Prediction and evaluation of urine and urinary nitrogen and mineral excretion from dairy cattle.

Urine excretion is a substantial factor in the amount of manure that needs to be managed, and urinary N can contribute to ammonia volatilization. Development and validation of prediction equations focusing on dietary factors to decrease urine and urinary nutrient excretion will provide information for managing urine and feces separately or for other future technologies. The objective of this study was to develop equations for prediction of urine excretion and excretion of urinary N, Na, and K and to evaluate both new and previously published prediction equations for estimation of urine and urinary nutrient excretion from lactating dairy cows. Data sets from metabolism studies conducted at Washington State University were compiled and evaluated for excretion of minerals. Urine excretion averaged 24.1 kg/d and urinary nitrogen excretion ranged from 63 to 499 g/d in the calibration data set. Regression equations were developed to predict urine excretion, urinary N excretion, and urinary Na and K excretion. Predictors used in the regression equations included milk yield, body weight, dietary crude protein percentage, milk urea nitrogen, and nutrient intakes. Previously published prediction equations were evaluated using data sets from Washington State University and the University of Wisconsin. Mean and linear biases were evaluated by determining the regression of residuals on predicted values. Evaluation and validation of prediction equations are important to develop equations that will more accurately estimate urine and urinary nitrogen excretion from lactating dairy cows.

Prediction of manure and nutrient excretion from dairy cattle.

Accurate estimates of manure excretion are needed for planning manure storage facilities and for nutrient management. Data sets from metabolism studies conducted at several universities were compiled and evaluated for excretion of total manure, N, P, and K. Animal groups included calves weighing up to 204 kg, heifers weighing between 274 and 613 kg, nonlactating cows, and lactating cows. Regression equations were developed to predict excretion of total manure, total dry matter, N, P, and K. Predictors used in the regression equations for lactating cows included milk yield, percentages of protein and fat in milk, dietary concentrations of crude protein and neutral detergent fiber, and intakes of nutrients. The regression equations provide improved predictions of excretion and enable more accurate planning of manure storage and nutrients to be managed at the farm level.

Implementation strategies for a Scottish national epilepsy guideline in primary care: results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) trial.

PURPOSE: To determine the effectiveness of two dissemination and implementation strategies to implement a national guideline for epilepsy management in primary care settings. METHODS: Three-arm cluster-randomized controlled trial. The participants were general practitioners from 68 practices in Tayside, Scotland, and 1,133 of their patients with self-reported epilepsy treated with antiepileptic medications (AEDs). Practices were randomized blind to a control, intermediate, or intensive intervention. CONTROL: Postal dissemination of a nationally developed clinical guideline. Intermediate intervention: Postal dissemination of the guideline supported by interactive, accredited workshops, and dedicated, structured protocol documents. Intensive intervention: Intermediate intervention plus a nurse specialist who supported and educated practices in the establishment of epilepsy review clinics. The primary outcome was the SF-36 health-related quality-of-life instrument. Secondary measures were a battery of prevalidated epilepsy-specific quality-of-life instruments. These were administered at baseline and after the intervention phase. Process of care was assessed by case-note review on number of review meetings and counseling sessions for epilepsy before and after the interventions. RESULTS: None of the intervention groups showed any change in the primary or secondary outcome measures or process-of-care measures. CONCLUSIONS: None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care. Further research is needed to discover why the interventions failed, to identify barriers to adoption of guidelines, and to develop strategies that might improve implementation and uptake in the future.

A randomised placebo controlled exploratory study of vitamin B-12, lofepramine, and L-phenylalanine (the "Cari Loder regime") in the treatment of multiple sclerosis.

OBJECTIVE: To determine whether combination therapy with lofepramine, L-phenylalanine, and intramuscular vitamin B-12 (the "Cari Loder regime") reduces disability in patients with multiple sclerosis. METHODS: A placebo controlled, double blind, randomised study carried out in five United Kingdom centres on outpatients with clinically definite multiple sclerosis, measurable disability on Guy's neurological disability scale (GNDS), no relapse in the preceding six months, and not on antidepressant drugs. Over 24 weeks all patients received vitamin B-12, 1 mg intramuscularly weekly, and either lofepramine 70 mg and L-phenylalanine 500 mg twice daily, or matching placebo tablets. Outcome was assessed using the GNDS, the Kurtzke expanded disability status scale; the Beck depression inventory, the Chalder fatigue scale, and the Gulick MS specific symptom scale. RESULTS: 138 patients were entered, and two were lost from each group. There was no statistically significant difference between the groups at entry or at follow up. Analysis of covariance suggested that treated patients had better outcomes on four of the five scales used. Both groups showed a reduction of 2 GNDS points within the first two weeks, and when data from all time points were considered, the treated group had a significant improvement of 0.6 GNDS points from two weeks onwards. CONCLUSIONS: Patients with multiple sclerosis improved by 2 GNDS points after starting vitamin B-12 injections. The addition of lofepramine and L-phenylalanine added a further 0.6 points benefit. More research is needed to confirm and explore the significance of this clinically small difference.

The costs of trauma caused by seizures: can they be reduced?

This study surveyed admissions of patients with trauma caused by seizures from a population of over 400 000 to a Regional Neurosurgery, Plastic Surgery, Orthopaedic Surgical Services and a short-stay ward. Information on duration of epilepsy, seizure type, antiepileptic drugs (AEDs) and the co-existence of other neurological or psychiatric factors was reviewed and the hospital costs calculated. Twelve patients (eight males, four females, aged 28 to 78 years) had 13 admissions with 14 injuries caused by seizures during the period August 1995 to November 1998 (1% of the total admissions with the diagnosis of epilepsy). Seven had head-injuries, four had limb fractures or dislocations, two had burns and one had severe lacerations. The average duration of stays were between 1 day (short-stay ward) and 9-24 days for the three major services. The direct healthcare costs of this small group were high ( L 49 421) or L 3802 per traumatic incident. Clinical review suggested that the trauma could have been prevented by alternative care in seven patients at the most optimistic. Epilepsy is uncommon as a cause of severe trauma, the seizures may be difficult to prevent and the direct healthcare costs are high.

Repeated daily cocaine alters subsequent cocaine-induced increase of extracellular dopamine in the medial prefrontal cortex.

Male Sprague-Dawley rats that were naive or that had been treated with five daily saline or cocaine injections (15 mg/kg i.p.) were subsequently challenged with an injection of cocaine, and extracellular dopamine content in the medial prefrontal cortex (mPFC) was measured using in vivo microdialysis. Cocaine challenge increased extracellular dopamine levels from base line in all three groups of rats, but the augmentation was significantly reduced in the cocaine-pretreated group, compared with the saline-pretreated group. In contrast, mPFC dopamine levels were not different among groups after challenge with systemic d-amphetamine. To test whether repeated cocaine treatment led to altered releasability of dopamine from mPFC terminals, challenge with KCI (10, 30 or 100 mM) or d-amphetamine (3, 30 or 300 microM) was made via infusion through the dialysis probe into the mPFC. No differences in dopamine levels were found between treatment groups for either drug at any dose. To determine whether the effects of cocaine were mediated by local actions within mPFC dopamine terminals, a cocaine challenge was administered through the microdialysis probe (1, 10 or 100 microM). In contrast to the systemic cocaine challenge, local infusion of cocaine elicited a significant increase in daily cocaine-pretreated rats, compared with saline-pretreated controls, at the lowest dose tested, with no differences at the higher two doses. In summary, daily cocaine-pretreated rats demonstrated a suppressed mPFC dopamine response to subsequent systemic, but not local, cocaine challenge. The results suggest that this apparent tolerance is not due to altered releasability of dopamine from mPFC terminals and may rely on altered afferent regulation of mesocortical dopamine neurons.

The cost of epilepsy in patients attending a specialist epilepsy service.

Epilepsy is a common disability, especially in young adults, and, as the costs to the community are likely to be high, estimates are required to plan health and community care. The neurological unit of Dundee Royal Infirmary provides an epilepsy clinic for the Tayside region (population 300,000) and in 1991 the records of over 303 patients were computerized using the Epicare system developed by Sanofi-Winthrop. It was calculated that the total state expenditure on care was 662,919 pounds (2188 pounds/head) in 1991. The direct health costs were obtained by reviewing database entries and medical records and were estimated to be 159,192 pounds (24%), including 77,171 pounds for drugs, 64,750 pounds for hospital care and 17,271 pounds for general practice consultations. The cost of welfare payments was 503,728 pounds/year (76%) (4419 pounds/recipient). The transfer payments to patients with epilepsy greatly exceed the costs of health care and any management strategy which improves the prospects for employment and independence of people with epilepsy is likely to produce significant fiscal benefits for both the individual and the state.

A multicentre comparative trial of sodium valproate and carbamazepine in adult onset epilepsy. Adult EPITEG Collaborative Group.

The long-term efficacy and safety of sodium valproate and carbamazepine in adult outpatients with newly diagnosed primary generalised or partial and secondarily generalised seizures were compared in a randomised, open, multicentre study at 22 neurology outpatient clinics. Patients were randomised to oral sodium valproate (Epilim EC enteric coated 200 mg tablets twice daily, n = 149) or oral carbamazepine (100 mg twice daily increasing to 200 mg twice daily in week 2, n = 151) and followed up for three years. If clinically necessary, dosages were regularly increased until seizures were controlled or toxicity developed. Sodium valproate and carbamazepine controlled both primary generalised and partial seizures equally effectively overall. Significantly more patients on sodium valproate than carbamazepine (126/140 (90%) v 105/141 (75%), p = 0.001) remained on randomised treatment for at least six months. Skin rashes occurred significantly more often in carbamazepine recipients than in sodium valproate recipients (11.2% v 1.7%, p < 0.05) and carbamazepine was associated with a higher withdrawal rate because of adverse events (15% v 5% on sodium valproate) in the first six months of treatment. There was no difference between the drugs in the rate of withdrawal because of poor seizure control at any stage, regardless of seizure type. At the end of the three year trial period, over 70% of the available patients were still on randomised treatment or had recently stopped treatment after achieving full seizure control. Sodium valproate and carbamazepine were both associated with a high degree of overall seizure control regardless of seizure type and both have good long-term tolerability in adult patients with newly diagnosed epilepsy. Recommendations are made for a higher initial dosage regime for sodium valproate in partial seizures.