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J MacFie

Publications and source records attributed to J MacFie.

At least 19 recordsLinked to original sources
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↗
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.

Explore the source record for details and available documents.

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↗
PubMed1998

Ultrasound-guided Tru-cut biopsy of the breast.

Ultrasound-guided automated Tru-cut needle biopsy may be used as an alternative to fine needle aspiration cytology for the assessment of discrete mass lesions of the breast. This is a retrospective study of 187 biopsies, comparing the results with a final diagnosis obtained from subsequent excision or outpatient follow-up. Biopsies were performed using a spring-loaded gun under ultrasound guidance. Invasive malignancy was demonstrated in 114 biopsies, 98 of which were subjected to surgery, with no false-positives. Twelve biopsies contained 'atypical cells', pre-invasive malignancy or risk factors for invasive carcinoma, ten of which proved to be invasive malignancy on excision. Normal or benign tissue was found in 61 biopsies, but of those that proceeded to excision biopsy, 16 were invasive or in situ carcinoma. The sensitivity of the procedure for detecting significant pathology was 88.7%, and the specificity 100%. When used as part of triple assessment, the sensitivity increases to 97.9%. Ultrasound-guided Tru-cut needle biopsy is a well-tolerated and reliable procedure for providing a tissue diagnosis of malignancy before definitive treatment, and obviating the need for formal excision biopsy of lesions for which there is a low index of suspicion.

Adult↗
PubMed1997

Ethics and nutrition.

Whilst much has been written on the implications of withholding or withdrawing nutritional support therapy from the terminally ill, the comatose or vegetative patients relatively little has been published on the ethical implications of nutritional therapy in other groups. This article outlines a surgeon's view of ethical issues as they apply to nutrition and concludes that failure to provide nutritional support in one form or another for patients who have or who are expected to have seven days or more of inadequate oral intake should now be considered unethical.

Enteral Nutrition↗
PubMed1996

Prospective study of the aetiology of infusion phlebitis and line failure during peripheral parenteral nutrition.

Four techniques of administering peripheral parenteral nutrition (PPN) were examined prospectively to investigate the role of mechanical trauma in the development of infusion phlebitis. Patients in group 1 (n = 15) were fed via a standard 18-G Teflon cannula which was removed on completion of the infusion and was rotated to the contralateral arm every day. Group 2 patients (n = 15) had a similar catheter sited in each forearm simultaneously, with rotation of the side of infusion each day. Patients in group 3 (n = 17) had a 15-cm Silastic rubber catheter inserted into a forearm vein and a standard cannula sited in the contralateral forearm, with alternation of infusion each day. Those in group 4 (n = 13) had a fine-bore 23-G silicone catheter sited in one arm only. Patients in groups 1, 2 and 3 were fed over 12-h cycles and those in group 4 for a 24-h continuous cycle. A total of 408 patient-days of PPN were given. Mean duration of PPN in groups 1-4 was 7.5, 9, 5.5 and 5 days respectively. Infusion phlebitis was not recorded in patients who had a daily change of cannula (group 1), but occurred in four patients in group 2, eight in group 3 and eight in group 4. Phlebitis scores were 0, 9, 15 and 12 for groups 1-4 respectively. Severe phlebitis and line occlusion occurred more frequently in patients with a 15-cm catheter (group 3) and in those fed continuously over 24 h (group 4). These results suggest that mechanical trauma is an important factor in the aetiology of infusion phlebitis. This can be minimized by reducing the time for which the vein wall is exposed to nutrient infusion and by reducing the amount of prosthetic material within the vein.

Adult↗