Dairy calf transportation in the United States: Challenges and strategies to improve animal welfare.

The objectives of this symposium review are to summarize relevant research and key welfare issues relative to calf transportation and identify strategies to mitigate welfare challenges. An important animal welfare concern across the US dairy industry is the transportation of preweaning calves from the source dairy to a calf-raising facility (e.g., calf ranches, heifer raising facilities, veal operations), auction, livestock market, or directly to slaughter. Millions of calves are transported annually in the United States and calf transport has garnered increased attention. Transportation stressors include limited (if any) access to food and water, commingling, environmental temperature changes, and a variety of handling techniques. Calves in the United States are often transported at an average age of 3 d, and in many cases, less than 24 h of age. Neonates are particularly vulnerable to transportation stressors due to their decreased ability to thermoregulate, underdeveloped immune system, and immature physiologic stress responses. In addition to age, fitness for transport is a key welfare consideration; recent data from the United States demonstrate that some source dairies transport compromised calves (i.e., dehydration, diarrhea, navel inflammation, and so on), leading to important welfare challenges during transportation. Calves arriving at US veal facilities have been reported to be dehydrated, lethargic, hypoglycemic, and may also have poor body condition, navel inflammation, and diarrhea. Thus, there is ample opportunity to target decision-making and producer-focused education not only at the source dairy, but also at each stage of transportation to address critical welfare concerns. In addition, the supply chain and procurement model that influence calf transport practices should be evaluated to determine potential opportunities to improve calf welfare. Here, we provide 5 potential strategies to improve the welfare of transported calves: (1) provide excellent newborn care that "preconditions" calves for transport, (2) assess calves' fitness-for-transport to ensure they can withstand the journey, (3) handle calves with care, (4) wait until calves are older to transport, and (5) reduce transport duration.

Preliminary exploration of the health and behavior around the time of transportation of beef × dairy calves and Holstein bull calves 3 days of age or younger in the western United States.

In the western United States, it is common practice for dairy and beef × dairy calves to be sold and shipped within the first few days of life, making transportation one of the first challenges that a calf will experience. To date, no published research has examined the effects of calf transport within the western United States. The objectives of this observational study were to describe the health status of calves leaving the source dairy, characterize transportation conditions and calf behavior during transportation, and determine if age at transportation and transportation duration are associated with dehydration, blood glucose and lactate, and behavior. An observational study was performed on 2 source dairies in the western United States. Initial enrollment consisted of dairy bull calves and beef × dairy calves (n = 126 total) across 16 transport cohorts which were sold and transported to separate calf-raising facilities approximately 80 km from the source dairy. Health exams and measurements were performed on all study participants 2 to 3 h before transport and ≤2 h after transport. Two researchers performed health exams using the Wisconsin calf health score, which included clinical respiratory scores, lung ultrasound, and fecal, navel, and joint scores. Hydration status was assessed using skin tent duration. Blood samples were collected and immediately analyzed for blood glucose and lactate using glucose and lactate meters. Accelerometers were attached at the source dairy on ≤10 calves in each of the 16 transport groups to record movement and behavior during transport (n = 90 had accelerometers attached). Results showed that about half of calves (49%) were identified with at least one health abnormality before transport. Researchers found an association between age and dehydration status in which calves <24 h of age were more likely to be dehydrated compared with calves 1 d of age. Additionally over half of the calves (56%) were identified as dehydrated after transport. To the authors' knowledge, this is the first observational study that investigates the effects of transportation on dairy bull and beef × dairy calf health and welfare in the western United States. Our findings support the need for improved management and decision making before transporting calves to reduce the negative effects of transport.

Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review.

BACKGROUND: People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence. METHOD: Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes. CONCLUSION: This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.

My assistive technology outcomes framework: rights-based outcome tools for consumers to 'measure what matters'.

AT outcomes research is the systematic investigation of changes produced by AT in the lives of AT users and their environments. In contrast to focal outcome measures, My Assistive Technology Outcomes Framework (MyATOF) envisions an alternative starting point, co-designing a holistic and evidence-based set of outcome dimensions enabling AT users to quantify their own outcomes. International classification systems, research evidence, regulatory and service delivery frameworks underpin six optional tools: supports, outcomes, costs, rights, service delivery pathway and customer experience. Designed to empower the consumer-as-researcher and self-advocate, MyATOF has the potential to fill an identified gap in policy-relevant, consumer-focussed and consumer-directed outcome measurement in Australia and internationally. This paper presents the need for consumer-focussed measurement and articulates the conceptual foundations of MyATOF. The iterative development and results of MyATOF use-cases collected to date are presented. The paper concludes with next steps in using the Framework internationally, as well as its future development.

Veterinarians' perspectives of pain, treatment, and diagnostics for bovine respiratory disease in preweaned dairy calves.

Background: Bovine Respiratory Disease (BRD) is a leading cause of morbidity and mortality in preweaned dairy calves. Early detection and therefore treatment are essential to minimize animal welfare concerns, particularly given that recent research also demonstrates that BRD is painful. Veterinarians are essential to ensuring calves with BRD receive appropriate treatment, but little to no research exists regarding veterinarians' perspectives about BRD detection and treatment in dairy calves. This is a critical step to determine education and outreach needs that can target BRD treatment to improve calf welfare. Thus, the objectives of the current study were to describe US veterinarians' current detection methods and treatment practices for BRD in preweaned dairy calves, understand veterinarians' rationale for treatment decisions, and identify gaps in knowledge regarding treatment and management of calf BRD. Methods: An online survey was sent to two veterinarian-focused list-serves and newsletter. Final responses (n = 47) were analyzed using qualitative and quantitative analyses. Results: On-farm necropsy was the diagnostic tool most considered "extremely important" (26, 55.3%). All veterinarians indicated that BRD was at least mildly painful. However, only 53% of veterinarians (n = 25) assess pain in preweaned calves with BRD in order to make treatment decisions. Furthermore, of the veterinarians that assessed pain, 40% (n = 10) reported that their knowledge of pain assessment and treatment was adequate, but most (n = 24) considered a calf's pain-level at least "moderately important" to make BRD treatment decisions. The most important ancillary therapy for antimicrobials were NSAIDs (21, 44.7%). The ancillary therapy most often considered "extremely important" for treating BRD was NSAIDs. Qualitative analysis identified the following as factors that influenced veterinarians' willingness to provide analgesia: the farm's willingness to administer drugs, clinical signs, perceived severity of pain, the need for anti-inflammatories, and the presence of fever and comorbidities. Discussion: This study included a small sample size and an extremely low response rate; results should therefore be interpreted with caution. Despite this limitation, important gaps in knowledge were identified, including pain assessment and consideration when making treatment decisions, and diagnostic tools. Addressing these needs in future research and outreach efforts could help ensure appropriate and timely treatment of calf BRD, including pain mitigation.

Short-term outcomes after primary reverse total shoulder arthroplasty in patients with cervical spine pathology or previous cervical spine surgery compared to those without.

BACKGROUND: Cervical spine (c-spine) and shoulder pathology have been known to cause similar symptoms and often co-exist, making an accurate diagnosis difficult, especially in an elderly population. Reverse total shoulder arthroplasty (rTSA) has been shown to decrease pain and improve quality of life when shoulder pathology is the source of pain and disability. The purpose of this study was to identify the prevalence of c-spine pathology in a cohort of patients who underwent rTSA and to compare postoperative outcome scores to a cohort without c-spine pathology. METHODS: A retrospective review was performed utilizing a single institution's operative records of primary rTSAs. Radiology reports, imaging, and operative reports were reviewed, and presence of any c-spine pathology or previous surgery were recorded. Additionally, postoperative outcome scores (American Shoulder and Elbow Surgeons [ASES], Constant Score, University of California, Los Angeles [UCLA], and Simple Shoulder Test [SST]) were evaluated at >2 years post-rTSA. RESULTS: A total of 438 primary rTSA cases were evaluated. Of these, 143 (32.6%) had documentation of prior c-spine pathology and/or history of previous c-spine surgery. After applying further exclusion criteria, a total of 50 patients with c-spine pathology and 108 patients without c-spine pathology were found to have complete medical records and postoperative outcome scores to allow comparison between groups. Patients without c-spine pathology were found to have statistically higher postoperative UCLA, ASES, and SST scores when compared to patients with c-spine pathology. Patients without c-spine pathology also demonstrated a significant improvement in the difference between their postoperative and preoperative UCLA and ASES scores. CONCLUSION: This study demonstrated a high prevalence of c-spine pathology (32.6%) in a cohort of patients who underwent primary rTSA. Additionally, short-term outcome scores of patients undergoing rTSA with concomitant c-spine pathology are significantly lower than those of patients without a history of c-spine pathology.

Dads in Distress: symptoms of depression and traumatic stress in fathers following poor fetal, neonatal, and maternal outcomes.

BACKGROUND: This study aims to explore the prevalence of symptoms of depression and traumatic stress in fathers in the setting of poor fetal, neonatal, and maternal outcomes. METHODS: A prospective mixed-methods study was conducted at an outer metropolitan public teaching hospital in Brisbane, Australia, with quantitative results presented here. Subjects included 28 fathers whose male partners had experienced pregnancy or childbirth complicated by a significant congenital abnormality or aneuploidy, termination of pregnancy, fetal death in-utero, stillbirth, admission to the neonatal intensive care unit or special care nursery or significant maternal morbidity, such as a postpartum haemorrhage or an emergency postpartum hysterectomy. These experiences were classified into two groups: anticipatory (time to prepare) and sudden (no warning). The fathers were screened using the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R) to assess subjective distress at 2-3 weeks (timepoint 1) and 3-4 months (timepoint 2) after the event. RESULTS: Data for both the EPDS and IES-R scales was available for 26 fathers (92.9%) at timepoint 1 and for 15 fathers (53.6%) at timepoint 2. High overall EPDS scores (≥10) were noted in 16/27 (59.3%) fathers at timepoint 1 and 6/15 fathers (40.0%) at timepoint 2. High overall IES-R scores ≥33 were noted in 12/26 (46.2%) fathers at timepoint 1 and 4/15 fathers (26.7%) at timepoint 2. A higher percentage of fathers who experienced anticipatory events had EPDS and IES-R score above these cut-offs at timepoint 1 (8/13 or 61.5%) compared to those experiencing sudden events (8/14 or 57.1%), however, percentages were similar between groups at time point 2 (2/7 or 28.6%% and 4/8 or 50.0%, respectively). More fathers who experienced anticipatory events had IES-R scores ≥33 at timepoint 1 (7/13 or 53.8%) compared to those experiencing sudden events (5/14 or 38.0%). CONCLUSION: Our study indicates high rates of distress in fathers exposed to poor fetal, neonatal, and maternal outcomes, which can persist for months after the event. Increased support for fathers in this setting may be required to prevent poor mental health. Further research on the long-term effects of these adverse events is warranted.

"It's a lot of pain you've got to hide": a qualitative study of the journey of fathers facing traumatic pregnancy and childbirth.

BACKGROUND: This study aims to explore the emotional and behavioural responses and coping strategies of fathers or expectant fathers who faced a significant traumatic event during a partner's pregnancy, labour, or the postpartum period. METHODS: This prospective qualitative study of 24 fathers was conducted at a public teaching hospital in Brisbane, Australia. 'Traumatic pregnancy' was defined as a pregnancy complicated by life-threatening or severe risk to the mother and the fetus, termination of pregnancy, intrauterine fetal death or stillbirth. Semi-structured interviews of participants were conducted 3-4 months after the traumatic event. An initial qualitative analysis with automatic coding was performed using Leximancer and later followed by a six-phase manual thematic analysis. RESULTS: A pregnancy-related traumatic event had significant mental and physical impacts on fathers. Participants' reactions and coping strategies were varied and influenced by their background history, pre-existing vulnerabilities, and the gap between expectation and reality. Most fathers described a fluctuating state between their needs 'not being met' and 'being met'. These needs were conceptualised using Maslow's hierarchy and Calman's gap theory to construct a composite thematic model to depict the universal requirements of men facing a traumatic pregnancy or childbirth. CONCLUSIONS: A greater understanding of the needs of men and gaps in their care is urgently needed. A targeted effort is required to make maternity services father-inclusive. This approach may assist in preventing long term consequences on fathers, partners, and their children.

Opioid requirements in primary versus revision reverse shoulder arthroplasty.

PURPOSE: The purpose of this study is to evaluate the inpatient pain medication use of patients who had a revision shoulder arthroplasty procedure performed and compare them to a cohort of patients who had a primary reverse total shoulder arthroplasty (rTSA) performed to determine whether revision shoulder arthroplasty requires more pain medication.. METHODS: A retrospective review was performed on patients undergoing revision arthroplasty (n = 75) and primary rTSA (n = 340). Inpatient medication records were reviewed to tabulate the visual analog pain (VAS) all narcotic medication use, and total morphine equivalent units (MEUs) were calculated for the duration of the inpatient stay. RESULTS: There was no significant difference between groups regarding age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, preoperative narcotic pain medication use, tobacco use, postoperative VAS scores or hospital length of stay. There were no predictors of total postoperative MEUs identified. Overall, patients in the revision arthroplasty group received significantly less total MEUs than those in the primary rTSA group, 134.96 MEUs vs. 69.79 MEUs, respectively (p < .0005). CONCLUSION: The perceived notion that revision shoulder arthroplasty is more painful may cause providers to be more inclined to increase narcotic use, or use more invasive pain control techniques. Based on these data, we found that revision shoulder arthroplasty did not require an increased opioid requirement, longer length of stay or increase VAS, suggesting that these patients can often be managed similarly to primary rTSA.

Use of electrocautery does not diminish the transmission rate of Cutibacterium acnes compared to a scalpel blade.

Many methods are used during shoulder surgery to prevent wound contamination with Cutibacterium acnes, but there are no accepted standards for prevention. Some surgeons use an electrosurgical instrument instead of a scalpel blade during open shoulder surgery in an effort to prevent deep tissue contamination with C. acnes. We sought to compare the transference rate of C. acnes between a scalpel blade at room temperature and an electrosurgical blade heated to 41°C (temperature of electrosurgical blade after standard deltopectoral approach). In our model, using a scalpel blade versus a heated electrosurgical blade resulted in no difference in pathogen transference.

Reducing post-caesarean delivery surgical site infections: a narrative review.

Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.

The forgotten father in obstetric medicine.

The role of fathers prior to conception, during pregnancy, and in the post-partum period has generally not been a key consideration for Obstetric Physicians. However, this view may need challenging. This paper outlines the key importance of fathers in all phases of obstetric medical care. We review the contribution of paternal factors such as genetics, health, and lifestyle to fetal development, pregnancy complications, and maternal and neonatal wellbeing. The role of fathers in complex care decisions during pregnancy is also reviewed. Postpartum, fathers have a substantial role in shaping the future of the family unit through encouraging breastfeeding and creating a supportive environment for motherhood. This review proposes areas for future research and recommends an evidence-based change in practice in obstetric medicine that focuses on recognizing the role of fathers in the pregnancy journey.

The effects of bolt length on penetration hole characteristics, brain damage and specified-risk material dispersal in finished cattle stunned with a penetrating captive bolt stunner.

The purpose of this study was to determine the effect of captive bolt lengths on penetration hole characteristics, brain damage, and specified risk material (SRM) dispersal. Cattle were stunned with a pneumatic captive bolt stunner using: standard (15.2 cm; STRD), medium (16.5 cm; MED), or long (17.8 cm; LON) bolts. Heads (N = 293) and exsanguination blood (N = 103) were collected for analyses. Penetration hole diameter and depth differed by treatment (P ≤ 0.004); both parameters were greatest for LON (P < 0.05). Presence of damage in frontal, parietal, and occipital lobes, olfactory bulb, and collective area including the corpus callosum, fornix and thalamus were impacted by treatment (P < 0.003). Treatment did not impact SRM dispersal (P = 0.33), determined by presence of glial acidic fibrillary protein. Data suggest that bolt length affects both the extent of brain damage and the specific structures damaged but all bolt lengths are successful in causing substantial brain damage and subsequent insensibility.

Young adult pregnancy status and the risk of developing overweight and obesity among women and men.

Pregnancies can end in miscarriage, birth or termination. Although it is well known that pregnancy results in weight gain across the life course, it is unknown whether pregnancies which end in termination and miscarriage contribute to this. The study used a sub-sample of 3630 adult offspring from the original cohort of the Mater University of Queensland Study of Pregnancy (MUSP) and its outcomes, in Brisbane, Australia. Anthropometric data were measured at 5, 14 and 21 years of age and experience of pregnancy including termination, miscarriage and births were self-reported at 21 years. Multivariable analyses were conducted to determine whether pregnancy status of young people independently associated with overweight or obesity status. The women who had at least one birth were more likely to have overweight (odds ratio [OR] 1.52; 95% confidence interval [CI]: 1.01, 2.27) or obese (OR 2.38; 95% CI: 1.58, 3.59) compared to women who did not experience any pregnancy. Women whose pregnancies were terminated or miscarried were at the same risk of overweight or obesity as women who did not experience any pregnancy. For men, there is no association between the pregnancies in their partners and the mean difference in their body mass index. Young women whose pregnancies result in a birth, but not terminations or miscarriages, are at greater risk of having overweight or obesity following the birth.

A review of blood pressure measurement in obese pregnant women.

Blood pressure monitoring is a critical component of antenatal, peripartum and postnatal care. The accurate detection and treatment of abnormal blood pressure during pregnancy is essential for the optimisation of maternal and neonatal outcomes. Increasing maternal obesity in western populations is well documented. The presence of a large arm circumference in obese pregnant women may lead to difficult and inaccurate blood pressure measurements. Difficulties measuring blood pressure in non-pregnant obese patients are well described. In the literature, the problem is uncommonly mentioned in relation to pregnant patients. This topic review will discuss the importance and challenges of blood pressure measurement in pregnancy. The currently available equipment for blood pressure monitoring in pregnancy will be identified and the process of validating devices described. The limitations of the current validation protocols in pregnancy will be highlighted. It is concluded that a pregnancy-specific validation protocol is required: this would facilitate the introduction of new technology for use in high-risk pregnant women. More accurate blood pressure measurement has the potential to improve the diagnosis and management of abnormal blood pressure in pregnancy and influence maternal and neonatal outcomes.

Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines?

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m2 and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".

Anaesthetists' experiences with the early labour epidural recommendation for obese parturients: a qualitative study.

Caring for obese pregnant women presents challenges for all medical professionals. Despite a lack of supporting evidence, expert opinion and international guidelines suggest early labour epidural insertion for obese women. Anecdotally this is not supported by all anaesthetists. This qualitative study explored the experiences of anaesthetists regarding early epidural analgesia in obese parturients, to answer the research question: Are anaesthetists consistent in how they apply early epidural analgesia in obese parturients? Personal in-depth interviews with 42 specialist anaesthetists working in south-east Queensland, Australia, were completed between February and April, 2015. Leximancer™ text analysis software applied a validated algorithm to the data to identify themes and concepts. The major themes were explored by the first author to answer the research question. Three major themes were identified: the demands associated with caring for obese women; concern regarding the anaesthetic technique used in obese women; and the importance of communication with obstetric staff. Disagreement regarding interpretation and application of early epidural analgesia was identified within this group of anaesthetists. These anaesthetists were inconsistent in how they interpreted and applied early epidural analgesia for obese parturients, with some questioning the validity of the practice. The combination of uncertainty, urgency and technical difficulty presented by obese parturients provoked anxiety in these clinicians, particularly the anticipation of unplanned general anaesthesia. Consistent anaesthetic practice could improve the implementation of early epidural analgesia in obese parturients.

Glycaemic behaviour during breastfeeding in women with Type 1 diabetes.

AIM: To describe glycaemia in both breastfeeding women and artificially feeding women with Type 1 diabetes, and the changes in glycaemia induced by suckling. METHODS: A blinded continuous glucose monitor was applied for up to 6 days in eight breastfeeding and eight artificially feeding women with Type 1 diabetes 2-4 months postpartum. Women recorded glucose levels, insulin dosages, oral intake and breastfeeding episodes. A standardized breakfast was consumed on 2 days. A third group (clinic controls) were identified from a historical database. RESULTS: Carbohydrate intake tended to be higher in breastfeeding than artificially feeding women (P = 0.09) despite similar insulin requirements. Compared with breastfeeding women, the high blood glucose index and standard deviation of glucose were higher in artificially feeding women (P = 0.02 and 0.06, respectively) and in the clinical control group (P = 0.02 and 0.05, respectively). The low blood glucose index and hypoglycaemia were similar. After suckling, the low blood glucose index increased compared with before (P < 0.01) and during (P < 0.01) suckling. Hypoglycaemia (blood glucose < 4.0 mmol/l) occurred within 3 h of suckling in 14% of suckling episodes, and was associated with time from last oral intake (P = 0.04) and last rapid-acting insulin (P = 0.03). After a standardized breakfast, the area under the glucose curve was positive. In breastfeeding women the area under the glucose curve was positive if suckling was avoided for 1 h after eating and negative if suckling occurred within 30 min of eating. CONCLUSIONS: Breastfeeding women with Type 1 diabetes had similar hypoglycaemia but lower glucose variability than artificially feeding women. Suckling reduced maternal glucose levels but did not cause hypoglycaemia in most episodes.