Is shade for horses a comfort resource or a minimum requirement?

Shade or shelter as protection from extremes of weather is required for horses at agricultural research and teaching facilities and is recommended or required by many states, professional organizations, and industry groups. The focus of this paper is the recent research on the responses of horses to hot, sunny weather, which has begun to provide scientific evidence that characterizes how and when shade is used and any benefits shade confers on horses. These behavioral and physiological findings support provision of shade as a resource for thermal comfort and the expression of normal behavior that should be included as a standard of best care practices for healthy adult horses living in the environmental conditions reviewed, rather than an absolute minimum care requirement. Additional research is required for horses living under other environmental conditions, for very young or old horses, horses in very poor body condition, or those with compromised health to determine if their responses to hot, sunny weather differ from those presented here.

Technical Note: Evaluation of individual ultraviolet radiation dosimeter sensitivity and specificity for assessing shade use.

The effects of solar or UV radiation on livestock are often evaluated in research focused on heat stress, dermatological conditions, and other topics, with radiation measurements recorded by instrumentation at a field or local weather station for a general geographical location. Individual sensors would be valuable for quantifying an individual animal's exposure, especially as they move about in a heterogeneous environment. Individual commercially available UV dosimeters were evaluated for specificity and sensitivity and found to be potentially valuable research tools for assessing and comparing the UV radiation exposure of individual animals.

Effect of time and weather on preference, frequency, and duration of shade use by horses.

The Federation of Animal Science Societies (FASS) recommends providing access to shade for horses in hot, sunny weather at equine facilities. Previously, we found that healthy, mature domestic horses use shade with behavioral and physiological benefits during those weather conditions. The objective of this study was to characterize preference, frequency, and duration of shade use by healthy, mature horses in a Bureau of Land Management (BLM) holding facility during hot, sunny weather. The study took place at the BLM's Palomino Valley Wild Horse and Burro Center in Reno, NV, from Aug. 10 to Oct. 1, 2014. Freestanding shade structures were constructed in each of 2 drylot pens with shade cloth covering the top that blocked 98% of UV radiation. A group of 4 mares was placed in each of the 2 pens. After a 2-d acclimation period, data were recorded for 5 d, the horses were moved to the opposite pen, and data collected for an additional 5 d. This schedule was repeated for a total of 4 consecutive trials and 32 horses. Footage from time-lapse cameras was viewed at 10 s intervals between 0930 and 1700 h to record each horse's position relative to shade. Dosimeters secured to horses' halters recorded UV exposure. Automated weather stations recorded daytime ambient temperature (mean 25.9°C [SD 5.8]), relative humidity (mean 25.4% [SD 17.1]), black globe temperature (mean 29.3°C [SD 6.5] in shade and 35.8°C [SD 8.0] in unshaded area), and solar radiation (mean 595 W/m [SD 235]). Horses spent 10.9% more time in shade than by chance ( < 0.0001) within the drylots across all 40 study days. Mean daily time spent in shade was 107.9 min/horse (SD 66.9), comprising 17.1 bouts (SD 12.1) with an average bout length of 6.3 min (SD 3.4). The mean daily UV Index experienced by horses in these partially shaded drylots was 1.52 (SD 0.58) compared with 3.4 (SD 1.5) for a control instrument in the sun. Horses used shade more on the sunniest days and greater than just by chance at all hours of the day, with greatest use in the morning before peak ambient temperature. This study supports the FASS recommendation for provision of shade and may be useful in management and facility design for both domestic and captive wild horses.

Shade use by small groups of domestic horses in a hot, sunny environment.

Horses in the United States are commonly managed in outside pens or pastures in small groups. Limited research on shade use by domestic horses housed singly in individual pens has shown benefits and a preference for using available shade. The objective of this study was to examine the amount of shade use and the behavioral and physiological responses of small groups of horses when housed with access to shade (SH) and without access to shade (SUN). Thirty-six horses were randomized into 3 consecutive trials using 3 horses per group and 4 groups per trial. Groups experienced 5 d in each treatment in a crossover design. Weather factors were measured with automated sensors 24 h/d throughout the study. The mean afternoon ambient temperature was 31.0°C with relative humidity of 32%. Rectal temperature, respiration rate, and skin temperature were recorded at 1000, 1330, and 1900 h daily. Venous blood samples were obtained on Days 0 and 5 to measure serum cortisol, the neutrophil:lymphocyte ratio, and hematocrit. Behavioral observations for presence in shade, standing near or away from water, locomotion, and foraging were recorded at 5-min intervals from 1400 to 1900 h daily. Insect avoidance behaviors were recorded hourly during that same time period for 1 min/horse. Horses in the SH treatment were observed using shade in 7.1% of observations between 1400 and 1900 h, and behavioral differences were observed between the SH and SUN treatments. When in the SUN treatment, horses stood near the water troughs more (18.5 vs. 14.2% of observations; = 0.029) and foraged less (29.3 vs. 33.8% of observations; < 0.001) than when in the SH treatment. There were no treatment differences for other behaviors or for physiological measures ( > 0.05). Provision of shade structures accessible to groups of mature, healthy horses in hot, sunny environments should be considered in developing future guidelines for best management practices for horses.

Role of U.S. animal control agencies in equine neglect, cruelty, and abandonment investigations.

Every state in the United States has regulations prohibiting acts of neglect and cruelty against animals. Local law enforcement and animal control agencies are responsible in many communities to enforce these statutes. As society's perception of horses has changed from their origin as livestock to companion animals in modern times, owners have transitioned their care and management. The goal of this study was to identify the role and capacities of local animal control services in the United States that investigate equine neglect, cruelty, and abandonment investigations and to identify challenges and outcomes of the investigations. A 128-question online survey was accessible for animal agencies to complete. Comprehensive questions included their capacity for investigating equine cases, funding, housing for horses, and causes and outcomes of investigations. Respondents also were asked to select a single case and provide detailed information on the condition of horses, seizure and custody procedures, costs, and prosecution proceedings. A total of 165 respondents from 26 states completed all or the majority of the questions. A total of 6,864 equine investigations were initiated between 2007 and 2009 by 90 agencies, which extrapolates to 38 investigations annually per agency. A typical agency has an average annual budget of $740,000, employs 7 animal control officers, and spends about $10,000 annually on equine cases. Neglect was ranked as the most common reason for investigation. Owner ignorance, economic hardship, and lack of responsibility were the highest ranked causes of neglect and cruelty. Individual cases were provided by 91 agencies concerning 749 equines. The physical condition of the horse was the primary factor of investigation, and low body condition, parasite infestation, and compromised dental condition were present in most seized horses. Over half of the equine owners previously had been investigated or charged with neglect or cruelty of animals or were identified with cruelty or abuse offenses to people. Less than 3% of the cases advanced to adjudication, and these were likely to be decided by a judge rather than a jury. Judgments of guilty verdicts and pleas were 9 times more common than acquittal. Challenges for equine investigations cases included lack of funding, limited availability of facilities for horses, and providing educational materials for horse owners to aid in prevention and resolution of neglect cases.

Preference of domestic horses for shade in a hot, sunny environment.

Provision of shade is recommended by best practice guidelines for horses living in hot, sunny environments despite a lack of research focused on potential benefits. We found in a previous study that horses without access to shade showed greater rectal temperature (RT), respiration rate (RR), and skin temperature (SK) and exhibited more sweat than horses that were completely shaded. Yet not known is whether horses will choose to stand in the shade when given a choice of areas with and without this resource. Our objective was to assess horse preference for shaded and unshaded areas in the hot and arid, sunny summer weather in Davis, California. For this preference test, 12 healthy, adult horses (6 mares, 6 geldings) were randomized into 3 sequential trials using 4 horses in each trial. The trials consisted of 2 d of acclimation and either 5 d (Trial 1) or 7 d (Trials 2 and 3) of observation. Horses were housed individually in dry lot pens. Half of each pen was covered by an open-sided shade structure. The amount of the pen shaded varied slightly throughout the day with a mean of 50.1% of the pen shaded. Physiological measurements (RT, RR, SK, sweat score) were recorded at 0900, 1230, and 1800 h. Behavioral observations (horses' location relative to shade, time spent walking, foraging, and standing) were recorded at 5-min intervals from 1300 to 1800 h daily and at 10-min intervals from 1800 to 1300 h on alternate days. Insect avoidance behavior was recorded for 1 min/h for each horse. Weather factors were recorded every 5 min, 24 h/d throughout the study; mean daytime ambient temperature was 29 °C ± 5 °C. Data were analyzed using PROC MIXED in SAS. Horses were located in the shade in 7.1% more observations than by chance (SE = 1.3, P < 0.001), with greatest use before and during peak solar radiation and then again following peak black globe temperature. Horses performed more walking and foraging behavior in the shaded areas (P < 0.01). Our research indicates that individually housed horses prefer shade when it is available in hot, sunny environments. These results support recommendations for access to shade when developing best practice guidelines for the care of domestic horses.

Involvement of autophagy in cervical, endometrial and ovarian cancer.

Autophagy is an intracellular molecular pathway that maintains cellular homeostasis. A role for autophagy in the development as well as in the treatment of gynecologic malignancies, while still under-investigated, is receiving increased interest. Depending on concomitant factors, autophagy can either promote or suppress development of cervical, endometrial and ovarian cancer. Moreover, these cancer cells can utilize autophagy to promote its resistance to chemotherapeutic agents or, conversely, autophagy can enhance the efficacy of cytotoxic agents by promoting autophagic cell death. In this review the key autophagy-related mechanisms in development and treatment of cervical, endometrial and ovarian cancer are elucidated and evaluated.

Clinical outcomes of patients with adenocarcinoma in situ of the cervix treated by conization.

OBJECTIVE: To describe the clinical outcomes of histologically confirmed adenocarcinoma in situ (AIS) of the cervix treated with cervical conization. MATERIALS AND METHODS: A retrospective chart review of patients with histologically confirmed AIS from July 1998 to February 2011 included 52 patients. The rates of residual disease in subsequent excisions, the clinical recurrence rate, the average disease-free interval, and risk of progression to adenocarcinoma were described. The clinical outcomes of patients treated with cold knife cone (CKC) and loop electrosurgical excisional procedure (LEEP) were compared. RESULTS: Fifteen LEEPs and 37 CKC procedures were performed as initial treatment and 26 patients (50%) had positive margins. There was no significant difference in rate of positive margins between LEEP and CKC (40% vs. 54%, respectively. p = 0.55). LEEPs and CKCs resulted in similar volumes of cervical tissue resected (4.98 cm3 vs. 5.04 cm3, p = 0.40). Of patients with positive margins, ten underwent immediate hysterectomy, six underwent a second cone biopsy, seven were managed expectantly, and four were lost to follow up. Residual AIS was found in 47% (eight of 17) of repeat cone biopsy and hysterectomy specimens performed for positive cone margins. Of the 26 patients with negative cone margins, no residual or recurrent disease was found after an average follow-up of 32 months. CONCLUSIONS: A positive surgical margin was associated with residual disease in 47% of patients with AIS treated with conization. No patient with negative cone margins had recurrent or progressive disease. Cervical conization with negative margins appears to be a safe treatment option for patients with AIS but requires further investigation. CKC and LEEP were equally efficacious treatments in our study population.

Physiological, behavioral, and serological responses of horses to shaded or unshaded pens in a hot, sunny environment.

Housing recommendations for horses invariably include providing access to shade on hot, sunny days, but the potential benefits have not been scientifically studied. This experiment measured physiological, behavioral, and serological responses of horses confined individually to completely shaded (SH) or completely unshaded (SUN) drylot pens during the summer in Davis, CA. Twelve healthy adult horses in a crossover design experienced both treatments for 5 d each. Rectal temperature, respiration rate, skin temperature, and sweat scores were recorded hourly from 1230 to 1730 h daily. Observations were recorded from 1200 to 1800 h for proximity to water, foraging, locomotion, and insect avoidance behaviors. Daily blood samples were obtained to measure cortisol, hematocrit, and neutrophil-to-lymphocyte ratio. Automated and handheld sensors were used to record environmental conditions. The mean ambient temperature from 1200 to 1800 h during the study was 30.6 °C. Rectal temperature was greater for horses in SUN than for SH (mean 37.8 °C and 37.5 °C, respectively, SE = 0.06, P = 0.002) as was respiration rate (25.5 and 20.5 breaths/min, SE = 1.3, P = 0.008), and skin temperature (35.6 °C and 34.6 °C, SE = 0.1, P < 0.001). Horses in SUN showed sweat in 51.4% of observations vs. 1.1% for horses in SH. Horses in SUN spent more time than SH horses standing near their water source (34.0% of observations vs. 20.2%, SE = 0.3, P = 0.004). No differences were observed for foraging, locomotion, or insect avoidance behavior (P > 0.05). Cortisol concentrations were greater in SUN than SH (3.4 and 2.6 µg/dL, respectively, P < 0.001) but remained within the normal range for resting horses. No treatment differences were observed for hematocrit or neutrophil-to-lymphocyte ratio (P > 0.05). Horses exhibited treatment differences in the physiological measures first, most notably in rectal temperature at 1230 h, corresponding to peak solar radiation. Behavioral responses followed these physiological changes, with treatment differences in time standing near water becoming apparent at 1400 h as ambient and black globe temperature increased. Our results indicate that both the SH and SUN treatment groups exhibited thermoregulatory responses to these summer conditions and horses benefited from shade, as it mitigated these physiological and behavioral changes. These results are applicable in developing best management practices for the care of domestic horses.

Role of surgical staging and adjuvant treatment in uterine serous carcinoma.

PURPOSE OF INVESTIGATION: This study evaluates the association of clinical and pathologic characteristics of patients with uterine serous carcinoma (USC) with disease recurrence. MATERIALS AND METHODS: Surgically-staged patients with USC at a single institution were identified and clinical and pathologic variables were compared. RESULTS: Of the 51 patients included in this analysis, 75% percent received adjuvant chemotherapy, 51% received radiation therapy, and 47% received both. After a median follow-up of 33 months, 42% of patients had disease recurrence. On multivariable analysis, positive pelvic lymph nodes were associated with a shorter interval between surgery and recurrence: 13.6 months progression-free survival (PFS) with positive vs 17.2 months with negative lymph nodes (p = 0.05). Patients with early-stage disease who did not receive any adjuvant treatments had a significantly greater risk of disease recurrence (44.4% vs 7.70%, p = 0.043). CONCLUSION: In this population of surgically-staged patients with USC, pelvic lymph node metastases were predictive of a shorter PFS.

Unwanted horses: The role of nonprofit equine rescue and sanctuary organizations.

Closure of US equine slaughter facilities in 2007 along with the concomitant economic recession have contributed to a sharp increase in the number of unwanted horses throughout the United States, with estimates totaling 100,000 horses per year. The objective of the study was to obtain comprehensive data regarding nonprofit organizations caring for unwanted horses, along with the characteristics and outcome of horses relinquished to these organizations. Nonprofit organizations that accept relinquished equines were contacted to participate in a 90-question survey. Responding organizations (144 of 326 eligible) in 37 states provided information on 280 cases representative of the 7,990 horses relinquished between 2007 and 2009. Data collected characterized these organizations as being in existence for 6 yr, financially supported through donations and personal funds, dedicated to the care of only 10 to 20 horses on a property of just over 30 acres, and reliant on volunteers for help. Funding was the greatest challenge to continued operation of nonprofit equine organizations, with maintenance costs for the care of a relinquished horse averaging $3,648 per year. Financial hardship, physical inability, or lack of time to care for the horses by owners were the most common reasons for relinquishment, followed by seizure through law enforcement agencies for alleged neglect or abuse. Relinquished horses consisted of mostly light horse breeds (79.3%), with Thoroughbreds and Quarter Horses as the most represented breeds. The age of relinquished horses ranged from 3 d to 42 yr old (12.4 ± 0.5 yr). About one-half of the horses entered in the survey were considered unhealthy due to illness, injury, lameness, or poor body condition. For every 4 horses relinquished to a nonprofit organization, only 3 horses were adopted or sold between 2006 and 2009, and many organizations had refused to accept additional horses for lack of resources. The estimated maximum capacity for the 326 eligible registered nonprofit equine rescue facilities of 13,400 is well below the widely published estimate of 100,000 horses that become unwanted in the United States every year. Nonprofit equine rescue and sanctuary facilities have historically played an important role in safeguarding the welfare of horses in society, but funding and capacity are limiting factors to their potential expansion in continuing to care for the current population of unwanted and neglected horses in the United States.

A novel vaccine (Zostavax) to prevent herpes zoster.

Varicella-zoster virus is the causal agent of varicella and herpes zoster (HZ) in humans. HZ results from reactivation of latent varicella-zoster virus (VZV) within the sensory ganglia. The incidence and severity of HZ increase with advancing age; more than half of all persons in whom HZ develops are older than 60 years. The most frequent debilitating complication is postherpetic neuralgia, a neuropathic pain syndrome that persists or develops after the dermatomal rash has healed, and can be prolonged and disabling. There are many limitations of the current therapies for HZ and postherpetic neuralgia. A live attenuated VZV vaccine has been developed and recently approved by the United States Food and Drug Administration (FDA) and the European Union for the prevention of HZ in individuals 60 years of age and older. In a randomized, double-blind, placebo-controlled trial 38,546 adults of 60 years of age or older, the use of the HZ vaccine reduced the burden of illness due to HZ by 61.1% (P<0.001), reduced the incidence of postherpetic neuralgia by 66.5% (P<0.001), and reduced the incidence of HZ by 51.3% (P<0.001). In this review, the authors will discuss the history of the use of the varicella vaccine in children, and the subsequent development of the new HZ vaccine.

Cone biopsy and pathologic findings at radical hysterectomy in stage I cervical carcinoma.

OBJECTIVE: To examine the association between cone biopsy and pathologic findings at radical hysterectomy in stage I cervical carcinoma. METHODS: Fifty-four patients diagnosed by cone biopsy with stage I cervical carcinoma and treated with radical hysterectomy comprised the study group. The association between the depth of invasion on conization, lymph-vascular invasion, positive cone margins, positive endocervical curettage (ECC), and the depth of residual invasion in the radical hysterectomy specimen was examined using Pearson r and point biserial correlation. Independent predictors of the depth of residual invasion were determined by multiple regression. RESULTS: The depth of residual invasion correlated significantly with the depth of invasion (r =.374) and presence of lymph-vascular invasion (r(pb)=.372) in the conization specimen, post-cone ECC status (r(pb) =.669), and age at diagnosis (r =.347). The same factors were jointly assessed using multiple regression (R(2) =.636, P<.001). Depth of invasion on conization, lymph-vascular invasion, and ECC status were identified as independent predictors of the depth of residual invasion. Patients with deep (5 mm or greater) stromal invasion and lymph-vascular invasion on conization had significantly higher rates of positive parametrial margins (22% compared with zero, P =.001) and adjuvant radiation (66.7% compared with 20%, P =.004) compared with all other patients. CONCLUSION: Depth of invasion, presence of lymph-vascular invasion, and age at diagnosis were independent predictors of the depth of residual invasion in the subsequent hysterectomy specimen. These factors should be considered in treatment planning. Patients with a combination of these factors may have increased risk for deep residual invasion, positive hysterectomy margins, and adjuvant radiation.

Microcystic adnexal carcinoma of the vulva.

BACKGROUND: Microcystic adnexal carcinoma (MAC) is a subset of sweat gland carcinoma first described as a specific entity by D. J. Goldstein, R. J. Barr, and D. J. Santa Cruz (Cancer 1982;50:566-72). We report the first case of MAC occurring on the vulva and review the literature pertaining to this rare tumor. CASE: A 43-year-old multiparous black woman presented initially to Kings County Hospital Medical Center with a chief complaint of a vulvar lesion arising on the left labia majora which she had noted for 4 years prior to presentation. Aside from increasing paresthesia in the area, she denied any constitutional symptoms. Her past medical history was significant only for hyperthyroidism and mild hypertension and surgical history was noncontributory. Gynecologic history was unremarkable, with sporadic care over the last 20 years. Physical examination revealed a 1.5 x 2.0-cm raised, well-circumscribed, firm mobile lesion on the left labia majora. It was noted to be yellow in color with the surrounding tissue being unremarkable in character. The remainder of her gynecologic examination and lymph node survey was unremarkable. Preoperative chest X ray was negative as was the CAT scan of the abdomen and pelvis. All laboratory values were within normal limits. A Pap smear done preoperatively was significant for atypical squamous and glandular cells of undetermined significance. Subsequent colposcopic examination of the cervix was remarkable for cervicitis and was adequate, with the entire transformation zone visualized. Both endocervical curettage and endometrial biopsy were normal. Initially, an excisional biopsy was performed with final pathology demonstrating microcystic adnexal carcinoma with positive surgical margins. She subsequently underwent a left radical hemivulvectomy with bilateral inguinal groin lymph node dissection. At the time of surgery, the left labia majora was noted to be well healed, with a residual surgical scar easily discernible. No areas of discoloration were noted and digital palpation of the area was unremarkable. Microscopic residual tumor was noted; however, all surgical margins and lymph nodes were negative for tumor. Her postoperative course was unremarkable. The patient has continued to do well since the time of her surgery and is being followed conservatively. CONCLUSION: Radical vulvectomy should be performed when MAC occurs in the vulva to secure negative margins of resection. Groin dissection should be reserved for cases in which the inguinal lymph nodes are clinically suspicious or in cases of tumor recurrence.

60Cobalt vs. linear accelerator in the treatment of locally advanced cervix carcinoma: a comparison of survival and recurrence patterns.

OBJECTIVE: To compare the survival and recurrence patterns of patients with locally advanced cervical carcinoma treated with 60cobalt radiotherapy units and linear accelerators. METHODS: Two hundred and forty-eight patients with cervical carcinoma stages IIB-IVA who were treated with primary irradiation between the years 1985 and 1988 comprised the study group. The median survival of patients treated with 60cobalt units and linear accelerators was calculated using the method of Kaplan and Meier and compared using the log-rank test. Recurrence patterns were compared using chi-square analysis; p < .05 was considered significant for all tests. RESULTS: One hundred and ninety-five patients were treated with 60cobalt units (Group 1) and 53 patients were treated with a linear accelerator (Group 2). Group 1 and 2 were similar with regard to mean age and weight, stage distribution, and mean dose to point A. The rate of recurrence was comparable between Group 1 and 2 (65.6% vs. 64.2%) and no significant difference was found in overall survival between the groups (20 months vs. 21 months. p = 81). There was a trend toward increasing pelvic recurrence in Group 1 (50.8%) compared to Group 2 (35.8%, p = .08). CONCLUSIONS: 60Cobalt units and linear accelerators offer comparable rates of overall survival in patients with locally advanced cervix carcinoma.

Magnetic resonance imaging in the preoperative determination of tumor resectability in previously irradiated groin tumor.

We present an unusual case in which magnetic resonance (MR) imaging was utilized in the preoperative determination of resectability of a large inguinal tumor. The patient had previously presented with a large fungating, surgically nonresectable mass, which impinged upon the anterior ramus of the pubic bone. Following chemotherapy and radiation, the mass appeared more mobile and surgically resectable. Due to fibrosis and induration, the relationship of the tumor and underlying femoral vascular bundle were unclear. MR imaging clearly depicted that the tumor was sufficiently distant from the vessels, to allow safe resection with an adequate surgical margin. Resection was performed with clear lateral and deep margins. Histopathology demonstrated squamous cell carcinoma of the inguinal skin replacing subcutaneous tissue.

The cost to immunize during well-child visits.

The objective of this study was to determine the incremental labor costs or opportunity costs associated with the provision of immunizations in ambulatory care settings. A time and motion analysis of primary care health visits by pediatric patients was performed in 10 community clinics and 5 private primary care practices. These clinics and practices were located in areas designated as Health Professional Shortage Areas, with traditionally low immunization coverage rates and other unmet primary care needs. The outcome measure for this study was the comparative duration of the visit, contrasting well-child visits during which immunization was given with well-child visits during which no immunization was given. The results suggested that immunizations present an opportunity cost during well-child visits. The average time of patient-provider contact found in this study supports other findings showing that this time is now significantly longer than that reported in the past. In order for providers to comply with increased recommendations and requirements for preventive health care services, the allotted visit time, capitation rates, and overall clinic system effectiveness need to be reexamined.

Circadian temperature rhythms in clockwise and counter-clockwise rapidly rotating shift schedules.

The purpose of this study was to examine the circadian temperature rhythm in clockwise (CW) and counter-clockwise (CCW) rapidly rotating shift schedules. Arguments against the CCW rotation of shifts are that they result in shortened sleep and promote greater disruption of circadian rhythms. The 3-week study included a week of day shifts (0800-1600) and 2 weeks of shiftwork. The CW 2-2-1 schedule rotated from two early mornings (0600-1400) to two evenings (1400-2200) to one midnight shift (2200-0600) allowing 24 hours off at each shift rotation and a 48-hour weekend. The CCW schedule rotated from two evenings to two early mornings to one midnight shifts allowing only 8 hours off at each shift rotation and an 80-hour weekend. Analysis of the 72-hr periods at the end of each workweek, including the midnight shifts and recovery periods during weeks 2 and 3 were compared to the same 72-hour period at the end of week 1 (baseline). A cosine function that fit the temperature curves by minimizing the sums of squares produced parameters that underwent analysis of covariance procedures. Significant differences were found between rotation conditions for amplitude and acrophase. An attenuation of amplitude and a delay in the acrophase was the found for the counter-clockwise condition. Features inherent in this schedule might explain these effects, particularly, the increased opportunity for "sleeping in" at the beginning of the week and an expanded (2-shift) workday at the end of the week.

Applying workflow analysis tools to assess immunization delivery in outpatient primary care settings.

BACKGROUND: As health care organizations face increasing pressure to institute quality assurance activities, the already-underfunded community clinics that treat the poor and underserved are challenged to perform these activities within tight constraints of human and financial resources. With pediatric immunizations as a marker, a workflow observation tool was used to identify causal processes affecting immunization delivery. METHODS: Ten clinics and five private practices, located in areas designated as health professional shortage areas, participated in the study, gaining access to a tool that would have been unaffordable to them from the private sector. Trained observers followed families through the clinic, using a 127-item workflow observation form--the Observational Checklist of Patient Encounters (OCPE)--assessing discrete activities that families encountered during the checkin/pre-exam, exam, discharge, and billing processes. A convenience sampling of the targeted population--children younger than three years of age--included observations of scheduled acute, scheduled well-child, follow-up, and walk-in visits. In the feedback session, a summary of each clinic's immunization delivery patterns was presented, with an emphasis on the individual health center's operational issues. RESULTS: The workflow observation tool was used to identify operational errors affecting both clinical and fiscal processes in each of the clinics that had not been previously apparent to either clinic management or the quality improvement (QI) teams. DISCUSSION: Feedback addressed and encouraged process-oriented improvements in response to the workflow observations, which were incorporated into the clinics' QI procedures. Twelve of the 15 clinics have formed process action teams to address QI issues on an ongoing basis.