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OBJECTIVE: To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. METHODS: This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician-scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. RESULTS: Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. CONCLUSIONS: When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.

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The effect of deep brain stimulation on the two speech-production subsystems, articulation and phonation, of nine Parkinsonian patients is examined. Production parameters (stop closure voicing; stop closure, VOT, vowel) in fast syllable-repetitions were defined and measured and quantitative, objective metrics of vocal fold function were obtained during vowel production. Speech material was recorded for patients (with and without stimulation) and for a reference group of healthy control speakers. With stimulation, precision of the glottal and supraglottal articulation as well as the phonatory function is reduced for some individuals, whereas for other individuals an improvement is observed. Importantly, the improvement or deterioration is determined not only on the basis of the direction of parameter change but also on the individuals' position relative to the healthy control data. This study also notes differences within an individual in the effects of stimulation on the two speech subsystems. These findings qualify the value of global statements about the effect of neurostimulatory operations on Parkinsonian patients. They also underline the importance of careful consideration of individual differences in the effect of deep brain stimulation on different speech subsystems.

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The present study deals with the dimensions of normal and pathological phonation. Separation of normal voices from pathological voices is tested under different aspects. Using a new parametrization of voice-quality properties in the acoustic signal, the vowel productions of 534 speakers (267 M, 267 F) without any reported voice pathology and the productions of 534 gender-matched pathological speakers were considered. In a first step, a gender-specific separation of the two groups is supported by a number of significantly different parameter means. In a second step, a clustering technique differentiates three subgroups within each group and gender on the basis of the acoustic parameters. Further, a statistical examination of the correct assignment in the database (DB-classification) as "normal" or "pathological" shows that the two groups overlap to some extent. The overlap of speaker assignment indicates a phonation continuum through the multidimensional space extending from normal to pathological voices. The validity of a categorical distinction of normal and pathological phonation in the sense of an individual or group-orientated labelling of voice quality as "normal" or "pathological", respectively, is discussed.

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An 81-year-old female patient suffering from disabling Holmes' tremor affecting both upper extremities, the head and additionally the vocal apparatus underwent bilateral thalamic ventralis intermedius nucleus (v.i.m.) stimulation. With the stimulation ON, the patient experienced complete suppression of the limb and head tremor and thorough voice normalization. Acoustic and electroglottographic (EGG) analysis showed a tendency towards hyperfunctional phonation with the stimulation ON as well as OFF, but a less disturbed vocal cord vibration pattern with the stimulation ON in comparison with a group of normal female speakers. This example shows that long-term monitoring of the vocal apparatus under deep brain stimulation therapy (DBS) of movement disorders must be planned in order to modify the stimulation parameters, if necessary, or to initiate logopaedic treatment.

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The present study examines the effect of neurostimulatory operations on glottal phonation of 3 parkinsonian patients and 3 patients with multiple sclerosis. With the help of two voice analysis programs (MDVP from Kay Elemetrics and EEG Program by Marasek) for the acoustic and electroglottographic definition of voice characteristics, vowel productions of the patients, which were recorded under two conditions (with and without stimulation), were analysed. In a first step, significantly different intrasubject means in the two conditions indicate the effect of neurostimulation. The strength of the effect differs among subjects, particularly in the case of patients with Parkinson's disease. In a second step, a gender-differentiated comparison of the individual patient's data (recorded with and without stimulation) with a group of normal voice speakers (150 male and 150 female speakers) is carried out. This intersubject comparison proves useful in that it relativizes the results from the intrasubject comparison. It is shown for the parkinsonian patients that stimulation causes a relative deterioration of the glottal cycle, while for the patients with multiple sclerosis a tendency for hyperfunctional phonation is observed. In the latter case, the results suggest the need for long-term monitoring of phonation behaviour during chronic electrical stimulation.

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The results of seven breeding bird censuses on an upland site in Connecticut from 1953 to 1976 are analyzed and related to changes in vegetation and surrounding urbanization during the same period. Turnover of breeding bird species on the old-field portion of the site was due to vegetational changes that caused the extinction of species preferring open shrub habitats and the colonization of species preferring forest. Turnover of breeding birds on the forest portion was due to its increasing isolation from similar forest habitat, resulting in the local extinction of forest interior species and the colonization of species characteristic of suburban habitats. The study site is too small for the preservation of forest interior bird species. It must be coordinated with larger preserves in a regional context if it is to be useful in preventing the regional extinction of forest interior bird species.