Using the alkanes and long-chain alcohols of plant cuticular wax to estimate diet composition and the intakes of mixed forages in sheep consuming a known amount of alkane-labelled supplement.

In a feeding trial with 24 sheep, we used the alkanes, long-chain alcohols (LCOH) or both of these plant wax markers, to estimate the diet composition of animals offered diets comprising alkane-labelled cottonseed meal (CSM) together with up to four forages. The diets used were: Diet 1 subterranean clover (Trifolium subterraneum); Diet 2 subterranean clover + phalaris (Phalaris aquatica); Diet 3 subterranean clover, phalaris + annual ryegrass (Lolium rigidum); and Diet 4 subterranean clover, phalaris, annual ryegrass + wheat straw (Triticum aestivum). Estimates of diet composition were made following correction of faecal alkane or LCOH concentrations for incomplete faecal recovery, using recovery estimates derived from individual animals, mean recoveries for a given dietary treatment or grand mean recoveries. Estimated dietary proportions of CSM and known intakes of CSM were used to estimate forage intake. The LCOH concentrations of the diet components were much higher than their alkane concentrations, especially for phalaris. Multivariate analyses showed that the discriminatory information provided by the LCOH was additional to that provided by the alkanes, and that a combination of (LCOH + alkanes) discriminated better between diet components than either class of marker alone. Faecal recoveries of LCOH increased with increasing carbon-chain length; there were no differences in recovery attributable to diet. The most accurate estimates of diet composition were obtained with the combination of (LCOH + alkanes). Estimates of diet composition based on LCOH alone were not as good as alkanes alone, due to the high correlation between the LCOH profiles of phalaris and ryegrass. Total grass content of the diet was very accurately estimated using LCOH. Diet composition estimates provided estimates of whole-diet digestibility, which did not differ from the measured values. Trends in the accuracy of forage intake estimates reflected those found with diet composition and almost two-thirds of estimates based on (LCOH + alkanes) had lower error than those found with alkanes alone. The results confirm that supplements labelled with plant wax components can be used to estimate forage intake, and also show that the LCOH are useful markers for estimating diet composition. Intakes were also computed using a combination of natural LCOH concentrations in the diet and the daily dose rate of even-chain alkanes administered by intra-ruminal device. Differences between intakes so estimated and the measured intakes were closely related to the difference in faecal recovery between the LCOH/alkane pair used to estimate intake, by an amount close to that expected on theoretical grounds. It is concluded that the use of plant wax LCOH, especially in combination with alkanes, will result in improved estimates of diet composition and intake in grazing animals.

Faecal alkane recoveries from multi-component diets and effects on estimates of diet composition in sheep.

In a feeding trial with sheep, four animals each were fed one of the three roughages (perennial ryegrass (PR), meadow fescue (MF) and red clover (RC)) or one of the four different mixtures (g/day 250 : 250 : 250, 375 : 75 : 300, 525 : 187.5 : 37.5 and 75 : 525 : 150, respectively) of those three roughages, both with and without the inclusion of 100 g of beeswax-labelled barley. Further, four sheep received a pure lucerne diet to enlarge available data on single species faecal recoveries. All sheep except those fed single-component diets and the 250 : 250 : 250 roughage mix were administered intra-ruminal alkane controlled-release devices (CRD). The aim of the study was to investigate the effect of diet composition on faecal alkane recoveries, and to assess the accuracy of the alkane-based estimate of diet composition and intake based either upon a general set of faecal recoveries across diets or upon dietary recoveries and dietary samples more specifically attributable to individual dietary treatments. For each roughage component independently, the accuracy of diet composition estimates was assessed using linear regression across all diets. The estimates of the proportion of barley were analysed further using mean differences and mean prediction errors. Faecal alkane recovery increased with increasing chain length and was affected by diet composition. RC had a significantly higher faecal recovery for alkanes C25, C27, C29 and C31 than at least one of the other single-roughage diets. When considering mixed diets consisting of PR, MF, RC and barley, the composition of the roughage component significantly affected faecal recovery of all alkanes except C30 and C33. The inclusion of beeswax-labelled barley caused a decrease in faecal recovery of alkanes up to C29. This effect was attributable to the beeswax rather than the barley itself. By contrast, the decrease of faecal recovery of synthetic dosed alkanes from the CRD in diets containing barley, compared with the corresponding diets without barley, was attributable to the supplement itself. It was concluded that synthetic dosed alkanes behaved differently during gut transit from natural alkanes. The proportions of individual dietary components were estimated well over a wide range of proportions. Generally, the more information available, the more accurate the estimates achieved. However, a general set of faecal alkane recoveries and bulked samples of dietary components yielded estimates of diet composition sufficiently accurate for a large number of studies, especially in situations where groups of animals are of concern and not the individual animal.

A self-assessment program for multidisciplinary mental health teams.

OBJECTIVE: The authors describe a self-assessment training program for multidisciplinary mental health teams that was developed in a public multihospital system, the process of implementing the training at a state psychiatric hospital, and a measurement instrument, the Scale for Leadership Assessment and Team Evaluation (SLATE), which they have used for self-assessment of multidisciplinary teams and which is currently being studied. They assessed whether changes in team self-assessments could be seen after the training program. METHODS: A total of 102 mental health professionals from 12 inpatient units representing the disciplines of psychiatry, psychology, nursing, social work, and occupational and activity therapy completed the SLATE before and after participation in a training program that consisted primarily of team self-assessment in the context of treatment planning sessions. The training program included structured feedback, didactics, consultation, and videotaping of sessions. Aggregate data were used to compare mean item scores for the SLATE overall and for its four subscales (team, psychiatrist, participation, and treatment plan) at baseline and after the training. RESULTS: Scores increased significantly for the overall SLATE and for all four subscales, indicating improved team functioning in the areas addressed. The increase in mean score was greatest for the subscale that assessed the leadership of the psychiatrist. CONCLUSIONS: Treatment planning sessions can be used successfully by multidisciplinary mental health teams to examine team functioning in various areas in a self-assessment model. Participation in a training program that included videotaping of sessions, consultation, and structured attention to team functioning was associated with improved ratings of team functioning.

Clicking in the throat: cinematic fiction or surgical fact?

The complaint of a clicking in the throat when swallowing is uncommon but very discomforting and painful for those who experience it. It is such an unusual complaint that symptoms may be dismissed as psychogenic because a cause for the problem may not be readily apparent. We present a series of 11 cases in which all patients had an audible clicking or popping noise in the throat associated with neck and throat pain when swallowing or turning the neck. The most helpful diagnostic procedure was careful examination and palpation of the neck while the patient swallowed to localize the side and source of the clicking. Laryngeal computed tomographic (CT) scans helped in some cases to demonstrate thyroid-cartilage and/or vertebral body asymmetry. Each case was treated with surgery of the neck and larynx to trim the portion of the thyroid cartilage causing the clicking. In most cases the superior cornu of the thyroid cartilage projected posteriorly and medially. Surgery was successful in all cases to eliminate the symptoms. Though an uncommon complaint, our experience suggests that the clicking throat is a surgically treatable problem.

Alkanes as internal markers to estimate digestibility of hay or hay plus concentrate diets in horses.

Dry matter intake (DMI), dry matter digestibility (DMD), and fecal output (FO) are difficult to measure directly in the field, and indirect methods using external and internal markers have thus been developed. An experiment was conducted consisting of two digestion trials with two periods in each trial to examine the use of five odd-chain alkanes (C25 to C33) of plant cuticular wax as internal markers to estimate DMD of hay or hay plus concentrate diets in horses. Eight mature Thoroughbred geldings were housed in 4- x 4-m stalls and randomly assigned to one of two mixed grass/legume hays (Diets 1 and 2) in Trial 1 and to mixed grass/legume hay plus one of two concentrates (Diets 3 and 4) in Trial 2. After the first 12-d period was conducted, dietary assignments for each group were switched for the second period in each trial. Each period consisted of a dietary accommodation from d 1 to 7 and total fecal collection from d 8 to 11. Results indicated that fecal recoveries of odd-chain alkanes were 88 to 90% for Diet 1, 75 to 92% for Diet 2, 71 to 81% for Diet 3, and 71 to 82% for Diet 4. Alkane recoveries were not related to alkane chain lengths. Digestibilities calculated from alkane concentration data adjusted using the mean fecal recovery of individual odd-chain alkanes (DA1) were not significantly different from the digestibilities estimated from total collection (DTC) for Diets 1 and 2 in Trial 1 and Diets 3 and 4 in Trial 2. When adjustment was based on the mean recovery of all alkanes (DA2; estimated by linear regression), all DA2 estimates for horses offered all diets were similar to DTC. Results indicate that accurate mean estimates of DMD can be obtained by using plant wax alkane markers and adjusting for the mean recovery of five odd-chain alkanes in a diet.

An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial.

Teachers commonly report voice problems and often seek medical assistance for voice-related complaints. Despite the prevalence of voice disorders within this occupation, there are no studies evaluating the effectiveness of treatment programs designed to remedy the voice problems of teachers. To assess the functional effects of two voice therapy approaches, 58 voice-disordered teachers were randomly assigned to 1 of 3 groups: vocal hygiene (VH, n = 20), vocal function exercises (VFE, n = 19), and a nontreatment control group (CON, n = 19). Subjects completed the Voice Handicap Index (VHI)-an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders-before and following a 6-week treatment phase. The VFE and VH subjects also completed a posttreatment questionnaire regarding the perceived benefits of treatment. Only the group who adhered to the VFE regimen reported a significant reduction in mean VHI scores (p <.0002). Furthermore, when compared to the VH group, the exercise group reported more overall voice improvement (p < .05) and greater ease (p < .02) and clarity (p < .01) in their speaking and singing voice after treatment. These findings suggest that the VFE should be considered as a useful alternative or adjunct to vocal hygiene programs in the treatment of voice problems in teachers.

Benchmarking medical group practices using claims data: methodological and practical problems.

As claims data for physicians and groups of physicians has improved in quality and quantity, health information vendors have begun marketing information about medical groups' productivity, utilization, and quality. Based on interviews with product developers and our understanding of the evolution of their products, several methodological and practical issues remain. For now and the immediate future, health information vendors will continue to face the limitations of physicians' claims data. Vendors and purchasers should be aware of common data shortcomings such as inadequate monthly enrollment figures, possible physician upcoding to circumvent utilization management restrictions, and incorrect coding when a test is used to rule out a disease. In the longer term, several avenues seem likely to make medical groups' data better and richer because of computer-based medical records and efficiencies possible from the Internet. The field of benchmarking products for group practices is still an immature market. However, several trends suggest such products are highly desirable. Provider organizations which bear medical risk need benchmarking data to help improve their efficiency. There are many important nonprovider organizations that need good information on group practices' utilization patterns and outcomes to help them plan new products and negotiate with physicians.

Psychiatric leadership and the clinical team: simulated in vivo treatment planning performance as teamwork proxy and learning laboratory.

Leadership is an important consideration at many levels within behavioral healthcare systems. The authors developed a training program in a large public hospital system that focused on psychiatric leadership and clinical team functioning. In a learning laboratory format, they used videotaped patient simulations as a stimulus for multidisciplinary treatment planning sessions. Structured self-assessments were performed using a preliminary Scale for Leadership Assessment and Team Evaluation (SLATE). Videotaping the sessions provided an additional team self-assessment tool. Other educational activities supplemented the sessions, and teams proposed steps for transferring their learning to other units. The authors emphasize that leadership must foster team learning, which involves developing adaptive capacities and applying them to new clinical situations.

Episode Treatment Groups (ETGs): a patient classification system for measuring outcomes performance by episode of illness.

The Episode Treatment Group (ETG) methodology is a patented case-mix adjustment and episode-building system that uses routinely collected inpatient and ambulatory claims data. The resulting clinically homogenous groups, of which there are approximately 600, adjust for severity by the presence of complicating conditions, comorbidities, and other characteristics of a patient's condition that affect resource utilization.

Measurement of dietary nutrient intake in free-ranging mammalian herbivores.

The nutrient intakes of mammalian herbivores depend on the amount and the nutrient content of the plant species and plant parts which they eat. We review the merits of oesophageal-fistulated (OF) animals, microhistological procedures, stable C-isotope discrimination and plant cuticular-wax markers as methods for estimating diet composition and intake in both ruminant and non-ruminant herbivores. We also briefly discuss methods based on grazing behaviour measurements or on H2O or Na turnover, and methods for estimating supplement or soil intake. Estimates of intake in ruminants are often based on separate measurements of faecal output and herbage digestibility. We review this approach and emphasize that, under some circumstances, the applicability of in vitro digestibility estimates based on OF extrusa is questionable. We discuss how plant-wax marker patterns can be used to check whether OF and test animals are consuming similar diets, but also emphasize that a major advantage of the use of plant-wax markers is that this approach may obviate altogether the need for OF animals. Estimates of total herbage intake can be partitioned into the intakes coming from different plant species and/or parts, provided diet composition can be measured. Diet composition estimates based on C-isotope discrimination have the major disadvantage that they cannot be taken to species level. By contrast, microhistological methods can identify many plant species in extrusa, digesta or faeces, but often a large proportion of plant fragments remains unidentifiable. Plant-wax hydrocarbons show great promise as markers for estimating diet composition and intake. However, we suggest that to be applicable in complex plant communities there is a need with this method either to recruit a wider range of wax markers (e.g. alcohols, sterols, fatty acids) or to use it in combination with other methods. We suggest that, in turn, this generates an urgent need for research on statistical aspects of the combined use of markers or methods, in relation to the error structures of the data or methods being combined and the standard errors of the resultant estimates of diet composition and intake. We conclude by discussing the extension of intake and/or diet composition measurements to the measurement of nutrient transactions within the gut, particularly in relation to the supply of absorbable nutrients.

Postgraduate education and training in addiction disorders. Defining core competencies.

The rising prevalence of substance abuse disorders in the general medical population makes it essential that more active training be initiated during general residency training across all specialties. Core competencies for general residencies are outlined and the need for advocacy for continuation of postgraduate fellowship in Addiction Psychiatry is recommended as a means of increasing the numbers of faculty to provide leadership teaching and research in the area of Addiction Psychiatry.

Experimental approaches to vocal fold alteration: introduction to the minithyrotomy.

Treatment of challenging laryngeal disorders, such as lamina propria loss or neuromuscular dysfunction, may require novel approaches and techniques. This paper discusses an evolution of experimental techniques for treatment of lamina propria loss and use of the minithyrotomy. These techniques have been used for surgical access for lamina propria substitution, as well as placement of stimulating electrodes. The minithyrotomy is tolerated well by patients, provides access for microscopic instruments with the surgeon's hand close to the tissue of interest, avoids intralaryngeal mucosal incisions, and lines up the direction of dissection in an anterior-to-posterior orientation. This orientation is favorable for particular situations herein discussed. We present anatomic and physiologic concepts relevant to the surgical treatment of lamina propria dysfunction, as well as presenting our clinical experience. This paper is not intended to state how these difficult problems should be handled, but rather, to present our experience in techniques that may prove useful through further development.

Frequency and effects of teachers' voice problems.

This study compared the frequency and effects of voice symptoms in teachers to a group of individuals employed in other occupations. Teachers were more likely to report having a voice problem (15 vs. 6%), having 10 specific voice symptoms, and having 5 symptoms of physical discomfort. They averaged almost 2 symptoms compared with none for nonteachers. Likewise, teachers were more likely to perceive that a voice problem would adversely affect their future career options, had done so in the past, and was limiting their current job performance. Over 20% of teachers but none of the nonteachers had missed any days of work due to a voice problem. These findings suggest that teaching is a high-risk occupation for voice disorders and that this health problem may have significant work-related and economic effects.

Plant wax components: a new approach to estimating intake and diet composition in herbivores.

The nutrient status of the herbivore depends on the nutritive value of the plants available, the botanical composition of the consumed diet and the intake of the animal. It has always been difficult to quantify these last two. At present, intake is usually calculated from separate estimates of fecal output and diet digestibility. In this review we discuss the errors inherent in this approach, especially those associated with the determination and application of digestibility in vitro. We then critically evaluate a new approach to the estimation of intake, based on the use of plant cuticular wax alkanes as markers. Plant alkanes are predominantly odd-chain and substantially indigestible. They can be used, in combination with orally dosed even-chain alkanes, to obtain an intake estimate which is essentially independent of marker recovery in feces and which is more truly "individual" because it accommodates the level of digestibility occurring in individual animals. We present published data which indicate that the method is accurate and can be extended to measure diet composition as well. Previous approaches to estimating diet composition have been based on the laborious microscopic examination of esophageal extrusa, stomach contents or feces. However, most plant species have a characteristic pattern of alkane concentrations in their cuticular wax. This permits the estimation of diet composition from the pattern of alkanes in the feces and in the plants available. We present data to show that this approach can provide accurate estimates of diet composition in terms of either plant species or plant parts. A major advantage of the approach is that, if the animals are also dosed with even-chain alkanes, estimates of total intake and diet composition can be obtained simultaneously. The method is equally applicable to domestic and wild herbivores and to animals receiving supplementary feeds. In future work, the method will be extended to the simultaneous estimation of plant species and plant parts in the diet, and to the use of other wax components as markers.

The effect of exogenous somatotropin on lactation performance of first-litter sows.

To determine the effect of exogenous porcine somatotropin (ST) on lactation performance of sows, 24 first-litter sows were injected daily at 0800 with either 10 mg of recombinant ST or an equivalent volume of buffer between d 8 and 39 of lactation. Litter size was standardized to six (n = 2), seven (n = 8), eight (n = 6), or 10 (n = 8) pigs within each pair of sows by fostering pigs within a few days after parturition. Milk yield and composition of sows given ST was similar at all stages of lactation to that of control sows. Combining treatment data revealed that the milk yield of sows was related linearly (P < .01) to litter size and was described with the following equation: MY = 1.03 (+/- .71) + .899 (+/- .102) LS (n = 24, r2 = .78), where MY is average milk yield (kilograms/day) of sows over 4 to 7, 11 to 14, 18 to 21, 25 to 32, and 32 to 39 d of lactation and LS is number of pigs in the litter. The body temperature of sows increased (P < .05) in response to administration of ST. Plasma IGF-I and glucose were increased (P < .05) by ST, but plasma urea concentrations were lower (P < .05) in ST-treated sows. Sows treated with ST lost more backfat (P < .05) during lactation, but neither voluntary feed intake nor body weight loss was significantly (P > .05) affected by ST. These data indicate that a 10-mg daily injection of ST from d 8 to 39 of lactation alters metabolism but does not increase milk production in lactating first-litter sows.

Helping financial analysts communicate variance analysis.

Healthcare organizations often use variance analysis to explain variation between planned and actual costs and charges. This type of analysis is becoming even more common as healthcare executives work to improve efficiency, to set priorities for organizational improvement as part of strategic planning, and to explain costs and charges to interested groups such as purchasers and payers. Variance analysis produces data that must be presented in a format useful to senior executives. An effective format would express the data in a visual summary that is simple enough to be readily understood and detailed enough to provide valuable information.

Arytenoid separation for impaired pediatric vocal fold mobility.

Impaired vocal fold motion may result from cricoarytenoid joint fixation, bilateral vocal fold paralysis, or interarytenoid scarring. Traditional surgical techniques have focused on lateralization or resection of the arytenoid for airway improvement. This paper discusses 3 cases of bilateral reduced vocal fold motion of neurogenic cause treated with posterior cricoid grafting to cause a wider resting position of the vocal folds and arytenoids. Airway improvement occurred in all. The voice results have been encouraging. Advantages of this procedure are that the vocal folds are symmetric, there is no vocal fold or joint scarring, and the larynx remains a candidate for electrical pacing when that becomes available. Acoustic and aerodynamic voice results are presented. The results should be considered preliminary.

Use of the resource-based relative value scale for private insurers.

Medicare's resource-based relative value scale (RBRVS) was implemented 1 January 1992 for physician payment using a conversion factor of $31 for each relative value unit (RVU). We calculated a conversion factor of $42.24 for The Travelers Insurance Company's group health plan business using the RBRVS methodology and the calendar year 1990 Travelers Large Case Norms Extract of active employees. This DataWatch describes two important applications of the relative value scale for private insurers: for pricing and for analyzing claims expenditures.

The response of first-litter sows to dietary protein level during lactation.

Thirty-six sows were used to study responses of milk production, milk composition, and N balance to six concentrations of dietary CP ranging from 63 to 238 g/kg (4.4 to 15.1 g of lysine/kg) during the first lactation. Sows, on average, were 149.3 kg live weight and had 26.1 mm of back fat at P1 (which is 45 mm from the midline at the level of the last rib) immediately after parturition. During lactation, all sows suckled nine pigs each and were offered up to 4,000 g of feed daily; diets contained similar balances of amino acids and similar amounts of DE (3.56 to 3.63 Mcal/kg). Nitrogen balance trials were conducted during early and late lactation and 5-d collection periods commenced on d 10 and 24 of lactation, respectively. During both periods of lactation, there were significant positive linear relationships between the level of dietary protein and milk yield and contents of fat and total solids in milk. Milk yield increased from 7.79 to 9.91 kg/d and from 7.02 to 8.90 kg/d, whereas total solids in milk increased from 199 to 225 g/kg and from 202 to 228 g/kg during early and late lactation, respectively, in response to increasing level of dietary protein from 63 to 238 g of CP/kg. A two-phase linear regression model used to describe the relationship between N balance and dietary CP level established that sows required a diet containing > or = 202 g of CP/kg or 12.8 g of lysine/kg to maximize N balances during both stages of lactation.(ABSTRACT TRUNCATED AT 250 WORDS)