An examination of the effects of labor efficiency on the profitability of grass-based, seasonal-calving dairy farms.

The seasonality of grass-based, seasonal-calving dairy systems results in disproportionately higher labor demands during the spring, when cows are calving, than in the remaining seasons. This study aimed to (1) examine the relationship between labor efficiency and profitability; (2) investigate strategies to reduce the hours worked per day by the farmer, family, and farm staff in the spring by having certain tasks outsourced; and (3) quantify the economic implications of those strategies. Data from an existing labor efficiency study on Irish dairy farms were used in conjunction with economic performance data from the farms. Tasks that required the highest level of farm labor per day in the spring were identified and hypothetical strategies to reduce the farm hours worked per day were examined. A stochastic budgetary simulation model was then used to examine the economic implications of employing these strategies and the effects of their use in conjunction with a proportionate increase in cow numbers that would leave the hours worked per day unchanged. The strategies were to use contractors to perform calf rearing, machinery work, or milking. Contracting out milking resulted in the greatest reduction in hours worked per day (5.6 h/d) followed by calf rearing (2.7 h/d) and machinery work (2 h/d). Reducing the hours worked per day by removing those tasks had slight (i.e., <5%) negative effects on profitability; however, maintaining the farm hours worked per day while utilizing the same strategies and increasing herd sizes resulted in profitable options. The most profitable scenario was for farms to increase herd size while contracting out milking.

Longitudinal assessment of von Willebrand factor antigen and von Willebrand factor propeptide in response to alteration of antiplatelet therapy after TIA or ischaemic stroke.

The impact of commencing or changing antiplatelet therapy on von Willebrand factor antigen (VWF:Ag) and von Willebrand factor propeptide (VWF:Ag II) levels has not been comprehensively assessed following TIA or ischaemic stroke. In this pilot, longitudinal, observational analytical study, VWF:Ag and VWF:Ag II levels were simultaneously quantified in platelet poor plasma by ELISA in patients within 4 weeks of TIA or ischaemic stroke (baseline), and then 14 days (14d) and >90 days (90d) after altering antiplatelet therapy. Ninety-one patients were recruited. Eighteen were initially assessed on no antiplatelet therapy, and then after 14d (N = 17) and 90d (N = 8) on aspirin monotherapy; 21 patients were assessed on aspirin and after 14d and 90d on clopidogrel; 52 were assessed on aspirin monotherapy, and after 14d and 90d on aspirin and dipyridamole combination therapy. VWF:Ag, VWF:Ag II levels and VWF:Ag/VWF:Ag II ratio were unchanged at 14d and 90d in the overall study population (p ≥ 0.1). VWF:Ag and VWF:Ag II levels remained stable at 14d and 90d after commencing aspirin (p ≥ 0.054), and after changing from aspirin to clopidogrel (p ≥ 0.2). Following the addition of dipyridamole MR to aspirin, there was a significant reduction in VWF:Ag levels at 14d (p = 0.03) and 90d (p = 0.005), but not in VWF:Ag II levels (p ≥ 0.3). The addition of dipyridamole to aspirin led to a persistent reduction in VWF:Ag but not in VWF:Ag II levels, suggesting that dipyridamole may inhibit release of platelet-derived VWF:Ag following TIA or ischaemic stroke.

Longitudinal assessment of thrombin generation potential in response to alteration of antiplatelet therapy after TIA or ischaemic stroke.

The impact of changing antiplatelet therapy on thrombin generation potential in patients with ischaemic cerebrovascular disease (CVD) is unclear. We assessed patients within 4 weeks of TIA or ischaemic stroke (baseline), and then 14 days (14d) and >90 days (90d) after altering antiplatelet therapy. Thrombin generation was assessed in platelet poor plasma. Ninety-one patients were recruited. Twenty-four were initially assessed on no antiplatelet therapy, and then after 14d (N = 23) and 90d (N = 8) on aspirin monotherapy; 52 were assessed on aspirin monotherapy, and after 14 and 90 days on aspirin and dipyridamole combination therapy; 21 patients were assessed on aspirin and after 14 days (N = 21) and 90 days (N = 19) on clopidogrel. Peak thrombin generation and endogenous thrombin potential were reduced at 14 and 90 days (p ≤ 0.04) in the overall cohort. We assessed the impact of individual antiplatelet regimens on thrombin generation parameters to investigate the cause of this effect. Lag time and time-to-peak thrombin generation were unchanged at 14 days, but reduced 90 days after commencing aspirin (p ≤ 0.009). Lag time, peak thrombin generation and endogenous thrombin potential were reduced at both 14 and 90 days after adding dipyridamole to aspirin (p ≤ 0.01). Lag time was reduced 14 days after changing from aspirin to clopidogrel (p = 0.045), but this effect was not maintained at 90 days (p = 0.2). This pilot study did not show any consistent effects of commencing aspirin, or of changing from aspirin to clopidogrel on thrombin generation potential during follow-up. The addition of dipyridamole to aspirin led to a persistent reduction in peak and total thrombin generation ex vivo, and illustrates the diverse, potentially beneficial, newly recognised 'anti-coagulant' effects of dipyridamole in ischaemic CVD.

Effect of socioeconomic deprivation and the appointment of Welfare Attorneys.

Most patients in intensive care unit (ICU) lack decision-making ability. The Adults with Incapacity (Scotland) Act 2000 allows someone to appoint a Welfare Attorney (WA) to act on their behalf should they lose capacity. Scotland has areas of major socioeconomic deprivation associated with lower life-expectancy and with a lack of knowledge about and consequently difficulty accessing services. The effect of socioeconomic deprivation on WA registration was investigated. A complete list of registered WAs was categorized by deprivation. The Public Guardian, Scotland indicated whether patients admitted to ICU at Glasgow Royal (April 2006-May 2009) had a WA registered. All Scottish ICU admissions (2004-2008) were categorized by deprivation. Twelve of 1152 ICU patients at Glasgow Royal had a WA. Of 165,997 WAs registered, 5984 were in the most deprived and 27,970 in the most affluent areas. Overall, 3.9% of the Scottish population had a WA (1.4% in the most, 6.5% in the least deprived population decile). In conclusion, the uptake of WAs was low, especially in deprived areas. The reasons could include a lack of knowledge, not anticipating the need for a WA or not being confident in the process. Any educational package needs to target the most socioeconomically disadvantaged.

Liaison neurologists facilitate accurate neurological diagnosis and management, resulting in substantial savings in the cost of inpatient care.

BACKGROUND: Despite understaffing of neurology services in Ireland, the demand for liaison neurologist input into the care of hospital inpatients is increasing. This aspect of the workload of the neurologist is often under recognised. AIMS/METHODS: We prospectively recorded data on referral and service delivery patterns to a liaison neurology service, the neurological conditions encountered, and the impact of neurology input on patient care. RESULTS: Over a 13-month period, 669 consults were audited. Of these, 79% of patients were seen within 48 h and 86% of patients were assessed by a consultant neurologist before discharge. Management was changed in 69% cases, and discharge from hospital expedited in 50%. If adequate resources for neurological assessment had been available, 28% could have been seen as outpatients, with projected savings of 857 bed days. CONCLUSIONS: Investment in neurology services would facilitate early accurate diagnosis, efficient patient and bed management, with substantial savings.

Patient mobile telephone 'text' reminder: a novel way to reduce non-attendance at the ENT out-patient clinic.

BACKGROUND: Non-attendance at out-patient clinics is a seemingly intractable problem, estimated to cost 65 pounds sterling (97 euros) per incident. This results in under-utilisation of resources and prolonged waiting lists. In an effort to reduce out-patient clinic non-attendance, our ENT department, in conjunction with the information and communication technology department, instigated the use of a mobile telephone short message service ('text') reminder, to be sent out to each patient three days prior to their out-patient clinic appointment. OBJECTIVE: To audit non-attendance rates at ENT out-patient clinics following the introduction of a text reminder system. STUDY DESIGN: Retrospective review. METHODS: Non-attendance at our institution's ENT out-patient clinics was audited, following introduction of a text message reminder system in August 2003. Rates of non-attendance were compared for the text message reminder group and a historical control group. RESULTS: Before the introduction of the text message reminder system, the mean rate of non-attendance was 33.6 per cent. Following the introduction of the system, the mean rate of non-attendance reduced to 22 per cent. CONCLUSION: Sending text message reminders is a simple and cost-effective way to improve non-attendance at ENT out-patient clinics.

In-flight medical emergencies: response of anaesthetists who were passengers on commercial flights.

All consultants and trainees in anaesthesia in a large teaching hospital were surveyed. Details of the number of flights per year and details of any medical emergencies in which they had been involved were recorded. The mean number of flights per year was 7.1 domestic and 3.4 international. Of the 45 anaesthetists surveyed, 14 had dealt with emergencies in flight, four had dealt with more than one. The minor emergencies (12) included transient ischaemic attacks, abdominal pain and otitis media. The seven serious events included seizures, angina, hypoglycaemic coma, respiratory arrest and two fatal cardiac arrests. No flights were diverted. On only two occasions were their medical qualifications checked. Requests for documentation were unusual. On several occasions the equipment which was available was inadequate. All doctors that responded were insured in the UK and most stated that they would assist Americans on American airlines. Medical emergencies were more likely on long haul flights.

Impact of new treatments for neonatal pulmonary hypertension on extracorporeal membrane oxygenation use and outcome.

OBJECTIVE: To determine the impact of new treatment modalities, including high-frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (INO), on extracorporeal membrane oxygenation (ECMO) use and outcome of neonatal patients with persistent pulmonary hypertension of the newborn. STUDY DESIGN: We reviewed the medical records of neonatal patients meeting established ECMO criteria from 1988 to 1995. Clinical data were gathered from this retrospective chart review. Comparison of ECMO experiences were made between the 1988-90 period (pre-HFOV and INO, or period 1) and the 1993-95 period (HFOV and INO fully established as treatment modalities, or period 2). RESULTS: One hundred three patients were treated with ECMO during the 8-year study period. After HFOV and INO were introduced in 1991 and 1992 respectively, the number of patients meeting established ECMO criteria who subsequently required ECMO therapy progressively declined, from 22.3 +/- 2.3 (mean +/- SD) patients per year during period 1 to 12 patients in 1991 when HFOV was introduced, 8 patients in 1992 when INO was introduced, and 5.3 +/- 2.9 patients per year in period 2. The number of patients referred for ECMO over time did not change. Survival after ECMO dropped from 84% during period 1 to 56% in period 2. Introduction of new pre-ECMO therapies has not delayed institution of ECMO, significantly increased the length of ECMO runs, or lengthened the hospital course of ECMO survivors. A comparison of the eight infants treated with ECMO in 1992 with the 10 infants treated with INO in 1993 showed a longer hospital stay and a larger average patient bill for the patients treated with ECMO. CONCLUSION: New treatment approaches for severe persistent pulmonary hypertension have reduced ECMO use, shortened the duration of hospitalization, and reduced costs for those infants responding to HFOV and INO. However, survival of patients requiring ECMO therapy has decreased.

Effects of legal pressure on prognosis for treatment of drug dependence.

The authors found that four measures of legal pressure were either unrelated or negatively related to retention and outcome in five drug abuse treatment modalities. This suggests that nonvolunteer clients are likely to be insufficiently motivated to benefit fully from treatment and their presence may adversely affect staff morale and prognosis of volunteer clients. The authors recommend that legal pressure not be used as a basis for assigning applicants to treatment modalities and suggest that treatment outcome might be improved by procedures that 1) deal clinically with motivational differences between volunteers and nonvolunteers, 2) establish stricter motivational criteria for admitting nonvolunteers, or 3) encourage enforcement of existing sanctions against violations of stipulations to treatment.