implementation of the bubble CPAP weaning guideline improves the successful weaning of CPAP and promotes oral feeding in preterm infants.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial

BackgroundInsertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections.MethodsDRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts.ConclusionWe present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility.Trial registrationClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

Management of external ventricular drain: to wean or not to wean?

PurposeExternal ventricular drain (EVD) is one of the most frequent procedures in neurosurgery and around 15 to 30% of these patients require a permanent cerebrospinal fluid (CSF) diversion. The optimal EVD weaning strategy is still unclear. Whether gradual weaning compared to rapid closure, reduces the rate of permanent CSF diversion remains controversial. The aim of this trial is to compare the rates of permanent CSF diversion between gradual weaning and rapid closure of an EVD.MethodsThis was a single-center, retrospective cohort study including patients between 2010 to 2020. Patients were divided into a weaning (WG) and non-weaning (NWG) group. The primary outcome was permanent CSF diversion rates, secondary outcomes included hospitalization time, EVD-related morbidity, and clinical outcome.ResultsOut of 412 patients, 123 (29.9%) patients were excluded due to early death or palliative treatment. We registered 178 (61.6%) patients in the WG and 111 (38.4%) in the NWG. Baseline characteristics were comparable between groups. The VPS rate was comparable in both groups (NWG 37.8%; WG 39.9%, p = 0.728). EVD related infection (13.5% vs 1.8%, p < 0.001), as well as non-EVD related infection rates (2.8% vs 0%, p < 0.001), were significantly higher in the WG. Hospitalization time was significantly shorter in the NWG (WG 24.93 ± 9.50 days; NWG 23.66 ± 14.51 days, p = 0.039).ConclusionGradual EVD weaning does not seem to reduce the need for permanent CSF diversion, while infection rates and hospitalization time were significantly higher/longer. Therefore, direct closure should be considered in the clinical setting.

A preliminary study on the feasibility of two different cow-calf contact systems in a pasture-based, seasonal calving dairy system: effects on cow production and health

Internationally, consumer dissatisfaction with cow-calf separation at birth has led to increased interest in alternative calf−rearing methods, specifically cow-calf contact (CCC) systems. The objectives of this preliminary study were to estimate whether CCC could be incorporated into an Irish spring-calving, pasture-based system, and to investigate the effects on cow milk production and health. Three systems were compared: the conventional Irish system (CONV;18 cows), cow and calf were separated < 1 h postbirth, cows were pasture-based and milked twice-a-day; a full-time access system (FT;14 cows), cow and calf were allowed constant, unrestricted access, were pasture-based, and cows were milked twice-a-day; and a part-time access system (PT;18 cows), cow and calf had unrestricted access when indoors at night, cows grazed outdoors by day while calves remained indoors, and cows were milked once-a-day in the morning. Cows were blocked and balanced across the three systems by previous lactation machine milk yield (MMY), BW, and body condition score (BCS). Following an 8-week CCC period, all calves were weaned (FT and PT underwent a 7-d gradual weaning and separation process) and all cows were milked twice-a-day. Cow MMY was recorded daily and milk composition was recorded weekly; milk data were analysed from weeks 1 to 8 (CCC period), weeks 9 to 35 (post-CCC period), and weeks 1 to 35 (cumulative lactation). Cow BW and BCS were taken weekly for weeks 1–12, and at the end of the lactation. During the CCC period, all systems differed (P < 0.001) in MMY (mean ± SEM; 24.0, 13.6, and 10.3 ± 0.50 kg/d for CONV, FT, and PT cows, respectively). After the CCC period, CONV MMY (20.2 ± 0.48 kg/d) remained higher (P < 0.001) than the FT (16.6 kg/d) and PT cows (15.7 kg/d). The FT and PT cows yielded 24 and 31% less in cumulative lactation MMY and 26 and 35% less in cumulative lactation milk solids yield, respectively, compared to CONV (5 072 ± 97.0 kg and 450 ± 8.7 kg). During the CCC period, somatic cell score was higher (P = 0.030) in PT cows (5.15 ± 0.118) compared to FT cows (4.70 ± 0.118), while CONV (4.94 ± 0.118) were inconclusive to both. The PT cows (523 ± 4.9 and 520 ± 6.8 kg) were heavier than the CONV (474 ± 4.9 and 479 ± 6.8 kg) and FT (488 ± 4.9 and 487 ± 6.8 kg) cows at week 4 and week 8 (both P < 0.001). The PT cows had higher BCS than CONV and FT at all observed times. This preliminary research suggests that although CCC was incorporated without impacting cow health, the two CCC systems investigated negatively affected cow production.

Immediate vs Gradual Brace Weaning Protocols in Adolescent Idiopathic Scoliosis

Lack of evidence and consensus for brace weaning protocol in adolescent idiopathic scoliosis (AIS) results in clinicians prescribing gradual weaning in the hope of avoiding curve deterioration after weaning. However, gradual weaning contributes to prolonged brace wear, which can affect spinal stiffness and health-related quality of life (HRQoL). To determine whether gradual weaning results in better curve magnitude and truncal balance maintenance after brace weaning vs immediate brace removal for patients with AIS. This was an open-labeled randomized clinical trial commenced in April 2017 with 24-month follow-up completed in January 2023. Outcome assessors were masked to weaning protocol assigned. The study took place at a territory-wide tertiary scoliosis clinic serving the largest number of referrals in the local population. Patients with AIS ready to wean off of brace wear were eligible (402 were screened; 33 were excluded [15 for <18 hours/day of brace-wear compliance before weaning, 11 were treated with Milwaukee brace, and 7 declined to participate]; and 369 were included), and those who were treated with a custom molded thoracolumbosacral orthosis and had reached skeletal maturity were consecutively recruited. Patients were randomized to gradual weaning protocol (n = 176) with an additional 6 months of nighttime wear before completely stopping or immediate weaning protocol (n = 193) with immediate brace removal at recruitment. Changes in major curve Cobb angle and truncal balance from the time of weaning to 6-month, 12-month, and 24-month follow-up. HRQoL was also assessed using the refined Scoliosis Research Society 22-item and EuroQol 5-dimension questionnaires. A total of 369 patients (mean [SD] age, 14.9 [1.1] years; 304 [83.4%] girls) were randomized with 284 (77.0%) completing 24-month longitudinal follow-up. Immediate and gradual weaning groups had no significant differences in change of major Cobb angle at postweaning 6-month (difference, -0.6°; 95% CI, -1.4 to 0.2; P = .17), 12-month (difference, -0.3°; 95% CI, -1.2 to 0.6; P = .47), and 24-month (difference, -0.3°; 95% CI, -1.2 to 0.7; P = .60) follow-up. The number of curve progression, nonprogression, and rebound cases were comparable (χ22 = 2.123; P = .35). Postweaning changes in truncal balance and HRQoL demonstrated no significant differences between groups. Gradual weaning did not demonstrate superiority to immediate weaning with predefined criteria of Cobb angle and truncal balance maintenance and HRQoL after brace weaning. Gradual and immediate weaning achieved very similar maintenance of brace outcomes in AIS. We therefore recommend the consideration of immediate brace weaning, which aims to benefit patients with earlier time for increased exercises and activity level. ClinicalTrials.gov Identifier: NCT03329716.

Effects of different production systems on health, zootechnical and metabolic parameters in Holstein calves in the extreme south of Brazil

The aim of this study was to evaluate the incidence of diseases as well as metabolic and zootechnical parameters in Holstein calves maintained in individual or collective housing systems in the extreme south of Brazil. One hundred calves were included immediately after birth and monitored for 90 days. Animals were randomly divided into two groups: individual stalls group (ISG; n=50) and collective stalls group (CSG; n=50). ISG calves were individually housed in 1.2m² wood pens and received 6 L of milk/day and concentrate food and water ad libitum for 90 days. Calves in the CSG were housed in groups of up to 25 animals, in a total of two stalls containing one animal per 3 m2. CSG calves received up to 8 L of milk/day at 0-15 days, milk ad libitum at 15-40 days, 7.2 L of milk. /day at 40-60 days, and gradual weaning at 60-90 days with concentrate food and water ad libitum, using an automatic feeder. In both groups, Zootechnical parameters (weight, thoracic perimeter, height at the withers, and rump width) were measured weekly during the first 28 days and once every 15 days until weaning. Blood samples were retrieved weekly during the first 28 days. Metabolic parameters evaluated in this study were total calcium, beta-hydroxybutyrate (BHBA), free fatty acids (FFA), and glucose. The animals were monitored daily for clinical signs of diseases diarrhea and respiratory symptoms. General morbidity was higher in CSG 92% compared to ISG 74% (p&lt;0.05). We observed increased diarrhea-related morbidity and a higher rate of recurrence in the ISG (50% and 60%, respectively; p&lt;0.05) compared to those in the CSG (both 20%, p&lt;0.05 between groups). The morbidity due to bronchopneumonia was higher in the CSG (92%) than in the ISG (74%, p&lt;0.05). Recurrence of bronchopneumonia and mortality were similar between groups (p&gt;0.05). Glucose, FFA, and BHBA concentrations were higher in the ISG (p&lt;0.05) and total calcium higher in CSG (p&lt;0.05). Finally, the weight and thoracic perimeter were higher in the CSG than those in the ISG, whereas the height and, rump width, at the withers was higher in the ISG than that in the CSG (p&lt;0.05). In conclusion, animals raised in a collective system with automatic feeders exhibited less diarrhea and increased serum calcium as well as improved zootechnical development, although they had a higher incidence of bronchopneumonia.

Abstract PO5-09-11: Abrupt involution of mouse mammary gland leads to inflammatory systemic changes along with mammary specific metabolic shifts that may enhance risk of breast cancer

Abstract Epidemiological data links higher parity and lack of breastfeeding with increased risk of breast cancer, specifically aggressive triple negative breast cancer (TNBC), and higher mortality rate. Following pregnancy and lactation, breast remodels to near pre-pregnancy stage through apoptotic cell death and adipocyte repopulation process. Long-term breastfeeding and gradual weaning of an infant leads to gradual involution (GI) of the breast, while lack of or abrupt discontinuation of breastfeeding after birth leads to abrupt involution (AI), when rapid and massive cell death takes place. Our studies have shown several precancerous changes, such as increased collagen deposition, inflammation, and hyperplasia in the mammary gland of mice after AI. However, the systemic impact of AI and how this increases risk of breast cancer is yet to be elucidated. Objectives: Our objective is to evaluate the systemic effects that are prompted by the AI mammary gland. We hypothesize that AI leads to marked alteration in lipid metabolism and systemic inflammation that enhances risk for breast cancer. Methods: FVB/n mice (8week old) were paired for breeding. At partum (day 0), dams were randomized to AI or GI cohort and standardized to 6 pups. AI mice had pups removed on day 7 postpartum (ppm) to mimic short-term breastfeeding. For GI mice 3 pups each were removed on day 28 and 31ppm to mimic gradual weaning. Tissues harvested on day 28, 56, and 120 postpartum. Body composition was measured by echo MRI. Glucose tolerance test (GTT) was performed after a 6 hour fast using a 2g/kg glucose intraperitoneal injection. Blood glucose was measured by glucometer. Serum insulin was analyzed by ELISA. HOMA-IR was calculated using blood glucose and serum insulin results. Serum was analyzed using multiplex ELISA by MesoScale Diagnostics. Mammary glands were subjected to untargeted lipidomics. Results: There were no significant differences in body weight, percent body fat or lean mass between AI and GI groups at any time point. However, at day 120 ppm (4 months after partum), we have observed significantly larger amount (1.29-fold increase) of perigonadal adipose tissue (visceral adipose) in AI mice than GI mice (p=0.0112; n=24-38/group). There were no significant differences in blood glucose, serum insulin, HOMA-IR, or GTT results between AI and GI groups at day 120. AI mice had significantly higher levels of cytokines IL-1β (3.1-fold increase, p=0.0417) and KC/GRO (1.5-fold increase, p=0.0196) than GI mice at day 120. At day 28, AI mammary glands had significantly higher amounts of level 3 identified oxidized ceramide containing sphingolipids that were linked to insulin resistance and diabetes. At day 56, GI mammary glands had significantly higher amounts of level 2 and 3 identified metabolites linked to cellular signaling and lipid metabolism. On day 120, there were no significant differences in lipid metabolites between groups. Conclusion: Although histologically GI and AI mammary glands return to near pre-pregnancy state within a month after partum, our data shows specific lipid changes in the AI mammary gland similar to what has been shown in women with TNBC. Furthermore, AI of the mammary gland leads to systemic effects on adiposity and inflammation that could be key to increased breast cancer risk. Further studies along these lines are in progress to understand the whole-body effects of AI and stratify preventive measures for women who cannot breast feed. Significance: Lack of breastfeeding is more prevalent in African American (AA) women and linked to higher risk of developing aggressive TNBC1. Our novel animal models of AI and GI help to link the impact of AI and systemic changes that may enhance breast cancer risk. In particular, we see an increase in visceral adiposity with AI. Understanding this mechanism will help identify strategies to reduce risk in women who are unable or choose not to breastfeed and ultimately help to reduce TNBC and TNBC-related mortality in AA women. Citation Format: Kate Ormiston, Kirti Kaul, Neelam Shinde, Djawed Bennouna, Rachel Kopec, Ramesh Ganju, Sarmila Majumder, Bhuvaneswari Ramaswamy. Abrupt involution of mouse mammary gland leads to inflammatory systemic changes along with mammary specific metabolic shifts that may enhance risk of breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-11.

How to Wean: A Case Report of Abrupt Weaning and Acute Dystonia

World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with complementary foods until 2 years of age or beyond. Despite these recommendations, there is limited research on the timing and methods of breastfeeding cessation, with abrupt weaning potentially causing unforeseen consequences. This report describes a case involving a 33-month-old girl who experienced acute dystonic reaction following the abrupt cessation of breastfeeding. It was learned that medication containing chlorpheniramine was given to the child to alleviate the uneasiness that developed due to abrupt cessation of breastfeeding. Patient’s symptoms were consistent with an acute dystonic reaction due to medication side effects, which improved with successful medical intervention. Breastfeeding initiation, continuation, and cessation influence the mental and physical health of the mother-baby pair. Abrupt weaning can pose challenges. While there are no strict guidelines for weaning, gradual weaning is generally considered a more comfortable approach for both mother and baby. To safeguard the well-being of the mother-baby pair, healthcare professionals should inform mothers about the discontinuation of breastfeeding and support a gradual weaning process. The presented case highlights the importance of careful consideration and professional guidance during the weaning process to prevent adverse outcomes.

Standardized Criteria to Initiate External Ventricular Drain (EVD) Weaning in a Neurological Intensive Care Unit to Increase the Safety of EVD Discontinuation and Reduce the Need for a Shunt.

Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) candevelop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning.Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days.However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAHpatients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement.A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chi-square analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.

Rapid versus gradual external ventricular drain weaning: a general review of best practices

Rapid versus gradual external ventricular drain weaning: a general review of best practices

Can a gradual weaning and separation process reduce weaning distress in dam-reared dairy calves? A comparison with the 2-step method

The weaning and separation phase remains one of the biggest challenges for cow-calf-contact systems, but a gradual process that better mimics the naturally occurring reduction in milk intake has not yet been scientifically investigated. Therefore, the aim of our study was to compare behavioral and physiological indicators of distress in 3 mo-old dam-reared dairy calves (with previous full-time cow-calf contact) weaned and separated either via gradual reduction of contact time with the dam (GR, 1 week half day contact, 1 week morning contact, 1 week fence-line contact before complete separation, n = 18) or via 2-step weaning using a nose flap (NF, 2 weeks access to dam with a nose flap, 1 week fence-line contact before complete separation, n = 18). Behavior was recorded 1 week before (or for lying 3 weeks before) weaning start and during the 3 week weaning and separation period with direct observations on 4 d per week or via accelerometers (locomotor play, lying behavior). Blood and fecal samples were taken twice per week from weaning start until 3 weeks after weaning start. Calves were weighed weekly. Statistical analysis was conducted using (generalized) linear mixed models. Over the whole weaning and separation phase, NF calves showed a stronger decrease in the number of lying bouts, amount of locomotor play and average daily weight gains, as well as a higher increase in total mixed ration feeding time compared with GR calves, whereas GR calves vocalized more often and showed more searching behavior than NF calves. Also, the neutrophil:lymphocyte ratio of NF calves was elevated on d 3 after insertion of the nose flaps compared with baseline, but showed no change for GR calves on any sampling day. Overall, results point toward a favorable effect of a gradual weaning strategy on reduction of weaning and separation distress in dam-reared dairy calves, but the method requires further improvement from the protocol used in our study.

Poland syndrome: A case of difficult weaning of ventilation after surgery

IntroductionPoland syndrome is a rare congenital anomaly that occurs in 1 in 30,000 children. It is characterised by unilateral underdevelopment or lack of the chest wall muscle that is apparent at birth. Rarely is it discovered to involve a bilateral chest muscular deficit. Poland syndrome presents in a wide variety of ways, which can often make diagnosis challenging.AimWe would like to highlight the rarity of Poland syndrome, and the challenges of post-operative recovery, primarily the ventilation.Case studyWe presented a case of a 44-year-old female with non-investigated chest wall deformity, whom required emergency surgical intervention under general anaesthesia. Post-operatively, she required prolonged ventilatory support, and was then diagnosed with Poland syndrome.Results and discussionThe patient had undergone an emergency laparotomy and left lateral hepatectomy for left hepatolithiasis with liver abscess. Post-operation, she required prolonged ventilation, with gradual weaning of oxygen. Imaging studies showed absence of left pectoralis major, thus a diagnosis of Poland syndrome. Gradually she was weaned off and had a successful post operative recovery.ConclusionsPoland syndrome is a rare congenital abnormality. In patients undergoing general anaesthesia, the normal mechanics of breathing while ventilated are absent. Their recovery is longer and requires prolonged ICU admission.

‘You have to be guided by yourself, your feelings and your child’: Women's experiences of weaning after breastfeeding beyond infancy

Mothers who breastfeed beyond infancy report a need for specialised support, and it is important to understand mothers’ experiences across the continuum of the breastfeeding journey, including weaning. This study explored women's experiences of weaning after breastfeeding for more than 1 year. Four mothers who had weaned after breastfeeding for more than 1 year took part in a semi-structured telephone interview, which invited them to share their breastfeeding journey, focusing on their experiences of weaning. Interpretative phenomenological analysis identified three themes: challenges associated with weaning; what worked well; and the need for information and support. Mothers experienced confusion about how to wean and how to deal with the emotional effects they encountered. The women emphasised the importance of a gradual weaning approach and trusting maternal instincts, as well as readily available, ongoing advice and access to judgement-free peer support.

Abstract A045: Elevated PGC1α during abrupt mammary gland involution leads to long-term metabolic reprogramming and genomic instability; hallmarks of breast cancer

Abstract Epidemiological data links higher parity and lack of breastfeeding with increased risk of breast cancer, specifically aggressive triple negative breast cancer, and associated higher mortality rate. Long-term breastfeeding and gradual weaning of an infant leads to gradual involution (GI) of the breast, while lack of or abrupt discontinuation of breastfeeding after birth leads to abrupt involution (AI), when rapid and massive cell death takes place. Our studies show several precancerous changes, such as increased collagen deposition, inflammation, and hyperplasia in the mammary gland (MG) of mice after AI1. Recent studies indicate peroxisome proliferator-activated receptor-gamma coactivator 1-apha (PGC1α) as a regulator of involution and energy metabolism. As metabolic reprogramming is a hallmark of cancer, metabolic changes in the MG related to involution warrant investigation. Objective: Our objective was to evaluate the metabolic effects of AI in MG. We hypothesized that AI leads to marked alteration in mammary lipid metabolism, mitochondrial biogenesis, and oxidative stress through elevations of PGC1α, which cause long-term metabolic reprogramming and genomic instability. Methods: FVB/n mice were paired for breeding. At partum, dams were randomized to AI or GI cohort and standardized to 6 pups per dam. AI mice had pups removed on day 7 postpartum (PPM). For GI mice 3 pups each were removed on day 28 and 31ppm. Tissues were harvested on day 28, 56, and 120 PPM. MG were subjected to Affymetrix, Gene Set Enrichment Analysis (GSEA), Seahorse Analysis, and lipidomics. Results were validated by qPCR and Western Blot. Superoxide species were detected by flow cytometry. DNA damage was analyzed via 8-hydroxy-2’-deoxygnuanosine (8-OHdG) ELISA. Results: Day 28 AI glands had significantly higher PGC1α expression than GI glands (p=0.006). Affymetrix and GSEA data showed day 28 AI glands to have enriched pathways related to fatty acid metabolism (p=0.004) and oxidative phosphorylation (p&amp;lt;0.001). Lipidomics showed elevated levels of oxidized sphingolipids and production of prostaglandin J2 (PGJ2) in day 28 AI glands (all p&amp;lt;0.02). Day 56 AI glands had higher levels of mitochondria superoxide species (p&amp;lt;0.0001) and higher PGJ2 synthesis (p=0.01). Day 120 AI MG had upregulation of an oxidized lipid (p=0.0476). Day 120 AI glands had significantly higher 8-OHdG levels (p=0.02), higher reliance of fatty acid substrates for energy (p=0.0185), and elevated extracellular acidification rates (p=0.0194). Conclusion: Although histologically both GI and AI MG return to near pre-pregnancy state within a month, our data shows long-term metabolic reprogramming in the AI MG similar to what is shown in breast cancer cells. These metabolic changes link to early elevations in PGC1α. Addressing the metabolic changes by targeting PGC1α provide a potential option to reduce the risk of developing breast cancer if a woman is unable to breastfeed. PMID6637535 *Fellowship T32CA229114 Citation Format: Kate S Ormiston, Kirti Kaul, Neelam Shinde, Gautam Sarathy, Morgan Bauer, Djawed Bennouna, Rachel Kopec, Ramesh Ganju, Sarmila Majumder, Bhuvaneswari Ramaswamy. Elevated PGC1α during abrupt mammary gland involution leads to long-term metabolic reprogramming and genomic instability; hallmarks of breast cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Advances in Breast Cancer Research; 2023 Oct 19-22; San Diego, California. Philadelphia (PA): AACR; Cancer Res 2024;84(3 Suppl_1):Abstract nr A045.

Effects of weaning age and pace on blood metabolites, cortisol concentration, and mRNA abundance of inflammation-related genes in gastrointestinal, adipose, and liver tissue of Holstein dairy calves

The objective of this study was to evaluate the effects of weaning age and pace on blood metabolites, cortisol concentration, and mRNA abundance of inflammation-related genes in Holstein dairy calves. A total of 70 1-d-old calves (38.8 ± 4.4 kg BW ± SD), blocked by sex and birth BW, were randomly assigned to a 2 × 2 factorial arrangement of treatments. The first factor was weaning age, which was either early (6 wk) or late (8 wk). The second factor was weaning pace, which was either abrupt (4 steps down over 3 d; the initial milk replacer was 7.6 L, which was reduced by 1.9 L in each step-down) or gradual (7 steps down over 14 d; the initial milk replacer was 7.6 L, which was reduced by 1.09 L in each step-down), generating early-abrupt (EA), early-gradual (EG), late-abrupt (LA), and late-gradual (LG) treatments. All treatments had 10 female and 8 male calves, except EA that had 1 fewer male calf. Milk replacer (24% CP, 17% fat) was bottle fed, up to 1,200 g/d, twice daily (0600 h and 1800 h). The EA and EG treatment calves received 46.2 kg of milk replacer, and the LA and LG treatment calves received 63 kg of milk replacer. The study had 2 cohorts (2020, n = 40; 2021, n = 31), and each cohort included all treatments. Blood was collected from the jugular vein at 0900 h at 3 and 7 d of age, and a day before starting and a day after weaning completion. Male calves were humanely killed a day after weaning. Rumen, jejunum, large intestine, liver, omental adipose and perirenal adipose tissues were sampled to determine the mRNA abundance of inflammation-related genes. Weaning pace, age, pace × age, birth BW, and sex were included as fixed and cohort was included as random effects in the model. Blood metabolites and cortisol were analyzed as repeated measures, and sampling day, pace × sampling day, and age × sampling day were also included as additional fixed effects. Significance was noted at P ≤ 0.05 and tendencies when 0.05 <P ≤ 0.10. The EA calves showed a tendency to have the greatest nonesterified fatty acid (NEFA) concentration compared with all other treatments. We observed a pace × day effect on serum NEFA and BHB; calves weaned at an abrupt pace had an increased level of NEFA after weaning compared with those weaned gradually. Calves weaned at the gradual pace showed the greatest serum BHB after weaning. Most mRNA abundances for inflammation-related genes affected by treatments showed a similar pattern. They were downregulated by the abrupt (liver IL-1β) and early weaning (jejunum TNF-α and ICAM), and in some cases, the interaction intensified the effect, demonstrating a weakened immune response in calves experiencing more stressful conditions (EA: IL-6 in the liver and NF-κB in the perirenal adipose tissue). Overall, the downregulation of the mRNA abundance of inflammation-related genes in EA calves may be attributed to the suppression of the immune system and an immature immune response. Furthermore, the greater NEFA in EA calves could be attributed to a reduced starter intake, less developed rumen, or shorter time during the weaning transition.

Effects of corn grain processing method in starter ration and weaning strategy on performance, nutrient digestion, rumen fermentation, and blood metabolites of Holstein calves

This research explored how corn processing methods and weaning protocols interact and impact calf performance, digestibility, ruminal fermentation, and blood metabolites. Forty-eight 3-day-old Holstein calves (24 females and 24 males; body weight = 38.2 ± 1.56 kg) were allocated to one of the four treatment groups using a 2 × 2 factorial design. The physical form of corn grain [steam-flaked corn (SFC) or ground corn (GC)] and weaning protocol [abrupt weaning (AW) or gradual weaning (GW)] were the experimental factors and resulted in the following treatments: 1) a starter diet containing SFC + AW protocol (SFC/AW), 2) a starter diet containing SFC + GW protocol (SFC/GW), 3) a starter diet containing GC + AW protocol (GC/AW), and 4) a starter diet containing GC + GW protocol (GC/GW). The starter feeds had similar feed ingredients (50.4% corn grain, 35.1% soybean meal, plus 5% chopped wheat straw) and were different only in the physical form of corn grain (SFC vs. GC). In the AW protocol, calves were given 4 L of milk/d from days 3 to 15, then increased to 7 L/d from days 16 to 67. Weaning occurred abruptly from days 68 to 69 by decreasing milk to 3.5 L/day. In the GW protocol, calves received 4 L of milk/day from days 3 to 15, followed by 7 L/day from days 16 to 59. Weaning occurred gradually from days 60 to 69, with this reduction schedule: 6 L/d from days 60–61, 5 L/d from days 62–63, 4 L/d from days 64–65, 3 L/d from days 66–67, 2 L/d on day 68, and 1 L/d on day 69. Total starter intake (d 1 to 90) remained unaffected by the corn grain processing method, but weaning strategy and corn processing method interacted for starter feed intake, as the greatest intake was observed in calves assigned in SFC/GW treatment. Feeding a starter diet containing SFC rather than GC increased DM and NDF digestion. Calves that were fed an SFC-based starter diet grew faster than calves fed a GC-based starter diet. The average daily gain (from d 1 and 90) was greater in calves assigned to GW vs. AW protocol. Calves fed an SFC-based starter feed and assigned to AW protocol converted nutrients toward growth more efficiently throughout the experiment (d 1 to 90). Feeding a GC- vs. SFC-based starter feed resulted in greater rumen ammonia-N concentration. Ruminal pH on day 80 was greater in calves weaned gradually compared to those weaned abruptly. Calves fed GC- vs. SFC-based starter diet had higher blood urea-N and β-hydroxybutyrate concentrations on day 60. Overall, an SFC- vs. GC-based starter feed (containing 5% chopped wheat straw) promoted faster calf growth and improved nutrient utilization. Feeding an SFC-based starter diet in combination with GW protocol resulted in the greatest starter feed intake.

Gradual weaning of 3-month-old calves from foster cows in dairy production

When calves are reared by cows, separation can be stressful, and it is often advised to use gradual weaning to minimize this stress. In foster cow systems, one gradual weaning method is to remove the foster cows, one by one, from the cow-calf group. The response to one-by-one removal of foster cows of 32 calves housed in 5 groups was studied. Calves were fostered to a designated foster cow individually, in pairs, or in trios, at the age of 1 to 2 wk and then housed in groups of 4 to 6 foster cows and 6 to 11 calves until gradual weaning started at 3 mo of age. Calf behavior and aggression received by calves from cows were recorded using video during 18 h before any foster cow was removed, as well as 18 h before and 18 h after the designated foster cow was removed from the group. Before any foster cow was removed, the calves spent a similar amount of time sucking the designated foster cow and other cows (in total 43 ± 5 min/18 h). The total duration of sucking was similar before and after the designated foster was removed, as the duration of sucking other cows increased. The number of aggressive events received from other cows also increased. The results indicate that milk availability for the group of calves decreases as foster cows are gradually removed and that the older and heavier calves increasingly compete with the younger and lighter calves for the available milk. This weaning method may also compromise the welfare of the foster cows that are left to wean off an increasing number of calves, and this warrants further research.

Behavioral responses of dairy cows and their calves to gradual or abrupt weaning and separation when managed in full- or part-time cow-calf contact systems

There is growing interest in managing cow and calf together for a prolonged period, but concerns remain about how best to wean and separate the cow and calf to minimize stress. One approach is to progressively reduce suckling opportunity over time, as in nature. There is also interest in part-time contact (suckling for part of the day) to improve milk yield for the farmer and potentially reduce stress at weaning and separation. The primary objective of this study was to compare the behavioral responses of dairy cows to gradual or abrupt weaning and separation, when managed either full or part time with their calves; a secondary focus was the vocal responses of calves under these management conditions. In a 3 × 2 factorial design (n = 14/ treatment), dairy cows and their calves (n = 84 in 7 blocks of 12 cow-calf pairs) were assigned to one of 3 dam-contact treatments at birth: (1) full-time contact between the dam and calf, apart from milking times (total 23 h/d) (2) part-time contact between the dam and calf, between morning and afternoon milking only (total 10 h/d); (3) no contact, where the dam and calf were separated after leaving the maternity pen and had no further contact. At wk 8, one of 2 weaning treatments was assigned: (1) gradual weaning by reduced contact time (50%, then 25% of original dam-contact time in wk 8 and 9, respectively), or gradually reduced milk allowance for no-contact calves (50%, then 25% of estimated 12-L milk intake in wk 8 and 9, respectively) until complete milk removal and dam-calf separation at wk 10; (2) abrupt weaning where milk removal occurred simultaneously with dam-calf separation at wk 10, or only milk removal for no-contact calves. Overall, part-time contact did not reduce weaning and separation distress for cows or calves for either weaning method. Part-time cows showed reduced behavioral responses to separation (greater lying time and less searching behavior), especially on the day of and 24 h after separation, but they showed a similarly strong vocal response to separation as full-time cows. Part-time calves made substantially more high-pitched vocalizations than full-time calves at 24 h after separation. Furthermore, gradual weaning by reducing contact time did not seem to better prepare cows or calves for complete milk removal and separation; most behavioral and vocal responses occurred on the day of separation for gradual-weaning cows and calves, but 24 h later, the reverse occurred for abrupt-weaning cows and there was no difference between gradual- and abrupt-weaning calves. Our results suggest that part-time contact and gradual-weaning conditions likely resulted in hunger and expectation for reunion, which together may have exaggerated behavioral responses at separation. Temporary daily separations may not have increased independence of cow and calf, and the gradual-weaning method here may not have reduced milk intake by calves. These elements are important criteria to facilitate the weaning process, so future work should explore ways to gradually reduce milk intake and promote social independence of cow and calf to minimize weaning distress.