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Biomedical subjects

R P Bolton

Publications and source records attributed to R P Bolton.

At least 19 recordsLinked to original sources
PubMed2002

Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in two district general hospitals in the United Kingdom.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is the accepted method for long-term enteral nutrition. Recent studies have suggested a higher mortality than was initially reported. The demands for gastrostomy insertion have risen, encompassing indications where the long-term outcomes are uncertain. We, therefore, constructed guidelines to try and improve the appropriateness of patient selection. Our aim was to prospectively assess the impact of guidelines for PEG insertion over a 1-yr period in a single center, Rotherham District General Hospital (hospital A) and compare against an adjacent center serving a similar population, Doncaster Royal Infirmary (hospital B) where guidelines had not been instituted. METHODS: Data were collected from June, 1998 to May, 1999. Indication for PEG was documented and survival analysis performed using the Kaplan-Meier survival method. RESULTS: The number of PEG insertions had been rising each year in both centers. After guidelines were introduced in hospital A, the number of procedures fell by 20, whereas in hospital B, the PEG insertion rate continued to rise (p = 0.02). There was a lower mortality observed in hospital A (at 1 month, 16%; at 3 months, 26%; at 6 months, 39%; and at 1 yr, 46%) than in hospital B (at 1 month, 26%; at 3 months, 44%; at 6 months, 58%; and at I yr, 68%), although this did not achieve statistical significance (log rank test, p = 0.1). CONCLUSIONS: This is the first study to prospectively assess the impact of guidelines and a proactive role in the decision for PEG insertion. Fewer procedures were performed, and there was a trend toward a reduction in mortality.

Adult↗
PubMed2000

Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) feeding has been validated in specific clinical situations such as acute stroke with dysphagia and oropharyngeal malignancy. The perception that gastrostomy insertion is safe and technically simple has led to an increase in the demands for PEG insertion, encompassing clinical applications such as in patients with dementia, in whom its role has not been justified. The purpose of this study was to compare the mortality of patients with dementia who were fed by PEG to that of other subgroups of patients requiring gastrostomy feeding. METHODS: The study focused on a cohort of 361 consecutive patients requiring PEG feeding between August 1992 and July 1997 from two District General Hospitals (Rotherham District General Hospital and Doncaster Royal Infirmary) in South Yorkshire. A retrospective cohort survival analysis was performed using the Kaplan-Meier survival method and Cox proportional hazards analysis. RESULTS: In all patients requiring gastrostomy feeding there is a high initial mortality of 28% at 30 days. However, patients with dementia have a worse prognosis compared to other subgroups, with 54% having died at 1 month and 90% at 1 yr (log rank test p < 0.0001). This difference remained significant (log rank p < 0.0001) after adjusting for age at the time of PEG insertion. CONCLUSIONS: This is the first demonstration in the United Kingdom that the mortality of patients with dementia who are fed by gastrostomy is considerable. Consequently, we may wish to advise against gastrostomy feeding in selected patients within this clinical setting.

Aged↗
PubMed1990

Prevalence of Clostridium difficile on a mixed-function ward for the elderly.

We studied the prevalence of Clostridium difficile over a period of 2 months on a mixed-function geriatric ward. Seven (14%) of the 49 patients were long-stay but the remainder were in hospital for acute illness or required a short period of active rehabilitation. Although 69% patients had recently received antibiotics, from only two (4%) was C. difficile isolated from their faeces. Our results show that C. difficile is not endemic in patients on all geriatric wards as has been previously suggested.

Aged↗
PubMed1990

The visual evoked potential in clinical hepatic encephalopathy in acute and chronic liver disease.

Flash visual evoked potentials were measured in 19 patients with chronic liver disease and in 19 patients with acute hepatic damage secondary to paracetamol overdose with and without clinical hepatic encephalopathy. The flash visual evoked potential showed a series of changes which correlated with the clinical grade and the delta activity of the electroencephalogram in chronic liver disease, and with the delta activity of the electroencephalogram but not with the clinical grade in acute hepatic damage. The changes observed in the flash visual evoked potential in the encephalopathy of chronic liver disease were different from those seen in the corresponding clinical grade of acute hepatic damage, suggesting different pathogenetic mechanisms for encephalopathy in these two conditions.

Acute Disease↗
PubMed1988

Dynamic liver scanning in cirrhosis.

Dynamic hepatic scintigraphy was performed in 49 patients with established cirrhosis, using intravenous 99Tcm-pertechnetate and 99Tcm-sulphur colloid in a prospective study of its predictive value. There was a close correlation between the hepatic perfusion index (reflecting the ratio of arterial to total hepatic blood flow) obtained with pertechnetate (HPI-P) and with sulphur colloid (HPI-C) (r = 0.775; p less than 0.0001), and both indices correlated with disease severity (HPI-P p less than 0.0001; HPI-C p less than 0.01). HPI-P was significantly increased in patients who died, in patients with varices and in those with hepatic encephalopathy. HPI-C was significantly increased in patients with varices, in patients with hepatic encephalopathy and in those who had bled from varices. Neither HPI-P nor HPI-C was able accurately to predict the development of complications during the follow-up period. The trapping index (TI), reflecting a combination of hepatic extraction efficiency, degree of intrahepatic shunting and extrahepatic extraction of colloid, was significantly impaired in patients who died and in those with ascites, varices and/or variceal bleeding, but not in patients with hepatic encephalopathy. The trapping index correlated with disease severity, as did the computer-derived spleen-liver ratio (S-L ratio). Neither TI nor S-L ratio was able to predict the development of complications. The clearance rate constant of colloid from peripheral blood, the uptake rate constants for liver and spleen, and splenic volume were all found to be unhelpful as indicators of disease severity or as predictors of complications. While perfusion indices derived by dynamic hepatic scintigraphy reflect the severity of the underlying liver disease, their determination on a single occasion appears to offer no benefit in predicting the likelihood of major complications.

Adult↗
PubMed1987

The use of the visual evoked potential (VEP) in delineating a state of subclinical encephalopathy. A comparison with the number connection test (NCT).

Visual evoked potential determinations and the number connection test were performed for 49 patients with stable chronic liver disease and portal hypertension but without clinical evidence of hepatic encephalopathy. The latencies of the evoked potential components N2, P2 and N3 were significantly prolonged compared to the controls. Seven patients had a prolonged N2, 10 had a prolonged P2, and 14 patients had a prolonged N3 latency. Only five of these patients had increased theta activity of the electroencephalogram. When age norms were applied, the number connection test was significantly prolonged only in the 16-36-years age group. It is concluded that the visual evoked potential identifies a group of patients with neurophysiological abnormalities and may be useful in identifying those at risk of developing overt encephalopathy.

Adult↗
PubMed1986

Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile.

Faecal metronidazole and hydroxymetronidazole concentrations measured by high pressure liquid chromatography are reported during 10 episodes of Clostridium difficile colitis in nine patients. Bactericidal faecal concentrations were present in all patients with acute disease receiving oral or intravenous metronidazole, and all responded to therapy. Metronidazole and hydroxymetronidazole concentrations fell as the diarrhoea improved and neither substance was detectable in the faeces of five patients after recovery. This demonstration of intracolonic therapeutic concentrations of metronidazole supports the clinical experience of oral metronidazole being effective in the treatment of antibiotic associated diarrhoea caused by C difficile and also suggests a potential role for intravenous metronidazole in this disease.

Administration, Oral↗
PubMed1986

Pseudomembranous colitis in children and adults.

Pseudomembranous colitis remains a potentially lethal complication of antibiotic usage. Identification of Clostridium difficile as the major pathogen has led to a rational successful approach to therapy and has widened the spectrum of associated disease. The frequent asymptomatic colonization of healthy neonates by C. difficile remains an enigma.

Adult↗
PubMed1985

Defective activation of neutrophils after splenectomy.

Neutrophil chemotaxis and phagocytosis in the presence of serum from 20 patients who had undergone splenectomy and from 15 healthy volunteers was studied. The mean distance migrated by normal neutrophils in the presence of serum from the patients after splenectomy was significantly less than that when normal serum was used (p less than 0.005). The percentage of neutrophils phagocytosing a yeast was also significantly reduced in the presence of serum from patients after splenectomy (p less than 0.02). In addition, when neutrophils from these patients were studied both chemotaxis and phagocytosis were enhanced in normal compared with autologous serum (p less than 0.05).

Adolescent↗
PubMed1984

Asymptomatic neonatal colonisation by Clostridium difficile.

In a prospective survey of infants born in a single maternity unit, asymptomatic faecal colonisation by Clostridium difficile occurred in 31 (47%) of 66 babies who provided a faecal sample during week one of life and at age 14 and 28 days, and in 46 (30.7%) of the total of 150 babies for whom at least one faecal sample was obtained during the month of study. There was no evidence for acquisition of the organism from the mother during delivery and colonisation was unrelated to the means of delivery, infant sex, means of feeding, duration of hospital stay, or antibiotic treatment. New colonisation occurred throughout the month of the study and further evidence for environmental acquisition was obtained by the finding of a similar strain of C difficile in 7 babies from one ward together with positive environmental cultures. Colonisation was frequently transient and occasionally intermittent; most infants kept the same strain during their period of carriage. Twenty two (47.8%) babies colonised by C difficile had low titres of cytopathic faecal toxin but none had symptomatic diarrhoea or features of necrotizing enterocolitis. The in vitro toxigenic potential of 57 toxigenic isolates from 36 babies was low and 12 babies carried non-toxigenic strains. Transient colonisation by C difficile in early life is almost certainly more common than is generally recognized and the neonate provides an important reservoir of potential infection.

Bacterial Toxins↗
PubMed1981

The role of dietary fiber in satiety, glucose, and insulin: studies with fruit and fruit juice.

Healthy volunteers ingested sugar-equivalent meals of oranges and orange juice and of grapes and grape juice. Satiety, assessed by two subjective scoring systems, was greater after whole fruit than after juice and the return of appetite was delayed. With oranges, as previously reported with apples, there was a significantly smaller insulin response to fruit than to juice and less postabsorptive fall in plasma glucose. With grapes, the insulin response to the whole fruit was, paradoxically, more than that to the juice, while postabsorptive glucose values were similar. The glucose in grapes appeared to be more insulinogenic than that in oranges and apples. Conversely, grape juice evoked less insulin than expected, possibly because its high osmolality delayed gastric emptying. However, diluting it did not increase its insulinogenicity. The plasma insulin and glucose responses to fruit appear to depend on the fiber as well as the glucose content of the fruit.

Adult↗