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J MacFie

Publications and source records attributed to J MacFie.

At least 19 recordsLinked to original sources
PubMed2003

Peripheral parenteral nutrition.

BACKGROUND: Peripheral parenteral nutrition (PPN) currently accounts for almost 20 per cent of all parenteral nutrition administered in the UK. In the absence of consensus guidelines there is wide variation in practice. Heterogeneity of clinical trials has made direct comparisons difficult and meta-analysis impossible. METHODS: Medline, Embase and Cochrane databases were searched for all clinical trials relating to the use of PPN in adults. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. RESULTS AND CONCLUSIONS: Effective PPN is possible in about 50 per cent of inpatients requiring parenteral nutrition. Evidence relating to optimal feed composition, choice of cannula, infusion technique and pharmacological manipulation is discussed, along with practical recommendations for the administration of PPN.

Administration, Topical↗
PubMed2002

A prospective randomised study of the probiotic Lactobacillus plantarum 299V on indices of gut barrier function in elective surgical patients.

BACKGROUND: Bacterial translocation occurs in surgical patients and may predispose to postoperative septic morbidity. Many factors are thought to influence the prevalence of bacterial translocation, one of which is the composition of the gut microflora. The aim of this prospective and randomised study was to assess the effect of the probiotic Lactobacillus plantarum 299v on the incidence of bacterial translocation, gastric colonisation, and septic complications in elective surgical patients. METHODS: Patients undergoing elective major abdominal surgery were randomised to either a treatment or control group. The treatment group received an oral preparation containing Lactobacillus plantarum 299v (Proviva) for at least one week preoperatively and also in the postoperative period. Bacterial translocation was determined by culture of a mesenteric lymph node and serosal scraping obtained at laparotomy. Gastric colonisation was assessed by microbiological culture of nasogastric aspirates. All postoperative septic complications were recorded. RESULTS: A total of 129 patients completed the study (probiotic group n=64). There was no significant difference between the two groups in terms of bacterial translocation (12% v 12%; p=0.82), gastric colonisation with enteric organisms (11% v 17%; p=0.42), or septic morbidity (13% v 15%; p=0.74). CONCLUSIONS: Administration of Lactobacillus plantarum 299v in elective surgical patients does not influence the rate of bacterial translocation, gastric colonisation, or incidence of postoperative septic morbidity.

Adult↗
PubMed2002

Gastric colonisation, intestinal permeability and septic morbidity in acute pancreatitis.

INTRODUCTION: Bacterial translocation (BT) may represent an important cause of septic morbidity in patients with acute pancreatitis. We have previously demonstrated an association between BT, septic morbidity and colonisation of the proximal GI tract. Alterations in intestinal permeability (IP) may also predispose to BT. The aim of this study was to assess the extent of gastric colonisation, measure IP in patients with acute pancreatitis and relate these to both disease severity and septic complications. METHODS: Gastric colonisation was determined by culturing a sample of nasogastric aspirate, and IP was measured using a dual sugar probe technique (lactulose/rhamnose test). Disease severity was assessed according to the modified Glasgow (Imrie) criteria. All septic complications were recorded prospectively. RESULTS: A total of 59 patients were studied (M:F ratio 32:27, median age 66 years, range 18-89), 24 (31%) of whom had severe disease. A nasogastric aspirate was obtained in 56 patients. There was a significantly higher incidence of colonisation with potentially pathogenic enteric bacteria in patients with severe disease compared to those with mild disease (57 vs. 6%, p < 0.001). Septic morbidity occurred in 29% of severe patients and 11% mild patients (p = 0.17). 33% of patients colonised with enteric organisms developed sepsis, compared to 16% with no enteric bacteria in the NG aspirate (p = 0.34). Enteric bacteria caused 77% of the septic complications. Intestinal permeability was neither associated with disease severity nor was it predictive of septic morbidity. CONCLUSIONS: There is significantly higher incidence of gastric colonisation with enteric bacteria in patients with severe acute pancreatitis, but no difference in IP. Enteric bacteria were implicated in the majority of septic complications. These findings support the gut origin of sepsis hypothesis in acute pancreatitis.

Acute Disease↗
PubMed2002

An investigation into the sensitivities of translocating bacteria to a prophylactic antibiotic regimen.

INTRODUCTION: It is well established that bacterial translocation is associated with a significant increase in septic morbidity. The purpose of this study was to determine the antibiotic sensitivities of translocating bacteria on the basis that this information may influence antibiotic prophylaxis in surgical patients. METHODS: Routine microbiological techniques were used to assess the antibiotic sensitivities of those bacteria cultured from a mesenteric lymph node harvested at laparotomy in a large series of patients. RESULTS: Culture of the mesenteric lymph nodes yielded growth in 51 out of a total of 447 patients studied (11.4%). The isolates from 40 patients, a total of 60 organisms, were available for sensitivity testing. The most common species grown was Escherichia coli (48% of isolates). Thirty-three patients (83%) grew organisms sensitive to the antibiotic prophylaxis used, but there was no significant difference in the incidence of postoperative septic complications between these patients and those in whom resistant bacteria were grown (39% versus 29%, P = 0.64 Fisher's Exact test mid P). CONCLUSIONS: The majority of translocating bacteria are sensitive to the prophylactic antibiotics commonly used in patients undergoing laparotomy. However, the occurrence of postoperative septic morbidity is independent of this variable.

Aged↗
PubMed2001

Enteral versus parenteral nutrition: a pragmatic study.

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route.

Adult↗
PubMed2001

Bacterial translocation and immunohistochemical measurement of gut immune function.

AIMS: The local immune response in the small bowel mucosa might play a role in bacterial translocation (BT). The aim of this study was to quantify immune cells and secretory antibodies in the small bowel mucosa, and relate this to BT as assessed by culture of a mesenteric lymph node. METHODS: Immunohistochemical techniques were used to measure the frequency of plasma cells and IgA and IgM positive cells in the lamina propria and semiquantitatively to assess mucosal surface IgA and IgM values in small bowel specimens obtained from 11 patients in whom positive evidence of BT had been identified in a mesenteric lymph node harvested at the time of laparotomy. These were compared with similar specimens obtained from 11 patients in whom a similar lymph node had yielded no growth. RESULTS: BT was associated with a significantly increased median frequency of plasma cells (p < 0.01) and IgA positive cells (p < 0.05) in the lamina propria. The frequency of IgM positive cells was also higher in these patients, although this difference was not significant. In addition, semiquantitatively scored IgA and IgM concentrations at the mucosal surface were both significantly higher in the patients in whom BT had been identified (p = 0.006 and 0.016, respectively). CONCLUSION: Higher numbers of plasma cells and higher IgA and IgM values are present in the small bowel mucosa of patients in whom BT has been shown to occur, suggesting an increased local immune response.

Aged↗
PubMed2000

Oral dietary supplements in pre- and postoperative surgical patients: a prospective and randomized clinical trial.

It has been suggested that the routine provision of oral dietary supplements (ODS) in postoperative surgical patients is of benefit in terms of morbidity and length of hospital stay. The aim of this study was to evaluate the effects of both pre- and postoperative ODS in patients undergoing an elective laparotomy. Patients requiring elective major gastrointestinal surgery were prospectively randomized into one of four groups: Group I received ODS in addition to normal diet both pre- and postoperatively, Group II were given ODS in the preoperative period only, Group III received ODS only in the postoperative period, and Group IV did not receive any supplements. Assessments of nutritional status, voluntary food intake, weight loss, serum albumin, morbidity and mortality, anxiety and depression, and postoperative activity levels were performed, and comparisons made between the groups. One hundred patients were included in the study. The mean daily energy intake from preoperative ODS was 507 +/- 140 kcal, significantly more than the 252 +/- 195 kcal in the postoperative period (P < 0.001). The postoperative voluntary food intake in patients receiving ODS was not significantly different from that in patients receiving normal diet alone (1090 versus 1268 kcal, 46.2 versus 49.1 g protein, P > 0. 05). All groups demonstrated an overall weight loss, with no significant differences between the groups, and there was no demonstrable effect on clinical outcome. At 6 mo postoperatively there were no differences between the study groups in terms of levels of activity. These results suggest that the routine use of perioperative ODS in well-nourished patients undergoing major gastrointestinal surgery confers no clinical or functional benefit.

Adult↗
PubMed2000

Bacterial translocation in patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Bacterial translocation occurs in humans and is associated with an increased incidence of septic morbidity. The aims of this study were to determine the prevalence of bacterial translocation in patients undergoing open abdominal aortic aneurysm (AAA) repair and to identify any association with postoperative septic complications. METHODS: This was a prospective observational study in which patients undergoing aneurysm repair were assessed for evidence of bacterial translocation by culture of a mesenteric lymph node (MLN), small bowel serosal exudate and thrombus within the aneurysm. All postoperative septic complications were recorded. RESULTS: A total of 51 patients was studied (40 men, 11 women; median age 72 years). Enteric bacteria were isolated from the MLNs of five patients (prevalence of bacterial translocation 10 per cent), one of whom also yielded growth from the serosal exudate. Septic morbidity occurred in four of five patients in whom bacterial translocation was identified, compared with nine of 46 in those without translocation (P = 0.013, Fisher's exact test, mid P). One patient in whom Escherichia coli was grown from the MLN developed an aortoenteric fistula, with a coliform species isolated from the graft. CONCLUSION: This study suggests that bacterial translocation occurs in patients undergoing AAA repair. It is associated with an increased incidence of postoperative septic morbidity and provides a possible mechanism for infection of prosthetic aortic grafts.

Aged↗
PubMed2000

Author's reply.

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Journal Article↗
PubMed2000

Ethical and legal considerations in the provision of nutritional support to the perioperative patient.

Despite the extensive current literature on ethics, very few publications have specifically addressed the ethical issues surrounding the provision of nutrition to perioperative patients. Four publications are particularly relevant and highly recommended [1-4]. This review is an attempt to draw attention to those ethical issues that are relevant to the use of nutritional support in the perioperative patient and offer guidance on appropriate action by clinicians. Emphasis is on adult patients rather than children and not on the issues that surround the terminally ill patient. General principles are discussed first and then the application of these principles.

Adult↗
PubMed1999

Gut origin of sepsis: a prospective study investigating associations between bacterial translocation, gastric microflora, and septic morbidity.

AIMS: To investigate the "gut origin of sepsis" hypothesis. METHODS: Prospective controlled study of 279 surgical patients in which cultures of nasogastric aspirates were compared with those obtained from mesenteric lymph nodes taken at laparotomy and the organisms cultured from subsequent septic complications. Bacterial translocation was confirmed if positive cultures were obtained from mesenteric lymph nodes. Postoperative sepsis was defined as any positive culture in the postoperative period. Bacterial species obtained in gastric microflora, mesenteric lymph nodes, and postoperative septic complications were compared. RESULTS: Only 85/279 patients (31%) had a sterile nasogastric aspirate; the most frequently identified organism was Candida spp. (54%) and the most common enteric organism cultured was E coli (20%). Multiple organisms were isolated in 39% and occurred more frequently in patients aged over 70 years, those undergoing non-elective surgery, and in those requiring proximal gastrointestinal surgery. Postoperative sepsis was more common in these patients. Bacterial translocation occurred in 21% and was significantly more frequent in those with multiple organisms in their nasogastric aspirates. E coli was the commonest organism isolated from the lymph node specimens (48%) and septic foci (53%). Fungal translocation did not occur. An identical genus was identified in the nasogastric aspirate and the septic focus in 30% of patients, in the nasogastric aspirate and the lymph node in 31%, and in the lymph node and a postoperative septic focus in 45%. CONCLUSIONS: Proximal gut colonisation is associated with both increased bacterial translocation and septic morbidity. The commonality of organisms identified supports the gut origin of sepsis hypothesis.

Adolescent↗
PubMed1999

Safety of pancreatic surgery in a small DGH.

The Combined Gastroenterology Service at Scarborough Hospital has a particular interest in pancreatic disease. The claim that pancreatic surgery should only be performed in larger, specialised units prompted a review of our experience in a small district general hospital (DGH). The case notes of 63 patients who had undergone pancreatic surgery over a 7-year period were examined retrospectively. The 30-day mortality was 8%, while 14 complications were recorded. Of 16 patients with acute pancreatitis, three died before discharge and three had long-term complications. Five patients who underwent surgery for chronic pancreatitis were discharged safely. There were 11 curative and 29 palliative procedures for patients with malignant disease. Median survival was 8 months (range 1-32 months) and median hospital stay was 16.8 days (range 7-89 days). Successful pancreatic surgery can be performed safely in a DGH setting. Patient selection and expertise are more important than numbers.

Adult↗
PubMed1998

Alterations in intestinal barrier function do not predispose to translocation of enteric bacteria in gastroenterologic patients.

Bacterial translocation from the intestinal lumen has been demonstrated in humans. Three mechanisms have been suggested to explain the phenomenon: altered intestinal barrier function, bacterial overgrowth, and impaired host defense. The aim of this study was to determine whether changes in intestinal barrier function assessed by measurement of intestinal permeability and morphology were associated with alteration in bacterial translocation. Intestinal permeability was assessed in 43 patients by the lactulose/L-rhamnose test with a 5-h urine collection. Mucosal atrophy was assessed from the villus height-to-mucosal thickness ratio in small-bowel biopsies. Bacterial translocation was determined by microbiologic analysis of harvested mesenteric lymph nodes. No significant differences were apparent in the incidence of bacterial translocation in patients with normal permeability (5 [23%] of 22 patients translocated) compared with patients with increased permeability (4 [19%] of 21 patients translocated). Similarly, no correlation was apparent between the incidence of bacterial translocation and the index of villus atrophy. The degree of villus atrophy failed to correlate with gastrointestinal permeability. These data suggest that the incidence of bacterial translocation is not related to increased intestinal permeability or mucosal atrophy.

Adult↗
PubMed1998

Microbiology of bacterial translocation in humans.

BACKGROUND: Gut translocation of bacteria has been shown in both animal and human studies. Evidence from animal studies that links bacteria translocation to the development of postoperative sepsis and multiple organ failure has yet to be confirmed in humans. AIMS: To examine the spectrum of bacteria involved in translocation in surgical patients undergoing laparotomy and to determine the relation between nodal migration of bacteria and the development of postoperative septic complications. METHODS: Mesenteric lymph nodes (MLN), serosal scrapings, and peripheral blood from 448 surgical patients undergoing laparotomy were analysed using standard microbiological techniques. RESULTS: Bacterial translocation was identified in 69 patients (15.4%). The most common organism identified was Escherichia coli (54%). Both enteric bacteria, typical of indigenous intestinal flora, and non-enteric bacteria were isolated. Postoperative septic complications developed in 104 patients (23%). Enteric organisms were responsible in 74% of patients. Forty one per cent of patients who had evidence of bacterial translocation developed sepsis compared with 14% in whom no organisms were cultured (p < 0.001). Septic morbidity was more frequent when a greater diversity of bacteria resided within the MLN, but this was not statistically significant. CONCLUSION: Bacterial translocation is associated with a significant increase in the development of postoperative sepsis in surgical patients. The organisms responsible for septic morbidity are similar in spectrum to those observed in the mesenteric lymph nodes. These data strongly support the gut origin hypothesis of sepsis in humans.

Adolescent↗