Historical and current molting practices in the U.S. table egg industry.

Induced molting is a management practice used primarily by commercial egg producers to optimize the utilization of their layer flocks. Historically, flocks produced eggs for a laying cycle of 1 yr duration and then were sold. With induced molting, flocks are molted and returned to lay for additional laying periods, thereby spreading fixed costs over longer time and more units of production. It is estimated that today more than 75% of all flocks are molted as a part of a regular replacement program. The decision to molt or to operate an all-pullet program is based upon comparisons of flock performance and prices for replacement pullets, eggs, and feed. Justification for the use of molting, therefore, is in the higher total productivity of flocks, reduced costs associated with production, and reduced industry investments in breeder farms, rearing farms, and hatcheries.

Egg marketing in national supermarkets: egg quality--part 1.

Two surveys were conducted to determine the quality of eggs offered to consumers in large supermarkets in various regions of the US. The first survey was conducted in California (CA) in 1994 and included 38 samples of large (L) and extra large (XL) white eggs in 15 markets. Individual eggs were weighed, candled, and broken out for Haugh unit (HU) determination. Regional differences in age of eggs, the number of eggs below 55 HU, and the percentage of cracked eggs were observed. The second survey was conducted in California (CA), Illinois (IL), Pennsylvania (PA), Texas (TX), North Carolina (NC), and New England (NE). This study included brown and white eggs and samples from 115 stores in 38 cities. Significant age, egg weight, HU, and cracked egg differences were observed between states. Brown and white eggs were different relative to age and HU, but egg weights and cracked eggs were statistically the same. The two surveys, 1994 and 1996, within CA demonstrated very similar measurements when L-white eggs were compared.

Egg marketing in national supermarkets: specialty eggs--part 2.

Large eggs promoted as having one or more features beyond conventional white or brown shell eggs (specialty eggs) were evaluated for quality and price in a national retail study. Subtypes of specialty eggs included: nutritionally altered eggs, organic eggs, fertile eggs, eggs from welfare-managed hens, or hens fed all-vegetable diets. Extension Poultry Specialists in California (CA), Connecticut, Illinois, North Carolina, Pennsylvania and Texas conducted a survey of egg quality and price and compared 246 dozen specialty eggs with 390 dozen conventional white shell eggs during the summer of 1996. Age of the eggs based on carton dating indicated specialty eggs were older (16.5 d) than white eggs (11.7 d). Average egg weights for specialty compared to white were 60.2 and 59.6 g, respectively. Interior egg quality evaluations including albumen height, Haugh units (HU), and percentage HU <55, indicated white eggs were superior (5.0 mm, 67.5, and 10.6%, respectively) compared to specialty eggs (4.7 mm, 63.8, and 16.3%). Although the percentage of cracked eggs was similar between specialty and white eggs (5.4 and 5.7%), the percentage of leakers was threefold higher for the specialty eggs (1.0 vs. 0.3%). Egg price was substantially higher for the specialty eggs, averaging $2.18/dozen with a range from 0.88 to $4.38, compared to white eggs, averaging $1.23/dozen and ranging from 0.39 to $2.35.

Egg marketing in national supermarkets: products, packaging, and prices--part 3.

As part of a national retail egg quality study, the variety of shell eggs and egg products offered for sale, type of packaging, and price relationships were compared in five major metropolitan regions. A total of 81 stores in 28 cities were sampled in California (CA), Illinois (IL), North Carolina (NC), Texas (TX), and New England (NE). Data were recorded for the variety of brands, sizes, white or brown shell eggs, specialty eggs, liquid or frozen eggs, carton sizes, package labeling and coding, and price relationships of shell eggs, liquid, and frozen egg products displayed for sale. The total variety of shell eggs displayed per store was the greatest for CA and NE stores. Stores in CA and TX offered more (P < 0.05) variety of white shell eggs than did stores in the other states, whereas stores in NE displayed the greatest variety (P < 0.05) of brown shell eggs. The average number of liquid and frozen egg products was highest (P < 0.05) for NC stores. Packaging type, USDA labeling, and carton coding differed somewhat among states. The price per one dozen cartons of all white shell egg sizes was highest (P < 0.05) in CA stores, and the average liquid plus frozen egg product prices were higher in CA and NE stores compared to the other states. However, the ratio of liquid and frozen product prices to all large shell egg prices was among the lowest for CA and NC stores. These data indicate that product selection, packaging, and consumer prices for shell eggs and egg products varied considerably across five separate regions of the country.

Postoperative laboratory and imaging investigations in intensive care units following coronary artery bypass grafting: a comparison of two Canadian hospitals.

OBJECTIVES: To compare the utilization and cost of common laboratory and imaging tests following admission to the intensive care unit (ICU) after coronary artery bypass surgery in two hospitals. The hospitals use different strategies to order tests postoperatively: one hospital uses a mandated protocol while the other does not. DESIGN: Demographic and testing data were prospectively collected in both hospitals as part of an ongoing ICU management program. Thirteen commonly performed laboratory tests or imaging procedures were compared. Average costs for each test were calculated, and utilization and cost of testing were compared per admission and per day in ICU. SETTING: Two tertiary care ICUs in different Canadian cities. PATIENTS: Consecutive patients admitted to ICU following coronary artery bypass graft surgery over a two-year period. MAIN RESULTS: There were 415 admissions to the Health Sciences Centre in Winnipeg, Manitoba and 504 to the Jewish General Hospital (JGH) in Montreal, Quebec. There were no demographic, length of stay or ICU mortality differences. A postoperative protocol for ordering investigations is used at JGH. Striking differences in test utilization were noted, with more investigations performed per admission and per unit day at JGH (P < 0.001). The average cost of the investigations was greater at JGH ($160 more per admission; $75 more per intensive care day). CONCLUSIONS: There are marked differences in the investigation pattern and costs for coronary artery bypass patients admitted to ICU in these hospitals. It is suggested that the benefits of frequent routine determinations of bloodwork, electrocardiograms and chest radiographs should be reevaluated in this patient population.

A citywide analysis of the utilization of common laboratory tests and imaging procedures in ICUs.

OBJECTIVE: To identify and discriminate between patient and institutional determinants of investigation costs in the ICU. DESIGN: Retrospective survey. SETTING: All seven hospitals in the city of Winnipeg, Manitoba, Canada. PARTICIPANTS: One hundred consecutive admissions to each of 11 ICUs. Two teaching hospitals (TH1 and TH2) each have three units (medical, surgical, and coronary care), the five community hospitals (CHs) have single combined units. TH1 operates an information-based management system. MEASUREMENTS: Each admission was categorized as MEDICAL, SURGICAL, or CARDIAC. The frequency and cost of 17 laboratory or imaging procedures were collected for each admission. Demographic data included age, length of ICU stay, APACHE II (acute physiology and chronic health evaluation) score, therapeutic intervention scoring system (TISS) data, and ICU survival. The primary diagnosis on admission and acquisition of significant problems or complications after admission were collected. RESULTS: Multivariate models revealed that length of stay, TISS score, and acquisition of a problem after ICU admission were strongly associated with increased costs in all categories (p=0.0001). Admission to TH2 was associated with greater costs in all categories (p=0.0001 MEDICAL and CARDIAC; p=0.0016 SURGICAL). Admission to a CH was associated with lower cost for SURGICAL admissions (p=0.0014), but costs at CHs were not significantly lower than at TH1 for MEDICAL (p=0.18) or CARDIAC (p=0.22) admissions. CONCLUSIONS: ICU investigation costs vary significantly between institutions and are not always linked to patient-dependent factors. Acquisition of nosocomial and iatrogenic events during ICU admission increases costs dramatically. Costs are not necessarily greater in teaching hospitals.

Intensive care unit admission following successful cardiopulmonary resuscitation: resource utilization, functional status and long-term survival.

A retrospective review of consecutive admissions (n = 285) to a university hospital intensive care unit (ICU) following cardiopulmonary resuscitation was conducted to determine long-term outcome, length of stay (LOS), and ICU resource consumption. Ninety-four patients (33%) survived to hospital discharge. Hospital survivors had longer ICU LOS than non-survivors (5.1 +/- 0.8 vs. 2.8 +/- 0.4 days, P < 0.001) and longer hospital stays (22.5 +/- 3.7 vs. 2.9 +/- 1.2 days, P < 0.001). Average laboratory and pharmacy costs per admission were greater in hospital survivors than non-survivors. Most patients returned to their pre-arrest homes functionally independent and 58% of hospital survivors were alive 2 years after discharge. It is possible that attempts to appropriately limit therapy in patients with poor prognosis may help direct resources towards patients who will benefit.

Eliminating needless testing in intensive care--an information-based team management approach.

OBJECTIVE: To determine if the application of an information-based management system in adult intensive care units (ICU) can produce sustained decreases in the use of laboratory resources and costs. DESIGN: Interventional study with prospective data collection on consecutive patients admitted during three time periods. SETTING: A 10-bed adult surgical ICU and an eight-bed adult medical ICU in a tertiary care hospital. PATIENTS: All patients admitted to an ICU during a 7-month baseline period (n = 647), a 1-yr intervention period (n = 1236), and a 2-yr follow-up period (n = 2349). INTERVENTIONS: Using a management database to track the use of 123 laboratory investigations during the baseline period, nine frequently ordered investigations (determination of blood gases, glucose, potassium, electrocardiogram, chest radiograph, sodium, chloride, complete blood count with differential, and serum osmolality) were targeted for reduction. Specific policies were developed by a multidisciplinary committee within the ICU to reduce the utilization of these laboratory, radiology, and cardiology tests. The policies were applied to all patients admitted during the 1-yr intervention period and during the 2-yr follow-up period. MEASUREMENTS AND MAIN RESULTS: A 25% reduction was observed in the frequency of all 123 monitored tests during the intervention period. The most dramatic reductions occurred in the nine targeted tests (range 19% to 46%) (p < .001). There were significant reductions in only 13 of the untargeted 114 investigations during this period. Potential annual cost savings were > $150,000 Canadian. No increases in ICU mortality rate, length of stay, or cost of medication were observed, and the reductions in the frequency of targeted tests were maintained during the 2-yr follow-up period. CONCLUSIONS: Application of an information-based multidisciplinary management system in the ICU can produce marked and sustained reductions in unnecessary testing in a cost-effective manner. Although rationing of intensive care services may be necessary, reducing needless testing can be a safe and effective cost-containment strategy in the ICU.

Hemodialysis access techniques.

Progression in hemodialysis technology and vascular access techniques has led to many patients remaining on chronic hemodialysis for significantly greater periods of time. The surgically constructed arteriovenous fistula at the wrist, mid-forearm, or antecubital fossa presents the most ideal and long-term angioaccess. Adequate radial or brachial arterial flow is mandatory for success, and moderate to large sized patent superficial arm veins are even more critical for immediate and long-term patency. A properly selected and constructed fistula has primary patency rates often exceeding five and ten years. Only 15 percent of the chronic renal failure population are candidates for arteriovenous fistula (autogenous) angioaccess. This percentage is significantly lower in the acutely ill hospitalized individuals who become semiurgent hemodialysis candidates. Resultantly, arteriovenous placement of a non-autogenous expanded PTFE graft has become the modern day mainstay for long-term chronic access construction.

First and second cycle egg production characteristics in commercial table egg flocks.

Egg production data for 1,231 first cycle and 887 second cycle commercial table egg layer flocks were studied to determine the shape of the production curve, the relationship between the two cycles, and the effects of strain and season on various measures of egg production. Means for peak egg production were 89.1 and 80.0%. Calculated slopes for the period from peak production to 60 wk of age and 40 wk postmolt were .596 and .671%/wk, and egg production levels at the end of each cycle were 71.2 and 61.7% for the first and second cycles, respectively. Egg production curves proved to be nonlinear with significantly greater slopes during the last 10 wk of each cycle compared with the earlier part of the cycle. This nonlinearity was shown to be associated with winter- and fall-hatched flocks for the first cycle of lay and with second cycle flocks that reached Week 30 in the spring and fall months. Calculated slopes averaged .565%/wk from peak to 50 wk of age compared with .655%/wk from 50 to 60 wk of age. Second cycle flocks had slopes of .590%/wk from peak to 30 wk postmolt compared with .819%/wk from 30 to 40 wk postmolt. Individual White Leghorn strains varied significantly in all measured traits with the exception of the calculated slope from peak egg production to Week 50 in the first cycle and from peak egg production to Week 30 in the second cycle.

Effect of beak-trimming age and high fiber grower diets on layer performance.

The performance of three commercial strains of White Leghorn layers was compared following beak trimming (BT) at 6 or 12 wk of age when fed diets containing 4.45 and 6.30% fiber between 6 and 12 or 12 and 18 wk of age, respectively. Body weights were lower at 12 wk in the 6-wk BT pullets, but were heavier at 18 wk when compared with the 12 wk BT pullets. Eighteen-week body weights were unaffected by feeding regimens. Six week BT resulted in higher hen-day and hen housed egg production, total egg mass, feed consumption, and total egg income. Profitability was superior for the 6-wk BT treatment (P = .072). Feeding the high fiber diets from 6 to 12 or 12 to 18 wk of age resulted in no differences in any of the adult performance traits measured compared with the control diet.

Intensive care management of pneumonia in the elderly.

Arterial hypoxemia, hypercapnic respiratory failure, hypotension, and depressed level of consciousness are the usual reasons for admitting a patient with pneumonia to an intensive care unit (ICU). Once the decision has been made to manage the patient in the ICU, age has little effect on the immediate goals of therapy, which include correction of hypoxemia, maintenance of adequate alveolar ventilation, and provision of sufficient blood pressure and cardiac output to support organ function until physiological homeostasis is restored as the pneumonia is controlled by appropriate antimicrobial therapy. Age-related decreases in physiological reserve are the major reasons specifically to consider ICU management of elderly pneumonia patients. These physiological changes increase the probability of major organ system failure with the development of pneumonia, and increase the likelihood that pneumonia will require ICU management. This has implications for the clinician regarding the selection and timing of therapeutic interventions. Unfortunately, the reduction of physiological reserve and the increased prevalence of coexistent chronic disease also result in significant mortality rates for elderly patients with pneumonia, potentially limiting the benefits of intensive care in this population. This raises a second issue: When, if ever, should intensive care not be used in the management of an elderly patient with severe pneumonia? A full discussion of the ethical issues surrounding this question is beyond the scope of this article, however, good medical ethics begin with sound medical judgment and are based upon solid clinical data. Accordingly, this article will also address the implications of age and underlying disease in the assessment of prognosis and use of the ICU in patients with pneumonia.

Selective use of arteriography in the assessment of aortic aneurysm repair.

Routine preoperative arteriography is advocated by many vascular surgeons before abdominal aortic aneurysm repair. We have used a selective approach based on the facts that arteriography is expensive, time-consuming, potentially hazardous, and often unwarranted. Based on preoperative indications, arteriography was used selectively in 41 of 100 consecutive patients prior to abdominal aortic aneurysmectomy. Many patients had more than one indication. A total of 82 specific indications were recognized. The most frequent indications were diminished lower extremity pulses (24), claudication (20), severe coronary artery disease (11), cerebrovascular disease (7), prior arterial reconstruction (8), hypertension in patients 60 years of age or less (5), evidence of other aneurysms (4), major renal anomaly (1), blue toe syndrome (1), and thoracic aneurysm (1). The 41 arteriograms produced 125 specific arteriographic abnormalities with an average of three per study. The most arteriographic abnormalities were in those patients with claudication and the least for those with hypertension. The arteriogram revealed information that would not have been obvious at operation, nor would it have led to operative procedure modification in only 10 patients. In the 59 patients not having arteriography, three had intraoperative findings which demanded a modification of the operative procedure. Thus, in only 13 patients was arteriography definitely useful. Presumably it was not indicated in the other 87. By comparing the cases in which the operation was modified with the presence of a specific indication, we have developed a predictability index as a guide for performing arteriography. Multiple indications increased the likelihood of operation modification only if four or more indications were present.

Antibasement membrane antibody disease without clinical evidence of renal disease.

A 20-yr-old man is described with the rare presentation of antibasement membrane antibody (ABMA) disease confirmed on renal biopsy, but with normal renal function and urinary sediment. This distinct subgroup of ABMA appears to have an excellent prognosis. The relevant literature is reviewed and summarized.

Arteriovenous graft life in chronic hemodialysis. A need for prolongation.

As long-term hemodialysis has become well accepted over the last 25 years, so has the need for more exacting and updated techniques for arteriovenous graft construction. The death rate for patients with chronic renal failure undergoing biweekly or triweekly hemodialysis was once generally 10% per year. This pertained to a small, highly selected group of good-risk younger patients. Advancement in dialysis technology and experience has failed to reduce this rate. Essentially, all patients (including ill, elderly, and high-risk patients) are now candidates for long-term hemodialysis. In many cases, prolonged patient survival has added new importance to the extension of arteriovenous graft life. Over the last five years, approximately 1300 arteriovenous graft salvage procedures and new constructions have been performed. Of these, 70% were thrombectomies and revisions for graft salvage. Simple thrombectomy and removal of accumulated neointimal hyperplastic material along the course of the PTFE graft, and especially at the graft-venous anastomotic junction, can often extend graft life another six months to one year or more and permit immediate usage postoperatively. Graft life is even more prolonged with patch angioplasty at venous outflow stenoses or by adding a new segment of PTFE to bypass areas of venous stenosis. Conservation of unused extremities for future arteriovenous graft construction is our goal.

Further studies on the prevalence of isolated sleep paralysis in black subjects.

In a previous study, one of the authors (C.C.B.) found isolated sleep paralysis was common in blacks. In this study, conducted by interviews, a recurrent pattern (one or more episodes per month) of isolated sleep paralysis episodes in blacks was described by at least 25 percent of the afflicted sample studied. Frequent episodes were associated with stress, and subjects with isolated sleep paralysis had an unusually high prevalence of panic disorder (15.5 percent). The genetic transmission of sleep paralysis was studied in a large black family, and in addition to stressful environmental factors being associated with the condition, there appears to be a dominant genetic factor associated with the predisposition for developing sleep paralysis. The implications of these findings for stress, anxiety, sleep, and psychophysiologic disorders are discussed.

Prolene sutures are not a significant factor in anastomotic false aneurysms.

Anastomotic false aneurysms have been a significant complication in vascular surgery, and the sutures used have been a major cause. Monofilament sutures have been indicated as contributing to the formation of false aneurysm. However, most of the monofilament sutures operative in the formation of false aneurysms have been made of polyethylene. Polypropylene, although significantly different from polyethylene, has been associated and possibly confused with it. Very few anastomotic aneurysms have resulted from breakage of polypropylene sutures. In this series of 2,400 vascular anastomoses in which polypropylene sutures were used, there were 10 false aneurysms; however, only one resulted from suture failure. In that patient, two Dacron grafts were anastomosed with 5-0 polypropylene suture. Polypropylene is a satisfactory and safe suture material for vascular anastomoses. It does not fragment or break easily when properly handled, and therefore is not a principal cause of false aneurysms.

Routine aortography before abdominal aortic aneurysmectomy. A prospective study.

Routine preoperative arteriography was studied prospectively in 104 patients with abdominal aortic aneurysms. The patients were from the private practice of 11 vascular surgeons. Information regarding patient clinical status was gathered and compared with aortographic and intraoperative findings. Special attention was focused on the question of operation modification as dictated by aortographic findings. The surgeons were further asked whether the information gained from surgical exploration was equal to that obtained from arteriography. It is concluded that because of low yield of benefit, economic considerations, time delay, and minor but distinct risks of the procedure, arteriography should be used selectively rather than routinely in such patients.