Longitudinal point prevalence survey of antibacterial use in Northern Ireland using the European Surveillance of Antimicrobial Consumption (ESAC) PPS and Global-PPS tool.

Antimicrobial resistance is a limiting factor for the success of the treatment of infectious diseases and is associated with increased morbidity and cost. The present study aims to evaluate prescribing patterns of antimicrobials and quantify progress in relation to targets for quality improvement in the prescription of antimicrobials in Northern Ireland's secondary care sector using three repetitive point prevalence surveys (PPS) over a 6-year period: the European Surveillance of Antimicrobial Consumption (ESAC-PPS) in 2009 and 2011 and the Global-PPS on Antimicrobial Consumption and Resistance in 2015. Out of 3605 patients surveyed over the three time points, 1239 (34.4%) were treated with an antibiotic, the most frequently prescribed antibiotic groups were a combination of penicillins, including ß-lactamase inhibitors. Compliance with hospital antibiotic policies in 2009, 2011 and 2015 were 54.5%, 71.5% and 79.9%, respectively. Likewise, an indication for treatment was recorded in patient notes 88.5%, 87.7% and 90.6% in 2009, 2011 and 2015, respectively, and surgical prophylactic antibiotic prescriptions for >24 h was 3.9%, 3.2% and 0.7% in 2009, 2011 and 2015, respectively. Treatment based on biomarker data was used in 61.5% of cases. In conclusion, a general trend in the improvement of key antimicrobial-related quality indicators was noted. The PPS tool provided a convenient, inexpensive surveillance system of antimicrobial consumption and should be considered an essential component to establish and maintain informed antibiotic stewardship in hospitals.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'.

OBJECTIVES: To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease. METHODS: As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status. RESULTS: 3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)). CONCLUSIONS: New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome.

BACKGROUND: Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation. METHOD: The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later. RESULTS: The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome. CONCLUSIONS: Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: how often does the diagnosis change at follow-up?

It has been previously reported that a substantial proportion of newly referred neurology out-patients have symptoms that are considered by the assessing neurologist as unexplained by 'organic disease'. There has however been much controversy about how often such patients subsequently develop a disease diagnosis that, with hindsight, would have explained the symptoms. We aimed to determine in a large sample of new neurology out-patients: (i) what proportion are assessed as having symptoms unexplained by disease and the diagnoses given to them; and (ii) how often a neurological disorder emerged which, with hindsight, explained the original symptoms. We carried out a prospective cohort study of patients referred from primary care to National Health Service neurology clinics in Scotland, UK. Measures were: (i) the proportion of patients with symptoms rated by the assessing neurologist as 'not at all' or only 'somewhat explained' by 'organic disease' and the neurological diagnoses recorded at initial assessment; and (ii) the frequency of unexpected new diagnoses made over the following 18 months (according to the primary-care physician). One thousand four hundred and forty-four patients (30% of all new patients) were rated as having symptoms 'not at all' or only 'somewhat explained' by 'organic disease'. The most common categories of diagnosis were: (i) organic neurological disease but with symptoms unexplained by it (26%); (ii) headache disorders (26%); and (iii) conversion symptoms (motor, sensory or non-epileptic attacks) (18%). At follow-up only 4 out of 1030 patients (0.4%) had acquired an organic disease diagnosis that was unexpected at initial assessment and plausibly the cause of the patients' original symptoms. Eight patients had died at follow-up; five of whom had initial diagnoses of non-epileptic attacks. Seven other types of diagnostic change with very different implications to a 'missed diagnosis' were found and a new classification of diagnostic revision is presented. One-third of new neurology out-patients are assessed as having symptoms 'unexplained by organic disease'. A new diagnosis, which with hindsight explained the original symptoms, rarely became apparent to the patient's primary care doctor in the 18 months following the initial hospital consultation.

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study.

INTRODUCTION: Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk. METHODS: This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother's linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour. RESULTS: ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. 'Clinical Classifications Software' ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported. CONCLUSION: There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners. KEY WORDS: Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol.

Clinically relevant fatigue in cancer outpatients: the Edinburgh Cancer Centre symptom study.

BACKGROUND: Fatigue is associated with cancer and its treatment but we know little about how many and which patients suffer fatigue of clinical severity. We aimed to determine the prevalence of clinically relevant fatigue (CRF) and its associations in outpatients with various cancer diagnoses. PATIENTS AND METHODS: A survey of outpatients with colorectal, breast, gynaecological, genitourinary, sarcoma, melanoma and miscellaneous tumours at a regional cancer centre. Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) fatigue subscale and the Hospital Anxiety and Depression Scale (HADS). These self-report data were linked to demographic and clinical variables. Data were available on 2867 outpatients. RESULTS: The prevalence of CRF (EORTC fatigue subscale > or =40) was 32% (95% confidence interval 31-34%). The variables independently associated with CRF were primary cancer site, having disease present, type of cancer treatment and emotional distress (total HADS score > or =15). Emotional distress had the strongest association with fatigue but half the cases of CRF were not distressed. CONCLUSION: CRF is common in cancer outpatients and is associated with type of disease and treatment, as well as with emotional distress. The association between CRF and emotional distress is strong but they are not equivalent conditions.

Reduced expression of insulin-like growth factor 1 messenger RNA in the hippocampus of aged rats.

Adult neurones remain dependent on neurotrophic factors such as insulin-like growth factor 1 (IGF-1) to sustain neuronal viability by maintaining cell phenotype, supporting synaptic plasticity and providing neuroprotective and neuroregenerative mechanisms. A decline in the cellular expression of neurotrophic factors has been speculated to contribute to the age-related changes that occur in the brain, where the hippocampus appears particularly susceptible. Using in situ hybridisation, we have made a detailed comparison of the expression of IGF-1 mRNA in the hippocampal formation between young (6 months) and aged (23 months) rats. IGF-1 mRNA expression was measured from cell populations containing only high density radioactive labelling (>20 grains/cell) to avoid ambiguity of signal. The amount of IGF-1 mRNA signal was significantly lower in cells of the alveus (P<0.05) and stratum lacunosum moleculare (P<0.01) of aged compared to young rats. These findings challenge reports that IGF-1 mRNA is unaltered in the ageing hippocampus and provide further evidence that changes in the IGF-1 system is a significant factor in the progressive age-related deterioration of normal neuronal function.

Short-term administration of fluoxetine and venlafaxine decreases corticosteroid receptor mRNA expression in the rat hippocampus.

Chronic treatment with antidepressant drugs (2 weeks or longer) increases corticosteroid receptor mRNA expression in the hippocampus and reduces hypothalamic-pituitary-adrenal axis activity in parallel with improving mood and neuroendocrine function. Earlier effects are less well documented. We examined the effects of short term (9 days) treatment with fluoxetine (10 mg/kg) and venlafaxine (10 mg/kg) on hippocampal mineralocorticoid receptor (MR) and glucocorticoid receptor (GR) mRNA expression and spatial memory in adult rats. In situ hybridization histochemistry showed that the antidepressants decreased MR mRNA expression in all hippocampal subregions (e.g. 45% decrease in CA1 with venlafaxine, P<0.001), while GR mRNA expression was selectively reduced in the CA3 subregion. There was a trend for decreased plasma corticosterone levels following fluoxetine (50% fall, P=0.07) and venlafaxine (30% fall, P=0.18) but neither antidepressants affected spatial memory in the watermaze. Thus antidepressants can have complex and opposing actions on hippocampal corticosteroid receptor expression depending on the duration of treatment.

Macromolecules inhibit calcium oxalate crystal growth and aggregation in whole human urine.

Removal of macromolecules with Mr greater than 10,000 had no discernible effect on the detectable nucleation of calcium oxalate crystals from undiluted human urine, but promoted the deposition of crystalline material and markedly increased the degree of aggregation of the precipitated crystals. Calcium oxalate crystals and crystal aggregates precipitated from ultrafiltered urine were, on average, 68% larger than those deposited from whole urine. These findings suggest that urinary macromolecules play a key role in preventing calcium oxalate kidney stone disease by inhibiting the formation of large crystal aggregates and thereby reducing the probability of particle retention in the kidney tubules.

Inhibitory activity of whole urine: a comparison of urines from stone formers and healthy subjects.

The inhibitory activity of whole urines from 32 healthy subjects and 50 calcium oxalate renal stone formers was assessed in terms of their ability to withstand increasing quantities of oxalate before undergoing spontaneous nucleation of calcium oxalate, and their response to a standard 30-mumol challenge of oxalate above their measured metastable limits. The concentrations of calcium (p less than 0.05), oxalate (p less than 0.05), urate (p less than 0.01) and glycosaminoglycans (p less than 0.005) were significantly lower in the stone formers than in the controls and were associated with a significantly higher 24-h urinary volume (p less than 0.001). The majority of urine samples precipitated envelope crystals of calcium oxalate dihydrate, while the remainder precipitated the monohydrate. A significantly (p less than 0.02) greater proportion of the urines from stone formers than from controls deposited calcium oxalate monohydrate, and this was attributed to a lower concentration of calcium in these urines. The minimum amounts of oxalate necessary to induce crystal nucleation did not differ between the two groups, but when the measured metastable limits were expressed as the product of the total (i.e. endogenous + that added to induce nucleation) concentrations of oxalate and calcium at which precipitation occurred, then these limits were significantly lower (p less than 0.05) in the stone formers than in the healthy subjects. However, when the metastable limits of a subgroup of stone formers and controls matched for 24-h urinary volume and calcium and urate concentrations were compared, no differences between the groups could be discerned.(ABSTRACT TRUNCATED AT 250 WORDS)

Intake and digestibility of low-quality native grass hay by beef cows supplemented with graded levels of soybean hulls.

Twelve Hereford cows and four mature, ruminally cannulated Hereford x Angus heifers were fed supplements providing either 0 (control), 1, 2, or 3 kg/d of soybean hulls and including 440 g of protein/d (cottonseed meal was used to equalize protein intake) to determine the effects of supplementation on intake and utilization of low-quality native grass hay. Cattle were housed in individual pens and fed coarsely chopped (5-cm screen) native grass hay harvested in mid-November (4.1% CP, 76.9% NDF). Hay OM intake peaked (quadratic, P = .04) at 10.1 kg/d with 1 kg of soybean hulls and decreased when 2 kg (9.8 kg/d) or 3 kg (9.1 kg/d) of soybean hulls were fed. Although hay intake decreased when soybean hulls replaced cottonseed meal, feeding 3 kg soybean hulls decreased hay OM intake by only .64 kg. Total OM digestibility increased linearly (P = .009) with added increments of soybean hulls (45.8%, 46.2%, 46.6% and 48.6% for 0 through 3 kg soybean hulls/d, respectively), indicating that hulls were more digestible than the hay. Digestibility of NDF was not affected (P = .14) by level of soybean hull supplementation, although ADF digestibility increased (linear, P = .03). Increases in OM intake and digestibility with soybean hulls combined to increase digestible OM intake (linear, P = .0001). Soybean hull supplementation increased ruminal VFA concentrations (linear, P = .04) and the molar proportion of propionate (linear, P = .006).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of pure and partial yellow endosperm sorghum grain hybrids on site and extent of digestion in beef steers.

To compare the effects of sorghum grain hybrids on site and extent of digestion, two yellow (Y1 and Y2), two cream (C1 and C2), and two hetero-yellow (HY1 and HY2) sorghum grains were fed (1.85% BW, DM basis) in an 81% dry-rolled grain diet to steers (342 kg BW) equipped with ruminal, duodenal, and ileal cannulas within a 6 X 6 Latin square. Yellow (YEL) hybrids had a homozygous yellow endosperm and a yellow seed coat; cream (CREAM) and hetero-yellow (HET-YEL) hybrids had a heterozygous (partial) yellow endosperm, with white or red seed coats, respectively. Total tract starch digestibility (percentage) was greater (P less than .10) for CREAM and HET-YEL (82.3) than for YEL (78.9), primarily because of greater (P less than .05) starch digestion in the large intestine. Ruminal starch digestibility (percentage) was greater (P less than .10) for HET-YEL (73.2) than for CREAM (66.3) and was a larger proportion of total tract digestion for HET-YEL (90.6) than for CREAM (80.1). Ruminal starch digestion was correlated negatively (r = -.46; P less than .08) with ruminal escape of feed N. Prececal starch digestibility (average 76.2%) was more strongly correlated with ruminal digestibility (r = .69; P less than .01) than with digestion in the small intestine (r = .41; P = .12). Total tract nonammonia N (NAN) digestibility (percentage) was greater (P less than .10) for CREAM than for HET-YEL, greater for Y1 (P less than .10) than for Y2, greater for C2 (P less than .05) than for C1, and greater for HY2 (P less than .05) than for HY1. Flow of NAN to the duodenum was correlated negatively (r = -.55; P less than .05) with prececal starch digestion. Small intestinal NAN disappearance (g/d) was greater (P less than .01) for HY1 (76.0) than for HY2 (52.2). Microbial N flow (r = .88; P less than .01), but not feed N flow (r = .17; P = .52), to the duodenum was correlated with partial NAN digestibility in the small intestine. Hybrids differed in site and extent of digestion. Differences were generally larger for N than for starch.

Effect of bird-resistant and non-bird-resistant sorghum grain on amino acid digestion by beef heifers.

The effects of sorghum type on amino acid digestion were determined by feeding heifers (230 kg) equipped with ruminal, duodenal, and ileal cannulas bird-resistant (BR) or non-BR grains that had a normal or waxy endosperm (NORMAL-BR, WAXY-BR, NORMAL, WAXY). Dry-rolled grain diets were fed at 2% of BW in a 4 x 4 Latin square design. Total (TAA), essential (EAA), and nonessential (NAA) amino acid intake (grams/day) tended to be greater for BR than for non-BR grains. Feed (plus endogenous) amino acids reaching the duodenum were calculated by subtracting amino acids of microbial protein from total flow. Flow (grams/day) of total and feed TAA, EAA, NAA, and proline-rich-protein (sum of aspartate, glutamate, glycine, and proline) to the duodenum was greater (P < .05) for BR than for non-BR grains. The ratio between feed proline-rich-protein and NAA reaching the duodenum was similar to that noted with feed intake. Amino acid disappearance (grams/day) from the small intestine was unchanged (P > .10) by sorghum type, although the digestibility (percentage of duodenal flow) of TAA, EAA, NAA, and most individual amino acids was decreased (P < .05) for BR varieties. Amino acid flow to the cecum (grams/day) was generally greater for NORMAL-BR than for WAXY-BR (P < .10) or for NORMAL (P < .01) and greater (P < .10) for WAXY-BR than for WAXY.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of corn with four sorghum grain hybrids: site and extent of digestion in steers.

Four diverse sorghum hybrids (yellow, cream, hetero-yellow and red) and corn grain were dry-rolled and fed in an 85% grain diet to Angus-Hereford steers (241 kg) equipped with ruminal and double L-type duodenal and ileal cannulas to compare the effects of grain source on site and extent of digestion. Yellow (yel) has a homozygous yellow endosperm, with a yellow seed coat, whereas cream and hetero-yellow (het-yel) have a heterozygous yellow endosperm with white and red seed coats, respectively. Red has a homozygous white endosperm with a red seed coat. Diets were fed at 2% of initial BW (DM basis) in a 5 x 5 Latin square. Total digestive tract starch digestibility (%) was greater (P less than .05) for corn (92.5) than for red (84.3), yel (84.3) and het-yel (82.9) but not greater (P greater than .10) than for cream (87.9). Ruminal starch digestibility (%) was greater (P less than .10) for corn (85.8) than for sorghum hybrids (69.1). Pre-cecal starch digestibility (%) was greater (P less than .05) for corn (90.6) than for het-yel (76.2), red (74.8) and yel (74.1). Ruminal escape (%) of grain N was greater (P less than .10) for red (79.9) than for het-yel (69.2), cream (66.5) and yel (66.1), with corn (53.6) being less (P less than .10) than sorghum hybrids. Pre-cecal and total tract non-NH3 N digestibilities (%) were not altered (P greater than .10) by grain source. Hybrid of sorghum altered site and extent of starch digestion and ruminal escape of grain N; hybrids had estimated gain:feed ratios that were 81 to 93% of those of rolled corn grain.

Combinations of high-moisture harvested sorghum grain and dry-rolled corn: effects on site and extent of digestion in beef heifers.

To determine the effects of blends of high-moisture harvested sorghum grain (HMS) and dry-rolled corn (DRC) on site and extent of digestion, high-grain diets were fed to Angus-Hereford heifers (315 kg) in a 5 x 5 latin square. The grain portion consisted of ratios (HMS:DRC) of 0:100, 25:75, 50:50, 75:25 and 100:0. Heifers were equipped with ruminal, duodenal and ileal T-type cannulas. Digestibilities of OM (P less than .05) and non-ammonia nitrogen (NAN; P less than .01) in the total tract declined linearly as HMS replaced DRC. Chyme flow (liters/d) through the duodenum increased linearly (P less than .01), and true ruminal OM disappearance tended to decline linearly (P less than .10) as HMS replaced DRC. A quadratic response (P less than .05) in extent of starch disappearance (g/d) in the rumen was noted; blends were lower than either individual grain. Ruminal escape of feed N tended to be quadratic (P less than .10); values for individual grain types were greater than blends. Microbial efficiency increased linearly (P less than .05) as HMS replaced DRC. Extent of starch digestion in the rumen averaged 82.7% compared to only 2.9% in the small intestine and 5.7% in the large intestine. Altering the ratio of HMS to DRC appeared to have more effect on ruminal fermentation than on digestion in the small intestine; most starch and nitrogen responses were quadratic. Increases in ruminal pH and chyme flow, potentially caused by increased salivary flow, may cause non-linear changes in the solubility of proteins in HMS and DRC, when fed as blends, altering the digestibility of protein and starch from values predicted from the individual grains.

Effect of sorghum grain variety and reconstitution on site and extent of starch and protein digestion in steers.

Hetero-yellow (HY), red (RED) and brown (BR, high tannin) sorghums were fed dry-rolled or reconstituted (RED and BR only) to evaluate the effect of variety and reconstitution on the site and extent of starch and protein digestion in steers fitted with ruminal, duodenal and ileal cannulae. Processed grains were incorporated into 88% sorghum (DM basis) diets fed at 2% of body weight in a 5 X 5 Latin square. Ruminal fermentation of organic matter, starch and protein tended to be lower for the dry-rolled RED than for either the dry-rolled HY or BR sorghum. Digestion of organic matter (OM) and starch in the small intestine was very low for dry-rolled sorghums. Total tract starch digestibility was lower for the dry-rolled RED sorghum (86.9%) than the BR (90.8%) and HY (91.4%). Nitrogen (N) digestibility ranged from 53.1% for the dry-rolled BR to 64.5% for the HY. Tannins were extensively (95.2%) degraded in the rumen, which may have enhanced fermentation of the BR sorghum. Reconstitution increased (P less than .05) total-tract starch digestion of the RED and tended to increase starch digestion of the BR as well. Total N flow to the duodenum tended to increase with reconstitution, with most of the increase being due to greater (P less than .05) microbial-N. Reconstitution also increased (P less than .05) total-tract N digestibility of the RED. The response to reconstitution for the RED sorghum appeared to be due primarily to an increase (P less than .10) in the extent of fermentation of organic matter and starch in the rumen. Reconstitution of BR, however, enhanced disappearance of starch from the small intestine. In both cases, most (97.3%) of the digestible starch of the reconstituted sorghums had disappeared before the terminal ileum. In contrast, 14.5% (621 g) of the digestible starch of dry-rolled RED disappeared in the large intestine. Sorghum grain variety and reconstitution appear to alter site and extent of starch and protein digestion, which may result in variable performance of cattle fed sorghum grain diets.

Technical note: a double L intestinal cannula for cattle.

A double L-shaped intestinal cannula was developed in an attempt to overcome problems observed previously with simple T-type cannulas. The cannula was constructed from cyclopolyvinyl chloride water pipe fittings. Construction materials were fairly rigid, but by connecting the split cannula pieces with elastic castration bands the cannula had some flexibility. Placing a short cone over the exposed cannula barrel reduced mechanical damage to the intestine. The double L cannula required a much smaller incision in the intestine during surgical insertion than a T-type cannula; it also simplified replacement. Construction is described; use and performance of the cannula has been satisfactory.

Detoxification of high tannin sorghum grains.

One in vitro and two in vivo experiments were conducted to determine appropriate methodology for and effects of detoxifying Darset, Redlan, and one commercial hybrid brown sorghum grain variety in threonine-deficient and nutritionally complete poultry rations. The detoxification procedure, which involves adding water to sorghum grain to bring dry matter to 70% and subsequent anaerobic incubation at 32 C, removes up to 100% of the chemically detectable tannin. Rate of tannin elimination was dependent upon sorghum grain variety with commercial brown sorghum requiring approximately 3 days longer than the Darset for tannin elimination. Detoxification of high tannin sorghum grains improved (P less than .05) growth rate and feed efficiency dramatically in threonine-deficient, crystalline amino acid-fortified rations; the same process applied to low tannin sorghum grains was without benefit. The desirable effects of this type of grain processing appear to be due to the reduced grain tannin content. Including detoxified sorghum grains in a practical-type broiler ration failed to elicit a weight gain response although feed efficiency was improved by 13% over untreated sorghum and 3% over corn grain. Lack of a gain response was likely due to the excess protein included in the basal diet. This type of grain processing offers an alternative method of reducing sorghum grain tannin content and is likely of greatest value in rations containing marginal indispensable amino acid and protein levels.

Who is referred to neurology clinics?--the diagnoses made in 3781 new patients.

OBJECTIVE: Information on the nature and relative frequency of diagnoses made in referrals to neurology outpatient clinics is an important guide to priorities in services, teaching and research. Previous studies of this topic have been limited by being of only single centres or lacking in detail. We aimed to describe the neurological diagnoses made in a large series of referrals to neurology outpatient clinics. METHOD: Newly referred outpatients attending neurology clinics in all the NHS neurological centres in Scotland, UK were recruited over a period of 15 months. The assessing neurologists recorded the initial diagnosis they made. An additional rating of the degree to which the neurologist considered the patient's symptoms to be explained by disease was used to categorise those diagnoses that simply described a symptom such as 'fatigue'. RESULTS: Three thousand seven hundred and eighty-one patients participated (91% of those eligible). The commonest categories of diagnosis made were: headache (19%), functional and psychological symptoms (16%), epilepsy (14%), peripheral nerve disorders (11%), miscellaneous neurological disorders (10%), demyelination (7%), spinal disorders (6%), Parkinson's disease/movement disorders (6%), and syncope (4%). Detailed breakdowns of each category are provided. CONCLUSIONS: Headache, functional/psychological disorders and epilepsy are the most common diagnoses in new patient referral to neurological services. This information should be used to shape priorities for services, teaching and research.